胸部理學檢查的技巧

1.1.病人衣服必須解開退至腰部.

2.2.周圍光線必須充足.

3.3.檢查必須有條不紊,循序漸進.

a.a. inspection, palpation , percussion , auscultation .

b.    b.兩側必須逐一比較.

c.c. 必須有系統性全面概括,例如由左至右,再由右往下, 再往左側,有如
"
"字型順序.

4.4.由體表要猜測出大概之肺葉所在.

5.5.當病人坐著時,要前後皆檢查,不要讓病人來回躺下及爬起來.

6.6.對女性病人做檢查,必須有護士在場.

7.7.女性病人躺下來,做前胸的檢查,因去除乳房的干擾,可做較好的診斷.

8.8.由後上背部做胸部理學檢查時,可請病人雙手交叉輕握雙肩,以便將兩側

 肩胛骨拉開, 可做較好的診斷.

 

正常呼吸聲音的特性

 

 

 

 

Pitch

Amplitude

Duration

Quality

Normal

Location

 

Bronchial (tracheal)

High

Loud

Inspiration

<expiration

Harsh, hollow,

tubular

Trachea and larynx

Broncho-Vesicular

 

Moderate

Moderate

Inspiration

=expiration

Mixed

Over major bronchi where fewer alveoli are located:  

posterior, between scapulae esp. on right

anterior, around upper sternum in first and second intercostal spaces

Vesicular

Low

Soft

Inspiration

>expiration

Rustling like the sound of the wind in the trees

Over peripheral lung fields where air flows through smaller bronchioles and alveoli

 

 

不正常的呼吸聲

 

1.聲音類別        2.  特性           3.  機轉        4.  臨床實例             

                                              

不連續聲音

 

Crackles-fine(rales, crepitations)

Discontinuous, high-

Pitched, short, crackling, popping sounds heard during inspiration and not cleared by coughing

Inhaled air collides /c previously deflated airways: airways suddenly pop open, creating crackling sound.

Late inspiratory crackles occur /c restrictive disease: pnumonia, congestive heart failure and interstitial fibrosis

Early inspiratory crackles occur /c obstructive disease: chronic bronchitis, asthma, and emphysema

Crackles-coarse

(coarse rales)

Loud, low-pitched, bubbling and gurgling sounds that start in early inspiration and may be present in expiration

Inhaled air collides /c secretions in the trachea and large bronchi

Pulmonary edema, pneumonia, pulmonary fibrosis, and in the terminally ill who have a depressed cough reflex

Atelectatic crackles

(atelectatic rales)

Sound like the crackles but do not last and are not pathologic.

Disappear after the first few breaths.

Heard in axillae and bases(usu. dependent) of lungs

When secretions of alveoli are not fully aerated, they deflate and accumulate secretions. Crackles are heard when these secretions reexpand /c a few deep breaths

In aging adults, bedridden persons, or in persons just roused from sleep.

Pleural friction rub

A very superficial sound that is coarse and low pitched; it has a grating quality as if two pieces of leather are being rubbed together. Sounds just like crackles, but close to the ear.

Caused when pluerae become inflamed and lose their normal lubricating fluid. Their opposing, roughened, pleural surfaces rub together during respiration

Pleuritis accompanied by pain with breathing.

(Rub disappears after a few days if pleural fluid accumulates and separates pleurae)

 

 

 

連續聲音

 

 

 

Wheeze- high-

pitched (sibilant rhonchi)

High-pitched, musical, squeaking sounds that predominate in expiration but may occur in both expiration and inspiration

Air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors

Obstructive lung disease such as asthma or emphysema

Wheeze-low- pitched(sonorous rhonchi)

Low-pitched, musical snoring, moaning sounds. They are heard throughout the cycle, although they are more prominent on expiration. May clear somewhat by coughing.

Airflow obstruction. The pitch of the wheeze cannot be correlated to the size of the passageway that generates it.

Bronchitis

 

 

常見肺疾病的理學檢查特性

 

 

Disorder

Inspection

Palpation

Percussion

Auscultation

Bronchial asthma (acute attack)

Hyperinflation

Use of accessory muscles

Impaired expansion

Decreased fremitus

Hyperresonance

Low diaphragms

Prolonged expiration

Wheezes

Pneumothorax

(complete)

Lag on affected side

Absent fremitus

Hyperresonant or tympanic

Absent breath sounds

Pleural effusion (large)

Lag on affected side

Decreased fremitus

Trachea and heart shifted away from affected side

Dullness or flatness

Absent breath sounds

Atelectasis (lobar obstruction)

Lag on affected side

Decreased fremitus

Trachea and heart shifted toward affected side

Dullness or flatness

Absent breath sounds

Consolidation (pneumonia)

Possible lag or splinting on affected side

Increased fremitus

Dullness

Bronchial breath sounds

Bronchophony

Pectoriloquy