臨床英語翻譯:心臟的物理檢查1

Physical Examination of the Heart (1)

心臟的物理檢查（1)

Introduction.

導(dǎo)言

Careful physical examination of the heart provides important information about the cardiovascular system. Together with a thorough history, the physical examination provides the initial database and suggests further diagnostic tests and therapeutic maneuvers. In many conditions, careful physical examination can yield information as important as that obtained by more complex and costly procedures.

仔細(xì)的心臟物理檢查可以提供心臟的重要信息。它和病史記錄一起構(gòu)成最初的基礎(chǔ)數(shù)據(jù)，并為以后的診斷檢查和治療方法提供依據(jù)。對很多疾病而言，仔細(xì)的物理檢查所提供的信息和通過其他復(fù)雜昂貴的手段所獲得的信息一樣重要。

It is also important to recognize the complex interplay between cardiac disease and other systemic illnesses or conditions. A common mistake made by the noncardiologist is ignoring the cardiac manifestations of a systemic disease process. Conversely, the cardiologist may fail to recognize the effects of cardiac disease on other organ systems. For these reasons every patient suspected of having cardiac abnormalities must be given a thorough physical examination.

認(rèn)識心臟疾病與其他系統(tǒng)性疾病或病癥之間復(fù)雜的相互作用關(guān)系也很重要。非心臟病醫(yī)師常犯的錯誤是勿略了某一系統(tǒng)性疾病發(fā)展過程中心臟的癥狀，而心臟病醫(yī)師也可能并未認(rèn)識到心臟病對其他器管所造成的影響。有鑒于此，每一個懷疑有心臟異常的病人都必須作徹底的物理檢查。

Observations, palpation, and percussion

望診、觸診和叩診

1. Jugular venous pulse (JVP). Two types of information are obtained from the JVP: the quality of the wave form and the central venous pressure (CVP).

1、頸靜脈搏動（JVP)-- 頸靜脈搏動可提供兩類信息：波形特性和中心靜脈壓。

(1) Technique of examination. The JVP is best observed in the right internal jugular vein. With normal CVP, the JVP is assessed with the patient's trunk raised less than 30 degrees. With elevated CVP the patient's trunk must be raised higher, sometimes to as much as 90 degrees. The JVP is accentuated by turning the patient's head away from the examiner and shining a flashlight obliquely across the skin overlying the vein.

（1)檢查方法 最佳觀察位置是右側(cè)頸內(nèi)靜脈。評估頸靜脈搏動時，中心靜脈壓正常的病人的軀干伸直角度應(yīng)小于30O；中心靜脈壓升高者的軀干直立角度應(yīng)加大，有時可達(dá)90O。檢查時，讓患者側(cè)過頭去，并用手電筒斜照靜脈上方皮膚，就可清楚看到頸靜脈。

(2) Wave form of the JVP. Two waves per heartbeat are generally visible in the JVP: the A wave and the V wave. The A wave appears as a brief "flicker" and represents increased venous pressure resulting from atrial contraction. The V wave is a longer surge that follows the A wave and represents increased venous pressure transmitted during ventricular contraction. The drop in pressure following the A wave is called the X descent, and the fall in pressure after the V wave is denoted as the Y descent. The JVP waves should be timed with simultaneous palpation of the carotid artery. The A wave immediately precedes the carotid pulse; the V wave follows the pulse. The diagnosis of a variety of pathologic states is assisted by observation of abnormalities in the JVP wave forms　(Table 1-1).

（2)頸靜脈波形 頸靜脈搏動時，每次心跳通常都會出現(xiàn)兩種波形：A波和V波。A波為短促的“撲動”，代表心房收縮產(chǎn)生的靜脈壓增加。V波為A波后的較長波涌，代表心室收縮期間傳導(dǎo)的靜脈壓增加。A波后的脈壓下降稱為X下降，V波后的下降則稱為Y下降。計算頸靜脈搏動時應(yīng)同步觸診頸動脈。A波先于頸動脈搏動；V波居后。頸靜脈波形觀察異�？芍С指鞣N病理狀態(tài)的診斷（見表1-1)。

(3) Determination of CVP. CVP can be estimated by observing the vertical distance from the top of the V wave to the right atrium. In the individual with normal CVP, the V wave rises 1-2 cm above the sternal angle. When the V wave rises to more than halfway to the angle of the jaw in a patient who is not recumbent, elevated CVP is present. In some pathologic conditions (e.g., cardiac tamponade, constrictive pericarditis), CVP may be so high that A and V waves are above the angle of the jaw. In this setting, exaggerated X and Y descents may suggest the diagnosis. As a rule of thumb, for a patient sitting upright, a JVP visible at the sternal angle represents a CVP of approximately 10 mm Hg.

（3)中心靜脈壓測定 觀察V波頂部至右心房的垂直距離即可估得中心靜脈壓。中心靜脈壓正常者，V波上升，高出胸骨角1 ~ 2cm。非橫臥病人V波升離至頜角一半以上位置時，就會出現(xiàn)中心靜脈壓升高。有些病理情況（如心臟填塞、縮窄性心包炎)的中心靜脈壓可以升得很高，以致A波和V波都可高出頜角。此時，突出的X和Y下降提示診斷成立。根據(jù)經(jīng)驗，對一個端座病人來說，胸骨角頸靜脈搏動就代表一個約10mmHg的中心靜脈壓。

During inspiration the height of the JVP typically declines (although amplitude of the X and Y descents will increase). In certain pathologic conditions such as chronic constrictive pericarditis and occasionally tricuspid stenosis, congestive heart failure, right ventricular dysfunction, or infarction the JVP actually increases with inspiration. This important clinical finding is known as Kussmaul's sign.

吸氣期間，頸靜脈搏動高度下降很典型（盡管X和Y下降的振幅加大)，但有些病理情況，如慢性縮窄性心包炎以及偶爾的三尖瓣狹窄、充血性心力衰竭、右心室功能不全或心肌梗死，其頸靜脈搏動實際上是隨吸氣增加的。這一重要臨床發(fā)現(xiàn)被稱為庫斯毛爾氏征。

2. Arterial pressure pulse. The central arterial pressure pulse is characterized by a rapid rise to a rounded shoulder peak with a less rapid decline. Information about the adequacy of ventricular contraction and possible obstruction of the left ventricular outflow tract may be assessed by palpation of the carotid artery. By the time the pulse wave is transmitted to peripheral arteries, much of this initial information is lost; however, pulsus alternans is best evaluated in peripheral arteries.醫(yī).學(xué)全.在.線網(wǎng)站gydjdsj.org.cn

2、動脈壓搏動 中心動脈壓搏動的特點是，迅速升高形成一個圓形肩峰，隨后下降，但速度放慢。頸動脈觸診即可評估有關(guān)心室收縮充分及左心室流出通路可能堵塞的信息。脈波傳到外周動脈時，此類初始信息會丟失很多。不過，最好是在外周動脈處評估交替脈。

A variety of pathologic conditions alters the characteristics of the carotid pulse. These conditions, and the corresponding modifications of the carotid pulse, are listed in Table 1-2. In patients with unexplained hypertension, simultaneous palpation of radial and femoral arterial pulses helps to rule out coarctation of the aorta.

有很多病理情況會改變頸動脈特征（見表1-2)。在不明因高血壓患者中，同時觸診橈動脈和股動脈脈搏有助于排除主動脈縮窄。

3. Precordial palpation. Information concerning the location and quality of the left ventricular impulse is available through precordiat palpation. In addition, intensity of murmurs may be gauged by palpating associated thrills. Palpation is best accomplished using the fingertips, with the patient either supine or in the left lateral decubitus position. Simultaneous auscultation can aid in the timing of events. A list of abnormalities detected by precordial palpation and their significance is found in Table 1-3.

3、心前區(qū)觸診 心前區(qū)觸診可提供左心室沖動的位置及特征信息。此外，還可通過觸診相關(guān)震顫推斷雜音的強(qiáng)度。觸診時最好用指尖，病人處仰臥位或左側(cè)臥位。同步聽診有助于計數(shù)。心前區(qū)觸診異常及其臨床意義見表1-3。

Auscultation

聽診

1. Sl. The first heart sound (SI) occurs at the time of closure of the mitral and tricuspid valves. It is probably generated by the closure of the valves. Si is frequently split (with mitral closure preceding tricuspid), but this event is often hard to appreciate and of little clinical relevance. More important is variation in intensity of the first sound. S1 varies with the P-R interval of the ECG. The shorter the P-R interval, the louder the Si. The best example of S1 variation with P-R interval occurs in complete heart block, in which atrial and ventricular contractions are dissociated.

1、S1 第一心音（S1)發(fā)生于二、三尖瓣關(guān)閉時，這可能是由瓣膜關(guān)閉造成的。S1常常呈分裂狀（二尖瓣先于三尖瓣關(guān)閉)，但這一點又往往難以正確評估，也沒有多少臨床實用性。第一心音的強(qiáng)度變化更為重要。S1隨ECG P-R間期而變。P-R間期越短，S1越大。S1隨P-R間期而變的最好例子是在完全心臟傳導(dǎo)阻滯期，此時的房、室收縮是分離的。

S1 may be loud and "snapping" in quality in mitral stenosis, indicating both that the valve is pliable and that it remains wide open at the beginning of isovolumic contraction. Conversely, a diminished or absent S1 in mitral stenosis suggests a rigidly calcified valve that cannot "snap" shut.

二尖瓣狹窄時S1響亮、呈喀嚓聲，既表明瓣膜柔軟，也表明瓣膜在等容量收縮開始時仍張開著。相反，二尖瓣狹窄時S1減弱或消失，表明瓣葉嚴(yán)重鈣化，無法關(guān)閉。

Other situations in which S1 may be diminished include mitral regurgitation, slow heart rates (long P-R interval), poor sound conduction through the chest wall, and a slow rise of left ventricular pressure. A summary of clinical information derived from variations in S1 is found in Table 1-4.

S1可能減弱的其他情形包括二尖瓣反流、心率緩慢（P-R間期長)、胸腔壁聲音傳導(dǎo)差、左室壓上升慢。S1變化情況見表1-4。醫(yī)學(xué).全.在線.網(wǎng).站.提供

2. S2. In contrast to S1, in which splitting is less important than changes in intensity, S2 reveals variations in both splitting and intensity that provide important clinical information.

2、S2 在S1中，強(qiáng)度變化要比分裂重要。與此相反，S2 既反映分裂的變化，也反映強(qiáng)度的變化，從而提供重要的臨床信息。

The second heart sound (S2) occurs at the time of closure of the aortic and pulmonic valves. In normal circumstances, aortic closure precedes pulmonic closure (A2 followed by P2). Under normal circumstances, the split in S2 is maximal at the end of Inspiration and minimal at the end of expiration. This phenomenon reflects an underlying movement of P2 with respect to a relatively constant A2. During inspiration, right ventricular filling increases and P2 is delayed, causing the widely split S2. During expiration, less right ventricular filling occurs and P2 "closes" toward A2, causing a diminished split in S2. This "normal splitting" of S2 is invariably present in individuals under 30 years of age, provided heart rates are not markedly accelerated. It is best appreciated over the "pulmonic area" and can be heard with either the bell or the diaphragm.

S2發(fā)生于主動脈瓣和肺動脈瓣關(guān)閉時。正常情況下，主動脈瓣關(guān)閉早于肺動脈瓣（A2先于P2)，S2分裂在吸氣末最大，呼氣末最小。這種現(xiàn)象反映了與A2相對衡定對應(yīng)的P2潛在運(yùn)動性。吸氣期間，右室充盈增加，P2延遲，導(dǎo)致泛分裂S2。呼氣期間，右室充盈減少，P2對A2“關(guān)閉”，導(dǎo)致S2分裂降低。在心律沒有明顯加速的情況下，30歲以下的個體中可始終見到這種S2“正常分裂”，在肺動脈區(qū)上方鑒別得最清楚，鐘式聽診器或膈膜式聽診器都能聽到。

(1) Fixed splitting of S2. The most common abnormality Of S2 is failure of splitting to close at the end of expiration. This "fixed splitting" occurs for either of two reasons: 1>2 is delayed or A2 is early. A split of S2 on expiration may also represent a normal variant. In the latter setting, however, some difference in the degree of split should occur between inspiration and expiration.

（1) S2的固定分裂 S2最常見的異常是分裂未能在呼氣末關(guān)閉。這種“固定分裂”的發(fā)生不是由于P2延遲，就是由于A2較早。呼氣時S2的分裂也可以是一種正常變數(shù)。不過，在后者情況下，應(yīng)在吸氣和呼氣之間出現(xiàn)某種分裂程度上的差異。

Fixed splitting of S2 due to delayed P2 is found in four clinical settings: acute right-heart pressure overload (e.g., pulmonary embolism), right bundle branch block, atrial septal defect (ASD), and pulmonic stenosis.

由延遲P2引起的S2固定分裂見于下例四種臨床環(huán)境：急性右心壓力過載（如肺栓塞)、右束支傳導(dǎo)阻滯、房間隔缺損、肺動脈瓣狹窄。

(2) Paradoxical splitting of S2. Paradoxical splitting of S2 is said to be present when S2 splits on expiration and closes on inspiration. Although fixed splitting denotes delay in normal closure of the pulmonic valve, paradoxical splitting denotes delayed closure of the aortic valve. This important clinical sign never occurs in the absence of cardiac disease. The most common states in which paradoxical splitting is encountered are aortic stenosis and left bundle branch block. Paradoxical splitting takes place in about 25% of individuals with these conditions.

（2) S2逆分裂 第二心音逆分裂據(jù)稱是在S2呼氣分裂、吸氣關(guān)閉時出現(xiàn)的。固定分裂表明肺動脈瓣正常關(guān)閉的延遲，逆分裂則表明主動脈瓣關(guān)閉已經(jīng)延遲。在無心臟病患者中決不會出現(xiàn)這種重要的臨床癥狀。在主動脈瓣狹窄和左束支傳導(dǎo)阻滯中，逆分裂見得最多，此類病人有25％會發(fā)生逆分裂。

Paradoxical splitting may occur in patients with coronary artery disease or hypertension or both. In these individuals a closely split S2 may be observed to close to a single sound at midinspiration. A similar finding is often made in early stages of aortic stenosis or in incomplete leil bundle branch block.

冠狀動脈病人或高血壓病人或兩者兼而有之的病人可能發(fā)生逆分裂。在這些病人中，觀察到的S2分裂銜接得很緊密，以致只能在吸氣中段聽到一個聲音。在主動脈瓣狹窄早期或完全左束支傳導(dǎo)阻滯病人中經(jīng)常會發(fā)現(xiàn)類似的檢查結(jié)果。

Alterations in the intensity of S2 can also yield important clinical information. A2 is frequently decreased in aortic stenosis. The presence of a normal A2 when aortic stenosis is clinically suspected raises the question of outflow obstruction at a site other than the valve. P2 may be augmented in pulmonary hypertension and diminished in pulmonic stenosis. Finally, P2 may appear unusually loud in thin-chested individuals without cardiac disease. A summary of clinical information derived from alterations in S2 is found in Table 1-5.

S2強(qiáng)度變化也可為我們提供重要的臨床信息。主動脈瓣狹窄病人的A2通常降底，臨床懷疑有主動脈瓣狹窄的病人如出現(xiàn)正常A2，則提示某一部位而非該瓣膜有流出道梗阻問題。肺動脈高血壓可加劇P2，肺動脈瓣狹窄時則P2減輕。無心臟疾病的薄胸個體，P2可能會顯得異常之大。S2變化情況見表1-5。

3. S3. The third heart sound (S3, or ventricular gallop) is low-pitched and best heard at the apex with the stethoscope bell. The S3 is probably the result of rapid filling and stretching of an abnormal left ventricle. The cadence of the S3 has been likened to the y in Kentucky. An S3 may be heard in any condition resulting in rapid ventricular filling. It is frequently an early sign of left ventricular failure. Third heart sounds may also be present in atrial septal defect, mitral or aortic insufficiency, ventricular septal defect, and patent ductus arteriosus. An S3 can also be a normal variant, particularly in young adults. A loud, early diastolic sound is often heard in constrictive pericarditis. This "pericardial knock" may be mistaken for an S3.

3、S3 第三心音，又叫室性奔馬律，低音調(diào)，用鐘式聽診器在心尖處聽得最清楚。S3很可能是異常左室快速充盈和擴(kuò)張的結(jié)果。導(dǎo)致心室快速充盈的任何病癥都可以聽到S3。它常常是左室衰竭的一個早期癥狀。房間隔缺損、二尖瓣或主動脈瓣關(guān)閉不全、室間隔缺損及動脈導(dǎo)管示閉等患者也可出現(xiàn)第三心音。限制性心包炎病人經(jīng)�？陕牭巾懥恋脑缙谑鎻堃簟＿@種“心包叩擊音”可以被誤診為S3。

4. S4. The fourth heart sound (S4, atrial gallop, presystolic gallop) is also the result of altered ventricular compliance. Its cadence has been likened to the soft a of appendix. It is a low-pitched sound, best heard with the stethoscope bell. It is loudest at the apex and may be accentuated by placing the patient in the left lateral decubitus position. The presence of an S4 implies effective atrial contraction; it is never heard in atrial fibrillation. An S4 may be heard in any condition causing reduced ventricular compliance: aortic stenosis, systemic or pulmonary hypertension, coronary artery disease, hypertrophic cardiomyopathy, acute mitral regurgitation, and myocardial infarction.

4、S4 第四心音，又叫房性奔馬律，收縮期前奔馬律，也是心室順應(yīng)性改變的結(jié)果。其音為低音調(diào)，用鐘式聽診器聽得最清楚。心尖部位最響亮，病人處左側(cè)臥位時聽得最清楚。S4的出現(xiàn)意味著心房收縮好，房性纖顫病人無S4。引起室順應(yīng)性降低的病癥都可聽到S4，如：主動脈瓣狹窄、系統(tǒng)性或肺動脈高血壓、冠狀動脈疾病及心肌梗死。