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心臓と頚動脈の疾患

心臓と頚動脈の疾患

・心臓の聴診をするときにどこをみている?

頚動脈波形
右心系の以上で、よくわかる!
 例えば、S2の弱いはずなのに、高くなったり

 肺高血圧とか、逆流とか

三尖弁閉鎖不全。 Vの法が大きくなる!

・Abdojuglar test
心不全、三尖弁逆流のある患者で
Vの増高みられる
肝下部の圧迫で、頚静脈波形の上端が上昇
圧迫解除で「4cm以上下降」する
LR 8.0  …左房圧上昇に対して

CVPに関しては、外頚静脈でも十分

胸骨角
 どの角度でも、右房から5cm
 →そこから何センチあるか? でCVP分かる →正常はほぼ鎖骨

心不全、肺炎の差は、首を見ればよく分かる
ストレッチャーで斜めで、外頚静脈が見えるか否か、でOK!

◆ただ、あくまでも右心系の情報
左心不全では、はらないこともある

→喘息か心不全の鑑別には、基本役に立つけれど
 心不全なら、吸気時にも静脈ひっこまない

・カテーテルCVP と、 外頚静脈CVP はよく相関
 経験が少ない医師ほど、特異度高い

見えたら意味がある

外頚静脈
 臥位でもまったく見えなかったら、虚脱!! 異常!

・67歳上大静脈症候群 …肺癌
  →怒張は強いけれど、拍動見えない

・82歳男性 呼吸困難
  外頚静脈怒張している
  心不全なら冷や汗あるがない…
   →緊張性気胸だった!

・フラッターも、頚静脈で細かい振動が裏に見える!

・心尖拍動
 鎖骨中線よりも内側にあるのが普通
 振戦拍動も大きくなる 28mmが基準 二つの肋間で触れたら異常
  EF<50% とLR 5〜6
 振戦拍動がゆっくり盛り上がるのは、心機能が悪い
   普通はタッピング、なのがへん
   大動脈弁逆流とかさなっていたら LR 4.1
   雑音無ければ心筋症の所見

・Double impulus
 
押さえつけてものこるのは、S4ではない →分裂
 …右脚ブロック

左脚ブロックは、左心系のおとが遅れる
 吸気時(幅広い)と呼気時(幅狭い)

・補助呼吸筋の使用、慢性呼吸不全の証明
 …心不全だったら、無い
  通常の呼吸不全では胸鎖乳突筋使わない

・BNP のたかさはLR 10
 術前S3 は、術後の合併症はLR 14.6とかある

・胸が痛い
 77歳 4日前から胸が痛い
 帯状疱疹、皮疹よりも痛みが先行することがある

・乳房の下に索状のものが触れる 59歳女性
 38歳男性 腕を挙げると線が出る、索状の線がふれることがある
 Mondor病
  皮下の静脈炎 原因は不明 
   エコーで見つかることある


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