物理诊断学：心音听诊1

AuscultationofHeartSounds

心音听诊normalheartsoundsabnormalheartsoundssplittingofheartsoundsextraheartsounds正常心音异常心音心音分裂额外心音NormalHeartSounds

正常心音

originationofheartsounds

心音产生机制

differencesbetweenS1&S2

第一心音和第二心音的区分OriginationofHeartSounds

心音产生Systole收缩Diastole舒张OccurringofHeartSounds

心音起源S1:causedbytheclosureofthemitralandtricuspidvalvesatthebeginningofventricularsystole

二尖瓣和三尖瓣关闭振动S2:causedbytheclosureofthepulmonaryandaorticvalvesattheendofventricularsystole

主动脉瓣和肺动脉瓣关闭振动S3:causedbybloodfillingventricleimmediatelyafteropeningoftheAVvalves

舒张早期心室壁振动S4:causedbythesystoleoftheatrium

舒张晚期心房收缩振动FirstHeartSound,S1

第一心音Signalingthebeginningofsystole.

提示收缩期开始Ithascharactersoflowpitch,longduration.

音调低时间长“咚”Itcanbeheardbestintheapexarea.

在心尖部听诊最清楚SecondHeartSound,S2

第二心音Signalingthebeginningofdiastole.

提示舒张期开始Itishigh-pitched,low-intensity,shorterandbrisker.

高调低强度时间短轻脆“嗒”Itcanbeauscultatedbestatthebaseoftheheart.

在心底部听诊最清楚DifferencesBetweenS1&S2

第一心音和第二心音的区分S1

第一心音S2第二心音Pitch音调Low低High高Intensity强度High强Low弱Quality音质Blunter低钝Brisker清脆Duration持续时间Long长Short短Interval两者间隔S1-S2长<S2-S1短Apicalimpulse心尖搏动Concomitant一致Post之后Bestsite最响部位Apex心尖Base心底AbnormalHeartSounds

心音异常changesofintensity强度改变

increase心音增强

decrease心音减弱

changesofquality性质改变

pendulumrhythm钟摆律

fetalheartrhythm胎心律InfluenceFactorofSoundIntensity

强度影响因素Soundproduction心音产生apexpart:valveelasticity,place,movementdegree,raisingspeedofpressurecombinedwithventriclefillingdegreeandcontractingforce

心尖部(S1)瓣膜弹性位置活动度压力上升速度（心室充盈度和收缩力）basepart:valvedisorders,pressureinartery

心底部(S2)瓣膜病变动脉内压力Soundconduction心音传导conductingdistance:pericardium,lungandchestwallthickness

传导距离:心包肺脏胸壁厚度ChangesofS1Intensity

第一心音强度改变Increase:增强mitraland/ortricuspidstenosis二尖瓣狭窄Hyperdynamiccirculatorystatessuchasfever,anemia,hyperthyroidism.

血流加速如发热贫血甲亢ShortingofthePRintervalorcompleteheartblockonECG.

P-R间期缩短或完全房室传导阻滞Decrease:减弱Myocardialdiseases.心肌病Mitraland/ortricuspidregurgitation.二尖瓣关闭不全ProlongationofPRinterval.P-R间期延长Aorticvalvesregurgitation.

主动脉瓣关闭不全心房→瓣膜→心室ChangesofS2Intensity

第二心音强度改变S2hastwoelements,A2andP2.

第二心音分为主动脉瓣第二音和肺动脉瓣第二音A2increase:hypertension,aortosclerosis.

主动脉瓣第二音增强:高血压主动脉硬化P2increase:mitralsternosisorinsufficiency,L.Vfailure,andcongenitalheartdiseaseswithlefttorightshunt.

肺动脉瓣第二音增强:二尖瓣狭窄及关闭不全左心功能不全先天性心脏病左向右分流A2decrease:aorticstenosisorinsufficiency

主动脉瓣第二音减弱:主动脉瓣狭窄及关闭不全P2decrease:pulmonicstenosisorinsufficiency

肺动脉瓣第二音减弱:肺动脉瓣狭窄及关闭不全动脉←瓣膜←心室ChangesofS1andS2IntensitySimultaneously

第一和第二心音强度同时改变Increase:bloodvelocityisincreased,asinanemia,fever,hyperthyroidism,anxiety,andduringexercise.

增强:血流加速如贫血

发热甲亢焦虑和运动Decrease:bloodvelocityisdecreased,asmyocardialdiseases,increasedoverlyingtissue,fat,orfluidobscuresounds.

减弱:血流缓慢如心肌病传导受阻如肺气肿心包积液脂肪增厚ChangesofQuality

心音性质改变ChangesofS1quality:S1sameasS2(blankness)

第一心音性质改变:第一心音与第二心音相同(单调)Diastolicphaseshorten:sameassystolic(singlerule)

舒张时限缩短:收缩期与舒张期时限相同(单律)Characteristic:pendularrhythm,embryocardia

听诊特点:钟摆律胎心律Clinicalmeaning:myocardialdamageseverely,asacutemyocardialinfarction,severemyocarditis.

提示:心肌严重受损如急性心肌梗塞重症心肌炎SplittingofHeartSounds

心音分裂firstheartsoundsplitting

第一心音分裂

secondheartsoundsplitting

第二心音分裂SplittingofFirstHeartSounds

第一心音分裂Areaforauscultation:apicalarea.

部位:心尖部Commondiseases:rightbundlebranchblock,pulmonaryhypertension,rightheartfailure

病因:右束支传导阻滞肺动脉高压右心功能不全SplittingofSecondHeartSounds

第二心音分裂Areasforauscultation:baseofheart

部位:心底部Mechanisms:asynchronybetweenclosureoftheaorticandpulmonicvalves.

机制:主动脉瓣与肺动脉瓣关闭不同步Variations:widesplitting,fixedsplitting,reversedsplitting.

类型:顺分裂固定分裂逆分裂WideSplitting

顺分裂Typicalattheendofinspiration

吸气末分裂明显Physiologicsplitting:deepinspiration

生理分裂:吸气相回右心血量增加Generalsplitting

通常分裂DelayedP2:pulmonaryhypertension,mitralstenosis,pulmonicstenosis,rightbundlebranchblock.

肺动脉瓣关闭延迟:肺动脉高压二尖瓣狭窄肺动脉瓣狭窄右束支阻滞EarlyA2:mitralinsufficiency,IVSD

主动脉瓣关闭提前:二尖瓣关闭不全室间隔缺损INPIRATIONEXSPIRATIONS1S2S1S2A2P2A2P2FixedSplitting

固定分裂Splittingisunaffectedbyrespiration

分裂不受呼吸影响Mechanism:delayedclosureofthepulmonicvalve(outputoftherightventricleisgreaterthanthatoftheleft)

机制:肺动脉瓣关闭延迟Bloodflowfromleftatriumtotherightpassingthroughseptaldefectsamortizedaffectionofrespiration.

房间隔缺损处血液左向右分流缓冲呼吸影响Commondiseases:largeatrialseptaldefectsandrightventricularfailure.

病因:大的房间隔缺损并右心功能不全INSPIRATIONEXPIRATIONS1S2S1S2A2P2A2P2ReversedSplitting

逆分裂Typicalattheendofexpiration

呼气末分裂明显ParadoxicalSplitting:P2occursfirstly,followedbyA2

反常分裂:肺动脉瓣第二音出现在主动脉瓣第二音之前Mechanism:closureoftheaorticvalveisdelayed

机制:主动脉瓣关闭明显延迟Commondiseases:Leftbundlebranchblock,Aorticstenosis.

病因:左束支传导阻滞主动脉瓣狭窄INPIRATIONEXSPIRATIONS1S2S1S2P2A2P2A2ExtraHeartSounds

额外心音

systolicextraheartsounds

收缩期额外心音

diastolicextraheartsounds

舒张期额外心音ExtraHeartSounds

额外心音SystolicEarlysystole:ejectionsoundsMid-/Latesystole:clickDiastolicEarlydiastole:openingsnap,pericardialknockMid-diastole:thirdheartsoundLatediastole:fourthheartsoundgalloprhythm收缩早期喷射音中晚期喀喇音舒张早期开瓣音心包叩击音中期第三心音晚期第四心音奔马律EarlySystoleEjectionSounds

收缩早期喷射音Soundsfromopeningofthesemilunarvalves

半月瓣开放产生的声音Mechanism:bloodflowpassingthroughstenosicvalvesmadevibrationofbloodvesselwallandvalves

机制:瓣膜狭窄时血流引起血管壁和瓣膜振动Areaforauscultation:baseoftheheart

听诊部位:心底部Character:shortandhighpitched,withaclickquality

特点:高调清脆短促Clinicalsignificance:aorticstenosis,pulmonicstenosis

提示:主动脉瓣狭窄肺动脉瓣狭窄MidsystolicClick

收缩中期喀喇音Duringballooningcreatestheclick

瓣叶翻入心房后出现的声音Mechanism:thesuddentensingofthevalveleafletsandthechordiaetendinaemadethevibration

机制:瓣叶和腱索突然拉紧产生振动Areaforauscultation:theapex

听诊部位:心尖部Character:shortandhighpitched,withaclickquality

特点:高调清脆短促Clinicalsignificance:mitralvalveprolapse

提示:二尖瓣脱垂OpeningSnap

开瓣音Mechanism:thedeformedmitralvalveopenswithanoise

机制:开放的二尖瓣突然振动Character:sharpandhighpitched,withasnappingquality

特点:高调清脆短促Areasforauscultation:thethirdorfourthleftinterspaceatthesternalborder,lesswellattheapex

听诊部位:胸骨左缘3,4肋间以及心尖部Clinicalsignificance:mitralstenosis(theelasticityofthevalvemaybefine)

提示:二尖瓣狭窄(瓣膜弹性尚好)PericardialKnock

心包叩击音Mechanism:pericardialincrassationandconglutination,ventriclesuddenstopindiastolicmadewallvibrancy.

机制:心包增厚粘连心室舒张骤停室壁产生振动Character:shortandlowering

特点:低沉短促Areaforauscultation:intheapex

听诊部位:心尖部Clinicalsignificance:pericarditis,pericardialincrassationandconglutination

提示:缩窄性心包炎心包增厚粘连Gallop

奔马律Mechanism:decreasedcomplianceoftheventriclecausedbyseveremyocardialdamage

机制:心肌严重受损致室壁顺应性差Classification:分类Protodiastolicgallop(Ventriculargallop,S3gallop)

舒张早期奔马律(室性奔马律第三心音奔马律)Latediastolicgallop(atrialgallop,S4gallop)

舒张晚期奔马律(房性奔马律第四心音奔马律)Quadruplerhythmandsummationsound

四音律和重叠奔马律Protodiastolicgallop

舒张早期奔马律Mechanism:pathologicalS3Origin:leftventricle,rightventricle

机制:病理性第三心音起源:左室和右室Character:tonelower,intensionfeeble

音调较低强度较弱Areaforauscultation:leftventricleintheapexandloudinexpiratoryend,rightventricleinsternumloweredgeleftsideandloudininspiratoryend.

左室:心尖部最清楚呼气末明显右室:胸骨下端左缘吸气末明显Clinicalsignificance:heartfailure

提示:心力衰竭PhysicalS3&PathologicalS3

生理性与病理性第三心音的区分

NormalS3生理性第三心音PathologicalS3病理性第三心音Individual人群Healthyunderage健康未成年Severeheartdisease严重心脏病HR心率<