Percussion
Dr. Laszlo Jakab
Technique
the pleximeter finger
hyperextension of the middle finger of the
left hand
its DIP joint press firmly
avoid contact by other part of the hand →
→ decrease of vibrations
the plexor finger
right middle finger→ partially flexed
tip of the plexor finger strikes the pleximeter finger
Technique
transmission of vibrations → through
the bones of DIP joint → to the
underlying chest wall
movement of the wrist
thick chest wall → heavier percussion
strike 2x in 1 location
percussion → audible sounds ←
motion of the chest wall
Technique
underlying tissues
air-filled
fluid-filled
solid
penetration → 5-7cm into the chest
deep-seated lesions → undetected
Medical percussion sounds
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NORMAL PERCUSSION SOUNDS
Resonance: heard over lung tissue
Tympany: heard over most portions of the
abdominal cavity
Dullness: heard over solid organs (eg, liver) and
muscles
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ABNORMAL PERCUSSION SOUNDS
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Lung: dullness, which may be produced by pneumonia,
tumor, infarction, or fluid collection;
hyperresonance or even tympany, which may result
from confluent air collection, as seen in pneumothorax
or emphysema
Abdomen: dullness, which may be produced by
intra-abdominal tumors or masses; shifting dullness
may indicate presence of ascites
Heart: an expanded area of dullness may indicate
cardiomegaly or pericardial effusion
The Posterior Chest
Percussion → compare one side with other
symmetrical areas
sitting position
undress to the waist
apex → base
omit the scapular areas ← thick
musculosceletal structures
normal lung percussion → resonance →
→ intensity: loud, pitch: low, duration: long
emphysema (lungs are hyperinflated) percussion →
→diffuse hyperresonance
→ intensity: very loud, pitch: lower, duration: longer
The Posterior Chest
Abnormal dullness
fluid in the pleural space = pleural effusion
hemothorax (blood), empyema (pus)
solid tissue in the lung → lobar pneumonia
alveoli filled with fluid, RBC, WBC
Unilateral hyperresonance
large air-filled bulla in the lung or large
amount of air in the pleural space
The Posterior Chest
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Identification of the level of diaphagmatic
dullnes
percussion: apex → base
resonance→ dullness = diaphragm
abnormally high level→ diaphragmatic
paralysis
Diaphragmatic excursion
distance between levels of dullness
on full exspiration
on full inspiration
5-6 cm
Summary
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Normal case:
percussion note → resonant
tactile fremitus → normal
Lobar pneumonia (bacterial infection,
alveoli filled)
percussion note → dull over the airless area
tactile fremitus → increased
Pleural effusion (fluid accumulates and separates the
ai-filled lung from the chest wall and blocks the
transmission of the sound)
percussion note → dull over the fluid
tactile fremitus → decreased
The Posterior Chest
 Ptx
air in the pleural space → blocks the
transmission of the sounds
percussion note → hyperresonant or
tympanic over the pleural air
tactile fremitus → decreased or absent
over the pleural air
The Anterior Chest
supine position
compare both sides
dullness behind the right breast → right
middle lobe pneumonia
identification of the upper border of liver
dullness
The Heart
supine position
estimation of cardiac size
percussion: lung resonance → cardiac
dullness
percuss for the right, left and upper
border
left border → LV
right border → RA
The Abdomen
relaxed patient
supine position
full exposure
warm hands
stand on patient´s right side
The Abdomen
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Orientation
4 quadrants
percussion
tympany predominates → gastric air
bubble, gas in the GI tract
dullnes → each side solid structures
(liver, spleen)
suprapubic area → distended
bladder, enlarged uterus
Traube's space
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Anatomical boundaries are:
1. Right : Lateral margin of left lobe of liver.
2. Left : Spleen.
3. Superior : Resonance of lung.
4. Inferior : Costal margin.
Contents
1. Fundus of stomach (Hence percussion of Traubes area normally
gives Tympanitic resonance).
2. Costo-phrenic recess of left pleura devoid of lungs.
Causes of obliteration of Traubes space:
1. Full stomach.
2. Left sided Pleural effusion.
3.Splenomegaly.
4. Enlargment ofleft lobe of liver due to any etiology.
5. Dextrocardia.
6. Proloiferative growth in fundus of stomach.
The Liver
liver dullness
vertical span = height
in cm
in the right midclavicular line
lung resonance → upper border of liver dullness
tympany → lower border of liver dullness
increased span → enlarged liver
=hepatomegaly
decreased span → small liver
liver dullness disappears → free air present
below the diaphragm → sign of perforation
The Spleen
posterior to the midaxillary line
splenic dullness → oval area
surroundings
pulmonary resonance
abdominal tympany
enlarged spleen = splenomegaly
→ large dull area
Ascites
protuberant abdomen
ascites fluid → sinks with the gravity
percussion → dullness outward →
central tympanic area
shifting dullnes
patient turns onto one side →
dullness shifts
fluid wave
impulse transmitted through the fluid