ExaminationoftheHeart1PPT課件Examination1PPT課件1ExaminationoftheHeart

Inthepresenteraoftechnologicaladvances,particularlyinthevariousimagingmodalities,thereisagrowingconceptionamongpracticingphysiciansincardiovascularmedicinethatbedsidephysicalexaminationisunnecessaryanddoesnotprovideusefulinformation.

2PPT課件ExaminationoftheHeartIn2精品資料精品資料3你怎么稱呼老師？如果老師最后沒有總結(jié)一節(jié)課的重點的難點，你是否會認為老師的教學(xué)方法需要改進？你所經(jīng)歷的課堂，是講座式還是討論式？教師的教鞭“不怕太陽曬，也不怕那風(fēng)雨狂，只怕先生罵我笨，沒有學(xué)問無顏見爹娘……”“太陽當(dāng)空照，花兒對我笑，小鳥說早早早……”心臟檢查---ppt課件4

Itshouldbeemphasized,however,thatforproperapplicationandinterpretationofvariousnewandoldteststhatareavailableforcardiovascularevaluationinagivenpatient.

5PPT課件Itshouldbeemphasized,ho5

Bedsideclinicalexaminationshouldbeperformedandpracticedinthesamewayfollowingsimilarsequences.

6PPT課件Bedsideclinicalexamin6PreparingthepatientTheheartexaminationshouldbemadeaseasyaspossibleforthepatient,whousuallyexpectsittobearelativelydistastefulexperience.Ifthephysicianisconsiderateandgentle,thepatientshouldfeelwhenitisallover,thatmostofhisorherfearsonthatscorewereunfounded.

7PPT課件PreparingthepatientTheh7Theidealexaminingroomisprivate,warmenoughtoavoidchilling,andfreefromdistractingnoiseandsourcesofinterruption.Adequate(preferablyfluorescentornatural)lightisessential.

8PPT課件Theidealexaminingroom8

Theexaminingtablemaybeplacedwithitsheadagainstthewall,butbothsides(particularlytheright)andthefootshouldbeaccessibletotheexaminer.Andtheresultsshouldberecordedcarefully.

9PPT課件Theexaminingtablemaybe9ExaminationoftheHeart

Landmarksandtopographicanatomy

Certainbasiclandmarks

midsternallinemidclavicularlines

10PPT課件ExaminationoftheHeartLand10Certainbasiclandmarksanterior,middle,andposterioraxillarylinessuprasternalnotchidentificationofvariousribsandintercostalspace11PPT課件Certainbasiclandmarksanteri11SpecificareasforcardiacPE

sternoclavicularareaaorticareapulmonaryarea

12PPT課件SpecificareasforcardiacPE

12SpecificareasforcardiacPE

anteriorprecordiumapicalareaepigastricareaectopicarea13PPT課件SpecificareasforcardiacPE13InspectionInspectionoftheprecordiumshouldbeginatthefootofthebed.Thesubjectshouldbesupinewiththeleghorizontalandtheheadandtrunkelevatedtoapproximately15-30degrees.14PPT課件InspectionInspection14Asymmetryofthethoraciccageduetoaconvexbulgingoftheprecordiumsuggeststhepresenceofheartdiseasesincechildhood,suchascongenitalheartdiseaseandrheumaticheartdisease,withskeletalmoldingtoaccommodatecardiacenlargement.

15PPT課件Asymmetryofthethoraci15Intheadult,precordialbulgemaybeproducedfromthemassivepericardialeffusion.16PPT課件16PPT課件16Precordialbulge

congenitalheartdisease(beforepuberty)pericardicaleffusion(adultlife)

17PPT課件Precordialbulge17PPT課件17Pulsationapicalimpulse

Theapicalimpulseisoccurringearlyinsystole.Theapeximpulseisnormallylocatedatormedialtothemidclavicularlineinthefourthorfifthintercostalspacewhenthepatientissupine.18PPT課件Pulsationapicalimpulse18PPT課件18Usuallyitisdetectableinonlyoneintercostalspaceandislessthan2-2.5cmindiameter.Thenormalapeximpulseischaracterizedbyabriefearlysystolicoutwardthrustofmoderateamplitude,whichendswellbeforethesecondheartsound.19PPT課件Usuallyitisdetectablein19Theapeximpulseisnormallyexaggeratedinthin,youngindividualsandwhenthesubjectisintheleftlateraldecubitusposition.20PPT課件Theapeximpulseisno20Diastolicmovementsarenotperceptibleinmostcases,butinchildrenandyoungadultsanearlydiastolicFwaveisoccasionallypresent.21PPT課件Diastolicmovementsare21Normallyapicalimpulse:

It’slocationdurationintensityamplitude22PPT課件Normallyapicalimpulse:22P22DisplacementoftheapicalimpulseHeartdisease

Someheartdiseasescausetheleftventricularhypertrophydilatationorboth,theapicalimpulseisdisplacedlaterallyandinferiorlyandsustained,23PPT課件Displacementoftheapicalimp23

anditmaybeshiftedtotheleftandupwardinrightventricularhypertrophy,dilatationorboth.Itcanbefoundattherightfifthintercostalspaceindextrocardiaandcannotbefoundinmassivepericardialeffusion.

24PPT課件anditmaybeshiftedtoth24Thoracicdisease:

Pneumothoraxandpleuraleffusionwilldisplacetheapicalimpulsetothenormalside.Pleural-adhesionandatelectasiswillresultinadisplacementofimpulsetowardthediseasedside.

25PPT課件Thoracicdisease:25PPT課件25

Abdominaldisease:

Theapicalimpulsealsocanbedisplacedbylargemass,massiveascites.26PPT課件Abdominaldisease:26PPT課件26

Theapicalimpulsemayhaveincreasedamplitudeanddurationinthosepersonswithathinchest,anemia,fever,hyperthyroidismandanxiety.

27PPT課件Theapicalimpulsemay27

Theexaminershouldalwaysobservetheshapeandcontourofpatient’schest.Depressionsofthesternum,Kyphosisofdorsalspine,scoliosisoftenaltertheshapeandpositionoftheapicalimpulse.28PPT課件Theexaminershouldalw28Abnormalpulsationsintheotherareas:

Rightvertricularhypertophy(RVH).Theimpulseisclearlyseeninleftthirdfourthintercostalspace.PulmonaryemphysemawithRVH,usuallythepulsationcanbefoundinferiorthexiphoidprocess.29PPT課件Abnormalpulsationsintheoth29Inascendingorarchaorticaneurysm,onemaydetectabnormalpulsationsinaorticarea,withbulgingorpulsationinsystole.Pulmonaryhypertensionwithdilatationthepulsationinsystolemaybedetectedinleftsecondintercostalspacetotheedgeofsternum.30PPT課件Inascendingorarchaortican30DisplacementoftheapicalimpulseHeartdisease

LVH,LVDorboth

displacedto

lateralandinferior31PPT課件Displacementoftheapicalimp31Displacementoftheapicalimpulse

RVH,LVDorboth

displacedto

leftandupward32PPT課件Displacementoftheapicalimp32DisplacementoftheapicalimpulseCongenitaldextrocardiarightCHF,myocarditis,myocardiopathyapicalimpulsedecreaseintensity33PPT課件Displacementoftheapicalimp33DisplacementoftheapicalimpulseMassivepericardialeffusionapicalimpulsedisappear34PPT課件Displacementoftheapicalimp34DisplacementoftheapicalimpulseThoracicdiseasepneumothorax,pleuraleffusionshiftedtohealthyside35PPT課件Displacementoftheapicalimp35DisplacementoftheapicalimpulsePleural-adhesion,atelectasisshiftedtodiseasesideEmphysemawithRVHtoinferiortosubxiphoid36PPT課件Displacementoftheapicalimp36PalpationUsuallyinspectionandpalpationarediscussedtogetherbecausethereisanintimaterelationshipbetweenthesetwoprocessesintheheartexamination.Palpationnotonlyconfirmstheresultsininspection,butalsodiscoversdiagnosticsigns.37PPT課件PalpationUsuallyinspec37Throughcarefulpalpation,theexaminershouldaimtodeterminethelocationandsizeofthecardiacapeximpulse,characterizeitscontour,andidentifyanyabnormalprecordialpulsations.38PPT課件Throughcarefulpalpati38Thepalmofthehand,ventralsurfaceoftheproximalmetacarpals,andfingersshouldallbeusedforpalpationbecauseeachisusefulforoptimalappreciationofcertainmovements.39PPT課件Thepalmofthehand39PalpationPrecordialpulsation

Apicalimpulse:locationdurationamplitudeintensityfrequencyregularity40PPT課件PalpationPrecordialpulsation40Precordialpulsation

LVH:lift,Forcefulsensation,throughsystolewithgreatamplitudemorethan2cmdiameter

41PPT課件Precordialpulsation

LVH:41P41Precordialsustained

orheavy:RVHDecreaseamplitude:myocarditisMassivepericardialeffusion:impulsecannotbepalpable

42PPT課件Precordialsustainedorheavy:42PalpationThrillThrillarepalpablemurmurssomewhatsimilartothesensationonthethroatapurringcat.Thrillsareactuallypalpablefinevibrations,mostcommonlyproducedbybloodfromonechamberofthehearttoanotherthrougharestrictedornarrowedorifice,itmayoccurinsystole,diastole,presystoleandattimesmaybecontinuous.43PPT課件PalpationThrill43PPT課件43PalpationAnythrillshouldbedescribedastoitslocation,itstimeincardiaccycle,anditsmodeofextensionortransmission.Theintensityofthethrillvariesaccordingtothevelocityoftheblood,thedegreeofnarrowingoftheorificeandwhichitisproducedanddifferenceinpressurebetweenthetwochambersoftheheart.44PPT課件PalpationAnythrillsho44PalpationQualityofathrilldependsonthefrequencyofvibrationproducingit,rapidvibrationsresultinfinethrillswhereasslowervibrationsproducecoarserthrill.45PPT課件PalpationQualityofath45PalpationRestrictedornarrowedorificethrill

accordingbloodvelocityIntensitydegreeofnarrowingtogradientbetweentwochambers46PPT課件PalpationRestrictedornarrow46Palpation

dependsqualityfrequencyonfrequency:rapidfinethrillslowercoarser47PPT課件Palpationdepends47PalpationdurationlocationdiseasesystolesecondrightICSAS

secondleftICSPSthirdfourthleftICSVSDdiastoleapicalareaMScontinuous2ndleftICSPDA48PPT課件Palpationduration48PalpationPericardialfrictionrub

Pericardialfrictionrubisato-and-frogratingsensation,whichisusuallypresentduringbothphasesofcardiaccycle,oftenrubsaremorereadilypalpatedwiththepatientsittingerectandleaningforwardduringtheendperiodofdeepinspiration.49PPT課件PalpationPericardialfriction49PalpationTherubiscausedbyafibrinouspericarditis.Inthepresenceofpericardialeffusiontherubwillusuallydisappearbecauseoftheseparationofvisceralandparietallayersbytheaccumulatedfluid.50PPT課件PalpationTherubiscausedb50PalpationShock(palpablesounds)valvecloseasatappingsensation2ndleftICS:PH2ndrightICS:SHapex:MS51PPT課件PalpationShock(palpablesound51PercussionMethodofpercussionforheart

Thechestispercussedtoconfirmthecardiacborders,size,contourandpositioninthethorax,patientshouldliesupineonanexaminingtableorsitonthechair,withthephysicianathisrightside.52PPT課件PercussionMethodofpercussion52PercussionUsuallyweemployindirectpercussionforpercussingheartborders.Itisoutlinedbypercussinginthe5th,4th,3rdand2ndintercostalspaceontheleftsequentially,startingneartheaxillaandmovingmediallyuntilcardiacdullnessisencountered.53PPT課件PercussionUsuallyweemploy53Percussion

Thebeginnershouldmarkwithaskinpencilwherethenotechanges.Thedistancefrommidsternallinetotheleftbordershouldbemeasuredandrecorded,measurementshouldbemadealongastraightlineparalleledtothetransversediameterinthethorax.54PPT課件PercussionThebeginnershou54PercussionHeartbordersRightborderoftheheartformedbysupvean,ascendingaorta,rightatrium55PPT課件PercussionHeartborders55PPT課件55HeartbordersLeftborderoftheheartformedbyaortaarch,pulmonaryarterialtrunkleftatriaappendage,LVInferiorborderoftheheartformedbyRV,lesserextentLV56PPT課件HeartbordersLeftborderofth56Percussion

Normalheartdullness

right(cm)ICS,MSLleft(cm)

2-3Ⅱ2-32-3Ⅲ3.5-4.53-4Ⅳ5-6Ⅴ7-9NormallyfrommidsternallinetoMCLisabout7-9cm57PPT課件PercussionNormalheartdullne57Changingcardiacdullness

Leftventricularenlargement,thecardiacdullnesswillbeextendedtotheleftanddownward,theheartsilhouetteislikeashoe.Itisfrequentlyseeninaorticregurgitationandcalledaorticheart.58PPT課件Changingcar