08心血管检查(7)

郑州大学第一附属医院CardiacandVascularExamination心血管检查cardiacmurmurs心脏杂音vascularexamination血管检查heartdisease心脏疾病郑州大学第一附属医院AuscultationofMurmurs心脏杂音听诊mechanisms产生机制characterization听诊要点clinicalmeaning临床意义郑州大学第一附属医院Mechanisms杂音产生机制turbulentflow-vortices-murmur湍流→旋涡→杂音Stenosisorinsufficiencyofvalves瓣膜狭窄或关闭不全Abnormalpathway(shunt)异常通道（分流）Floatingmaterialsincirculation心腔内漂浮物Stenosisordilationofbloodvessels血管腔扩大或狭窄Enhancedbloodflowvelocity血流加速Diminishedviscosity血液粘度降低郑州大学第一附属医院Organic&Relative器质性与相对性Organic:valvedisease器质性:瓣膜本身病变stenosis狭窄insufficiency关闭不全Relative:pathwaywide相对性:通道扩大stenosis狭窄insufficiency关闭不全郑州大学第一附属医院CharacterizationofMurmurs杂音听诊要点LocationDurationPitchandQualityIntensityandTimingTransmissionorradiationEffectmurmursoffactor杂音的部位杂音的时期杂音的性质杂音的强度杂音的传导影响杂音的因素郑州大学第一附属医院Location杂音部位Apicalarea:mitralvalveAorticarea:aorticvalvePulmonicarea:pulmonicvalveInferiorsternum:tricuspidvalve3rd,4thICS,LSB:ventricularseptaldefect2nd,3rdICS,LSB:patentductusarteriosus杂音出现和最响部位与病变部位血流方向传导介质相关心尖部:二尖瓣主动脉瓣听诊区:主动脉瓣肺动脉瓣听诊区:肺动脉瓣胸骨下端:三尖瓣胸骨左缘34肋间:室间隔胸骨左缘23肋间:动脉导管郑州大学第一附属医院Duration杂音时期Systolicmurmur(SM)HolosystolicEarlyMidsystolicLateDiastolicmurmur(DM)HolodiastolicEarlyMiddiastolicLate(presystolic)Continuous收缩期杂音全收缩期收缩早期收缩中期收缩晚期舒张期杂音全舒张期舒张早期舒张中期舒张晚期连续性杂音郑州大学第一附属医院DistinguishDuration时期的区分systolicmurmur收缩期杂音appearbetweenS1andS2,sameasapicalimpulse在第一心音与第二心音之间出现与心尖搏动一致diastolicmurmur舒张期杂音appearbetweenS2andS1,nonsameasapicalimpulse在第二心音与第一心音之间出现与心尖搏动不一致郑州大学第一附属医院BothPhaseandContinuesMurmur双期杂音与连续性杂音Bothphasemurmur双期杂音Cause:mitralstenosisandinsufficiency疾病:二狭二闭Heartmurmurappearsinsystoleanddiastolerespectively.收缩舒张期分别出现杂音Auscultation:QualitydifferentandS2still特点:杂音性质可不同不遮盖第二心音Continuesmurmur连续性杂音Cause:Patentductusarteriosus疾病:动脉导管未闭Startsinsystole,continueswithoutinterruptionthroughS2intodiastole.跨越收缩期和舒张期Auscultation:QualitysameandS2disappear.特点:杂音性质相同遮盖第二心音郑州大学第一附属医院PitchandQuality杂音性质Pitch:dependsonpressureandrateofbloodflow音调:与血流的压力和流速相关high,mediumandlow高调中等低调Quality:dependsondegreeofvalvecompromise,forceofcontractionsandbloodvolume音色:与瓣膜状况收缩力和血容量相关Harshorraspy粗糙或刺耳machine-likevibratory机器样musical乐音样blowing吹风样rumbling隆隆样signingsound叹气样（泼水样）warblesound鸟鸣样（鸥鸣鸽鸣雁鸣）郑州大学第一附属医院Intensity杂音强度Influencingfactors:影响因素Degreeofchangebetweencalibersofthepassagesthroughwhichthebloodisflowing通道口的大小Degreeofpressuredifferentialbetweenthepassages通道两端的压力差Speedofthebloodflow血流速度Thicknessofthetissuesbetweentheheartandthesurfaceofthechest传导距离郑州大学第一附属医院IntensityofSystolicMurmur收缩期杂音强度GradeⅠ:barelyaudibleinquietroom1级:仔细听方可听到GradeⅡ:quietbutclearlyaudible2级:容易听到但不响亮GradeⅢ:moderatelyloud3级:较响亮GradeⅣ:loud,associatedwiththrill4级:粗糙且响亮伴传导震颤GradeⅤ:veryloud,thrilleasilypalpable5级:震耳GradeⅥ:veryloud,audiblewithstethoscopenotincontactwithchest,thrillpalpableandvisible6级:离开胸壁亦可闻及郑州大学第一附属医院ConfigurationorShape杂音形态Typesofintensityvariety杂音强度变化类型Crescendo:increasingintensity递增型:强度逐渐增加Decrescendo:decreasingintensity递减型:强度逐渐减小Crescendo-decrescendo:递增递减型:强度先增加后减小Continuous:连续型:收缩期增强到舒张期减弱Plateau:sameintensity一贯型:强度大体保持一致郑州大学第一附属医院TransmissionorRadiation杂音传导Thegreatestfactorinfluencingradiationisintensity随距离增加响度减弱性质不变Radiationdirectioncanbeinfluencedby:originofthemurmur,directionofflowofturbulentstream传导方向:与病变部位及血流方向相关Mitralinsufficiency:transmittoleftoxterandscapular二尖瓣关闭不全:向左腋下肩胛下传导Aorticstenosis:transmittorightcervix主动脉瓣狭窄:向右侧颈部传导Aorticinsufficiency:transmittoapicalarea主动脉瓣关闭不全:向心尖部传导Mitralstenosis:notransmission二尖瓣狭窄:不传导郑州大学第一附属医院EffectMurmursofFactor影响杂音强度因素Exercise:murmurswhichareinaudibleorjustbarelyheardwiththepatientatrestmaybemoreclearlyheardafterphysicalexertion.运动影响:运动后使杂音增强Respiration:fullexpirationmadeleftcardiacmurmur,deepinspirationmaderightcardiacmurmur.呼吸影响:用力呼气使左心杂音增强深吸气使右心杂音增强Position:influencethelocationoftheheartandthereturnedbloodvolume体位改变:使心脏位置和回心血量相应改变郑州大学第一附属医院ClassificationofMurmurs杂音的分类Functionalmurmurs功能性杂音Physiologic:velocityofbloodflow生理性:血流加速Relative:enlargementoftheorifice,usuallyreversible相对性:有腔隙或瓣环的扩大有可逆性Organicmurmurs器质性杂音Organicdamage有器质性损害Mostofthediastolicandcontinuesmurmursareorganic舒张期及连续性杂音绝大多数为器质性杂音郑州大学第一附属医院FunctionalandOrganicMurmurs收缩期杂音的鉴别Functional功能性Organic器质性Age年龄Young儿童青少年Unlimited不定Location部位Pulmonic/apical肺动脉瓣或心尖部Anyarea各部位Character性质Soft,smooth柔和Coarse,highpitch粗糙高调Duration时间Short短Long(wholesystole)长（全收缩期）Intensity强度3/6or=3/6Thrill震颤no无Yes有Transmission传导Localized局限extensive传导郑州大学第一附属医院LocationandDurationtoDiagnose杂音部位时期对诊断的提示systolic收缩期Insufficiency关闭不全stenosis狭窄mitralvalve二尖瓣aorticvalve主动脉瓣tricuspidvalve三尖瓣pulmonicvalve肺动脉瓣stenosis狭窄insufficiency关闭不全Graham-Steelldiastolic舒张期Austin-FlintSystolicmurmurinleftsternumintercostal3~4:ventricularseptaldefect胸骨左缘34肋间收缩期杂音:室间隔缺损Continuousmachine-likeinleftsternumintercostal2:patentductusarteriosus胸骨左缘第2肋间连续型杂音:动脉导管末闭郑州大学第一附属医院SystolicMurmursattheApex心尖部收缩期杂音Quality:blowing性质:吹风样Physiologic生理性Pathologic:病理性Insufficiencyofmitralvalve二尖瓣关闭不全Transmissionofasy