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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