Landmarks on the Chest Wall

The Chest 锁骨
胸骨柄
Department of Physical Diagnostics 胸骨角 (Louis
1st Teaching Hospital 角)
Henan Medical University 肋骨和肋间隙

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Reference Lines
Landmarks on the Chest Wall
脊柱棘突 前正中线
肋脊角 胸骨线
肩胛骨 胸骨旁线
肩胛下角 锁骨中线
腋前线
腋中线
腋后线
肩胛线
后正中线

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Reference Lines Fossas and Regions胸部四窝和背部四区

胸部四窝和背部四区

Fossas
„ Suprasternal fossa 胸骨上窝,

„ supraclavicular fossa 锁骨上窝,

„ infraclavicular fossa 锁骨下窝,

„ axillary fossa 腋窝

Regions
„ Scapular region肩胛区,

„ supra- ~ 肩胛上区,

„ infra- ~ 肩胛下区,

„ interscapular region肩胛间区

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Chest Wall Chest Wall
Visible veins静脉显露
静脉显露:
collateral circulation侧枝循环
侧枝循环 Local tenderness: inflammation,
Pay attention to the direction of blood flow
rib fracture
„

Regional enlargement:
„ Rib fracture
„ Tumor on the chest wall
„ Cardiac enlargement
Local Tenderness : Inflamation,
Inflamation, Rib fracture
“Gripping snow” sensation皮肤握雪感
皮肤握雪感: subcutaneous
emphysema皮下气肿
皮下气肿
Sternum tenderness and percussion pain胸骨压痛叩击
胸骨压痛叩击
痛: leukemia
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Chest
Abnormal Intercostal Space
Recessed or narrowed凹陷或变窄
凹陷或变窄（胸内容积缩小）
（胸内容积缩小） Normal正常形态: Ap: T=1：1.5前后径
前后径::横径≈1:1.5
横径≈1:1.5
吸气时凹陷: air way
„ Depressed when inspirating吸气时凹陷
obstruction大气道阻塞
大气道阻塞 Abnormal:
„ One –side depression一侧变窄凹陷: atelectasis, pleural
„ Flat chest扁平胸, barrel chest桶状胸
adhesion肺不张 胸膜粘连
„ Rachitic chest佝偻病胸

Š Pigeon chest鸡胸
Wide or swelling膨隆或增宽
膨隆或增宽（胸内容积增大）
（胸内容积增大）
Š rachitic rosary串珠胸
„ General呼气时膨隆—emphysema肺气肿, bronchial asthma
Š funnel chest漏斗胸
支气管哮喘
Š harrison groove肋膈沟
„ One-side一侧膨隆或增宽—pleural effusion胸腔积液,
„ Regional transfiguration局部变形
pneumothorax气胸
„ Thorax-vertebrae-malformation-induced 胸椎严重畸
形

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Funnel Chest Deformity Pigeon Chest Deformity

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Breasts Inspection of Breast

Contour:
Š Normal: symmetric hemisphere 对称半
球形
Š Asymmetric不对称 :
„ Enlarged—inflammation, tumor
„ Under-sized缩小: hypogenesis发育不良

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Breast Examination Breast Examination

Skin
„ Redness—inflammation Nipple乳头异常
„ Peau d’orange (orange peel) Nipple retraction回缩
桔皮样水肿
„ Bilateral and lifelong: hypogenesis发育异常
—malignancy
„ Unilateral and recent: inflammation and
neck
Retraction回缩下陷
回缩下陷: scar, tumor malignancy 肿瘤

Discharge分泌物:—benign or malignant 乳腺导管病变

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Indrawing of the Nipple Palpation

Position
„ Sitting坐位

„ Supine两臂下垂

Technique检查手法:
„ Examine with the flat of the hand and
tips of the fingers用指腹或手掌屈侧轻压

„ Bimanual palpation

检查顺序
先健侧后患侧
外上→外下→
内下→内上

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Breast Palpation Examination area

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American Cancer Society

breast cancer screening guidelines 1997
Examination pattern (for asymptomatic women)

Age 40 and
Age 20 – 39
elder
Breast self-
Monthly Monthly
examination
Clinical breast Every 3
Annually
examination years

Mammography None Annually

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Clinical Examination Clinical Examination

Inspection of the Breasts Palpation of Regional Nodes

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Clinical Examination
Palpation of the Breasts Pathological Findings
Increased consistency , diminished elasticity,
tenderness硬度增加 弹性消失 压痛
Masses包块包块
„ Location部位

„ Size 大小

„ Contour, margin, rigidity,tenderness, mobility

外形 边缘 硬度 压痛 活动度

Lymphadenovarix 淋巴结增大
„ Axillary腋窝, suprasternal fossa锁骨上窝

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Common Diseases

Acute mastadenitis 急性乳腺炎

Tumor乳腺肿瘤
„ Cystic hyperplasia乳腺囊性增
乳腺囊性增
„ Fibroma乳腺纤维瘤
乳腺纤维瘤
„ cancer乳腺癌
乳腺癌
„ Gynecomastia in the male男性乳房增生
男性乳房增生

27 Gynecomastia 28

肺部（胸膜）检查
pulmonary examination

肺部视诊
肺部触诊
肺部叩诊

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 The Lung
Inspection
„ Respiratory movement呼吸运动 呼吸运动
„ Normal: Symmetric对称胸腹式呼吸
对称胸腹式呼吸
„ Enhanced or decreased 增 强 或 减 弱
(unilateral or bilateral)单侧或双侧
单侧或双侧
„ Dyspnea呼吸困难
呼吸困难
Š Inspiratory— “Three depressions sign”三凹征
三凹征
Š Expiratory —protraction of intercostal space肋
肋
间隙膨隆 呼气延长
„ Respiratory frequency (12~18/min)
Š Tachypnea —>24/min呼吸过速
呼吸过速
Š Bradypnea—<12/min呼吸过缓
呼吸过缓
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Š 呼吸深度与节律

Respiratory Rate Effort of Ventilation

Bradypnea: rate less than 8 per minute
Tachypnea: rate greater than 25 per
minute
Person appears uncomfortable.
Breathing seems voluntary.
Accessory muscles are in use,
expiratory muscles are active and
expiration is not passive any more.
The degree of negative pleural pressure
is high.
The respiratory rate is increased.

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Barrel Chest
Resting Size and Shape of Thorax

Barrel chest
AP Diameter = Transverse
Kyphosis Diameter

Scoliosis
Pectus excavatum
Gibbus

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Depth and Rhythm Pattern of Breathing
浅快 深长 节律不齐 叹气样

Kussmals
Sleep apnea
Cheyne strokes
Pursed lip breathing
Orthopnoea: Short of breath in supine
position, gets some relief by sitting or
standing up.

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Palpation
Breathing Patterns
Chest expansion (dynamic events of respiration)胸廓
胸廓
扩张度
„ One-sided recession一侧受限—— pleural diseases,
atelectasis
Pleural friction fremitus胸膜摩擦感
胸膜摩擦感（胸膜表面粗糙）
（胸膜表面粗糙）
随呼吸感觉到 如皮革相互摩擦 胸廓下前侧部位易触及
„ a sign of acute pleuritis 提示胸膜炎

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Tracheal Position:
Chest Expansion Mediastinum
Asymmetrical chest expansion is Any deviation of the mediastinum is abnormal
abnormal Lateral shift: The mediastinum can be either
„ The abnormal side expands less and lags pulled or pushed away from the lesion
behind the normal side „ Pull: Loss of lung volume (Atelectasis, fibrosis,
agenesis, surgical resection, pleural fibrosis)
„ Any form of unilateral lung or pleural
„ Push: Space occupying lesions (pleural effusion,
disease can cause asymmetry of chest pneumothorax, large mass lesions)
expansion „ Mediastinal masses and thyroid tumors
Global expansion decrease

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 Vocal (Tactile) Fremitus
Principle机制
机制
声波→气道→肺泡→胸膜腔→
胸壁振动→手掌
Technique方法
方法 自上而下 由前至后 交替对比
影响因素 喉音大小 气道通畅
传导介质 传导距离

Tracheal shift to right 43 44

Vocal (Tactile) Fremitus :

Pathological Conditions
Weaken or disappear:
„ Obstructive atelectasis, emphysema, Pleural
effusion, pneumothorax, subcutaneous
emphysema
Enhanced
„ Consolidation of lung tissue肺实变 : lobar
pneumonia, pulmonary infarction.
„ Large cavity in the lung肺空洞, esp. near the
pleura: lung abscess, cavernous pulmonary
tuberculosis

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Percussion

Techniques叩诊方法
机制 肺内含气量————胸壁厚度
肺内含气量————胸壁厚度
„ Mediate percussion间接叩诊法
间接叩诊法
分度 鼓音 过清音 清音
„ Immediate percussion
浊音 实音
„ 自上而下 由外向内 前胸沿肋间叩 后背水平叩
Content叩诊内容
叩诊内容
Percussion note叩肺音
„ Lung border叩肺界（上下界）
叩肺界（上下界）
„ Diaphragmatic excursion叩肺下界移动度
叩肺下界移动度
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Percussion Notes of the Lung Lung Border
Characters：
Kronig’s isthmus: 5~6cm
„ Normal chest: resonance肺部清音
Anterior border: IC
„ Inferior>superior, left>right, anterior>posterior Lines
spaces
Dullness if the lung overlaps with neighboring
Inferior border:
„
midclavicular 6th
organ (liver)与邻近脏器重叠相对浊音
与邻近脏器重叠相对浊音
midaxillary 8th
Influencing factors Diaphragmatic
scapular 10th
„ Chest wall thickness
excursion: 6~8cm
„ Air in the pleural space and the lung
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Pathological Percussion Notes Pathological Percussion Notes

Dullness, flatness浊音及实音
浊音及实音:
Hyperresonance 过清音:
清音
„ Volume reduction 肺含气量减少 : pneumonia, TB,
„ Emphysema 肺气肿
atelectasis, lung edema.炎症实变 肺肿瘤肺不张
Tympany 鼓音
„ Airless tissue 胸 膜 胸 壁 增 厚 : lung tumor, lung
„ Cavernous
abcess, pleural effusion.胸腔积液 胸膜肥厚 TB tuberculosis肺部空洞
肺部空洞
„ Lung abscess,
MASS „ Pneumothorax 气胸.
气胸

FLUID

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Percussion: Decreased or Increased

Resonance is Abnormal
Abnormal Lung Border

Dullness Kronig’ isthmus肺上界 :

„ Widening: —emphysema肺气肿 肺气肿
„ Decreased resonance is noted with pleural
„ Narrowing (unilateral):—tuberculosis, tumor 肺 结
effusion and all other lung diseases
核 肺肿瘤
„ The dullness is flat and the finger is painful to Inferior border肺下界
肺下界 :
percussion with pleural effusion „ Lowered: —emphysema肺气肿

Hyper resonance: Increased resonance can „ Rised :—atelectasis, increased intra-abdominal

be noted either due to lung distention as pressure肺不张 腹压升高

„ Undetectable 叩 不 出 : — Pleural effusion,
seen in asthma, emphysema, bullous disease pneumothorax胸腔积液 气胸
or due to Pneumothorax
Traube's space

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Abnormal Diaphragmatic Excursion 预告下次内容
Decreased: <4cm

„ Unilateral: atalectasis, pleural adhension

„ Bilateral: emphysema, lung fibrosis肺纤维化

肺部听诊
肺部疾病
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