PercussionPercussionDr. Laszlo JakabDr. Laszlo Jakab

TechniqueTechnique

the pleximeter fingerthe pleximeter fingerhyperextension of the middle finger of thehyperextension of the middle finger of the

left handleft handits DIP joint press firmlyits DIP joint press firmlyits DIP joint press firmlyits DIP joint press firmlyavoid contact by other part of the hand →avoid contact by other part of the hand →

→ decrease of vibrations→ decrease of vibrationsthe plexor fingerthe plexor finger

right middle finger→ partially flexedright middle finger→ partially flexedtip of the plexor finger strikes the pleximeter fingertip of the plexor finger strikes the pleximeter finger

TechniqueTechnique

transmission of vibrations → through transmission of vibrations → through the bones of DIP joint → to thethe bones of DIP joint → to theunderlying chest wallunderlying chest wall

movement of the wristmovement of the wristmovement of the wristmovement of the wristthick chest wall → heavier percussionthick chest wall → heavier percussionstrike 2x in 1 locationstrike 2x in 1 locationpercussion → audible sounds ← percussion → audible sounds ← motion of the chest wallmotion of the chest wall

TechniqueTechnique

underlying tissuesunderlying tissuesairair--filledfilledfluidfluid--filledfilledsolidsolidsolidsolid

penetration → 5penetration → 5--7cm into the chest7cm into the chestdeepdeep--seated lesions → undetectedseated lesions → undetected

Medical percussion soundsMedical percussion sounds

�� NORMAL PERCUSSION SOUNDSNORMAL PERCUSSION SOUNDS�� Resonance: Resonance: heard over lung tissueheard over lung tissue�� Tympany: Tympany: heard over most portions of theheard over most portions of the�� abdominal cavityabdominal cavity�� Dullness: Dullness: heard over solid organs (eg, liver) andheard over solid organs (eg, liver) and�� musclesmuscles�� ABNORMAL PERCUSSION SOUNDSABNORMAL PERCUSSION SOUNDS�� ABNORMAL PERCUSSION SOUNDSABNORMAL PERCUSSION SOUNDS�� Lung: Lung: dullnessdullness, which may be produced by pneumonia,, which may be produced by pneumonia,�� tumor, infarction, or fluid collection;tumor, infarction, or fluid collection;�� hyperresonance hyperresonance or even or even tympanytympany, which may result, which may result�� from confluent air collection, as seen in pneumothoraxfrom confluent air collection, as seen in pneumothorax�� or emphysemaor emphysema�� Abdomen: Abdomen: dullnessdullness, which may be produced by, which may be produced by�� intraintra--abdominal tumors or masses; abdominal tumors or masses; shifting dullnessshifting dullness�� may indicate presence of ascitesmay indicate presence of ascites�� Heart: Heart: an expanded area of an expanded area of dullness dullness may indicatemay indicate�� cardiomegaly or pericardial effusioncardiomegaly or pericardial effusion

The Posterior ChestThe Posterior ChestPercussion → compare one side with otherPercussion → compare one side with other

symmetrical areassymmetrical areassitting positionsitting positionundress to the waistundress to the waistapex → baseapex → baseomit the scapular areas ← thick omit the scapular areas ← thick

musculosceletal structuresmusculosceletal structuresmusculosceletal structuresmusculosceletal structures

normal lungnormal lung percussion →percussion → resonanceresonance →→

→ intensity: loud, pitch: low, duration: long→ intensity: loud, pitch: low, duration: longemphysemaemphysema (lungs are hyperinflated) percussion → (lungs are hyperinflated) percussion →

→→diffuse hyperresonance diffuse hyperresonance → intensity: very loud, pitch: lower, duration: longer→ intensity: very loud, pitch: lower, duration: longer

The Posterior ChestThe Posterior Chest

Abnormal dullnessAbnormal dullnessfluid in the pleural space = pleural effusionfluid in the pleural space = pleural effusion

hemothorax (blood), empyema (pus)hemothorax (blood), empyema (pus)solid tissue in the lung → lobar pneumoniasolid tissue in the lung → lobar pneumoniasolid tissue in the lung → lobar pneumoniasolid tissue in the lung → lobar pneumonia

alveoli filled with fluid, RBC, WBCalveoli filled with fluid, RBC, WBCUnilateral hyperresonanceUnilateral hyperresonance

large airlarge air--filled bulla in the lung or large filled bulla in the lung or large amount of air in the pleural spaceamount of air in the pleural space

The Posterior ChestThe Posterior Chest

�� Identification of the level of diaphagmatic Identification of the level of diaphagmatic dullnesdullnes

percussion: apex → basepercussion: apex → baseresonance→ dullness = diaphragmresonance→ dullness = diaphragmabnormally high level→ diaphragmatic abnormally high level→ diaphragmatic abnormally high level→ diaphragmatic abnormally high level→ diaphragmatic

paralysisparalysis�� Diaphragmatic excursionDiaphragmatic excursion

distance between levels of dullnessdistance between levels of dullnesson full exspirationon full exspirationon full inspirationon full inspiration55--6 cm6 cm

SummarySummary

�� Normal case:Normal case:percussion note → resonantpercussion note → resonanttactile fremitus → normaltactile fremitus → normal

�� Lobar pneumoniaLobar pneumonia (bacterial infection, (bacterial infection, alveoli filled)alveoli filled)

percussion note → percussion note → dulldull over the airless areaover the airless areapercussion note → percussion note → dulldull over the airless areaover the airless areatactile fremitus → tactile fremitus → increasedincreased

�� Pleural effusionPleural effusion (fluid accumulates and separates the (fluid accumulates and separates the aiai--filled lung from the chest wall and blocks the filled lung from the chest wall and blocks the transmission of the sound)transmission of the sound)

percussion note → percussion note → dulldull over the fluidover the fluidtactile fremitus → tactile fremitus → decreaseddecreased

The Posterior ChestThe Posterior Chest

�� PtxPtxair in the pleural space → blocks the air in the pleural space → blocks the

transmission of the soundstransmission of the soundspercussion note → hyperresonant or percussion note → hyperresonant or percussion note → hyperresonant or percussion note → hyperresonant or

tympanic over the pleural airtympanic over the pleural airtactile fremitus → decreased or absent tactile fremitus → decreased or absent

over the pleural airover the pleural air

The Anterior ChestThe Anterior Chest

supine positionsupine positioncompare both sidescompare both sidesdullness behind the right breast → right dullness behind the right breast → right

middle lobe pneumoniamiddle lobe pneumoniamiddle lobe pneumoniamiddle lobe pneumoniaidentification of the upper border of liver identification of the upper border of liver

dullnessdullness

The HeartThe Heart

supine positionsupine positionestimation of cardiac sizeestimation of cardiac sizepercussion: lung resonance → cardiac percussion: lung resonance → cardiac

dullnessdullnessdullnessdullnesspercuss for the right, left and upper percuss for the right, left and upper

borderborderleft border → LVleft border → LVright border → RAright border → RA

The AbdomenThe Abdomen

relaxed patientrelaxed patientsupine positionsupine positionfull exposurefull exposurewarm handswarm handswarm handswarm handsstand on patientstand on patient´́s right sides right side

The AbdomenThe Abdomen

�� OrientationOrientation4 quadrants4 quadrantspercussionpercussiontympany predominates → gastric air tympany predominates → gastric air tympany predominates → gastric air tympany predominates → gastric air bubble, gas in the GI tractbubble, gas in the GI tractdullnes → each side solid structures dullnes → each side solid structures

(liver, spleen)(liver, spleen)suprapubic area → distended suprapubic area → distended

bladder, enlarged uterusbladder, enlarged uterus

Traube's spaceTraube's space

�� Anatomical boundaries are:Anatomical boundaries are:

1. Right : Lateral margin of left lobe of liver.1. Right : Lateral margin of left lobe of liver.2. Left : Spleen.2. Left : Spleen.3. Superior : Resonance of lung.3. Superior : Resonance of lung.4. Inferior : Costal margin.4. Inferior : Costal margin.

ContentsContentsContentsContents

1. Fundus of stomach (Hence percussion of Traubes area normally 1. Fundus of stomach (Hence percussion of Traubes area normally gives Tympanitic resonance).gives Tympanitic resonance).2. Costo2. Costo--phrenic recess of left pleura devoid of lungs.phrenic recess of left pleura devoid of lungs.

Causes of obliteration of Traubes space:Causes of obliteration of Traubes space:1. Full stomach.1. Full stomach.2. Left sided Pleural effusion.2. Left sided Pleural effusion.3.Splenomegaly.3.Splenomegaly.4. Enlargment ofleft lobe of liver due to any etiology.4. Enlargment ofleft lobe of liver due to any etiology.5. Dextrocardia.5. Dextrocardia.6. Proloiferative growth in fundus of stomach. 6. Proloiferative growth in fundus of stomach.

The LiverThe Liver

liver dullnessliver dullnessvertical span = heightvertical span = height

in cmin cmin the right midclavicular line in the right midclavicular line

lung resonance → upper border of liver dullnesslung resonance → upper border of liver dullnesslung resonance → upper border of liver dullnesslung resonance → upper border of liver dullnesstympany → lower border of liver dullnesstympany → lower border of liver dullnessincreased span → enlarged liver increased span → enlarged liver

=hepatomegaly=hepatomegalydecreased span → small liverdecreased span → small liverliver dullness disappears → free air present liver dullness disappears → free air present

below the diaphragm → below the diaphragm → sign of perforationsign of perforation

The SpleenThe Spleen

posterior to the midaxillary lineposterior to the midaxillary linesplenic dullness → oval areasplenic dullness → oval areasurroundingssurroundings

pulmonary resonancepulmonary resonancepulmonary resonancepulmonary resonanceabdominal tympanyabdominal tympany

enlarged spleen = splenomegaly enlarged spleen = splenomegaly → large dull area→ large dull area

AscitesAscites

protuberant abdomenprotuberant abdomenascites fluid → sinks with the gravityascites fluid → sinks with the gravitypercussion → dullness outward → percussion → dullness outward →

central tympanic areacentral tympanic areacentral tympanic areacentral tympanic areashifting dullnesshifting dullnes

patient turns onto one side → patient turns onto one side → dullness shiftsdullness shifts

fluid wavefluid waveimpulse transmitted through the fluidimpulse transmitted through the fluid