What is dullness to percussion

The sound should wax and wane. Loss of tidal percussion: Pleural effusion Hyperinflation such as emphysema from a maximally contracted diaphragm. Major and Minor Fissures of the Lung. The major fissure can be located by drawing a line from the T2 spinous process to where the 6th rib meets the sternum. The minor fissure can be approximated by drawing a horizontal line from the 4th rib attachment of the sternum to the major fissure.

Easier method: Simply ask the patient to put their hands over their head. The scapula will rotate externally and its medial border will outline the major fissure see figure below. Historical Perspective of the Pulmonary Exam. Inspection During the Pulmonary Exam. Use of accessory muscles.

Pursed lips on exhalation provides a small amount of PEEP. Increased AP diameter barrel chest. Normal in infancy and increased with aging. Prominent angle of Louis or sternal angle. Flaring of the lower costal margins.

Dahl Sign: Above the knee, patches of hyperpigmentation or bruising caused by constant 'tenting' position of hands or elbows. Hoover's sign: briefly, during inspiration a paradoxical medial movement of the chest. The "subcostal angle" is the angle between the xiphoid process and the right or let costal margin. Normally, during inhalation the chest expands laterally, increasing this angle.

When the diaphragms are flattened as in COPD , inhalation paradoxically causes the angle to decrease. Consult the Expert. Peadar Noone Dr. Clinical Pearl Insert in a normal individual three fingers vertically in the space under the cricoid cartilage, and above the sternal notch.

As the person breathes in, the space may reduce to two fingers at most i. In a patient with severe hyperinflation, the crico-sternal distance is much shorter because the sternum is elevated , maybe fingers at most. If that doesn't help, please let us know. Unable to load video. Please check your Internet connection and reload this page. If the problem continues, please let us know and we'll try to help. An unexpected error occurred.

Medical percussion is based on the difference in pitch between the sounds elicited by tapping on the body wall. The auditory response to tapping depends on the ease with which the body wall vibrates, and is influenced by underlying organs, strength of the stroke, and the state of the body wall.

There are three main medical percussion sounds: resonance heard over lungs , tympany heard over the air-filled bowel loops , and dullness heard over fluid or solid organs.

The contrast between dullness vs. Percussion remains an intricate part of the physical diagnosis since it was first introduced more than years ago, and is especially useful in examination of the lungs and abdomen. As a part of an abdominal examination, percussion follows visual inspection and auscultation. The examiner should first percuss over each of the nine abdominal regions epigastric region, right hypochondriac region, left hypochondriac region, umbilical region, right lumbar region, left lumbar region, hypogastric region, right inguinal region, and left inguinal region.

Tenderness elicited by percussion is abnormal, and peritoneal inflammation should be suspected. As the air-filled bowel loops are positioned in the closest proximity to the abdominal wall, the percussion over most parts of the abdominal cavity elicits a predominantly tympanic sound.

The presence of large areas of dullness should prompt evaluation for organomegaly, intra-abdominal masses, or fluid. In addition to assessing the amount and distribution of abdominal gas, an abdominal exam should include an estimation of liver and spleen size by percussion. As the liver and spleen are covered by the rib cage, the examiner should percuss over the lower anterior chest as well.

Normally, one expects to hear dull sound on percussion of the right anterior chest over the liver, and tympanic sound on percussion of left anterior chest over the gastric air bubble and the splenic flexure of the colon Figure 1.

Figure 1. Normal percussion notes over abdominal region. With the exception of an area of dullness over the liver in the right lower anterior chest, tympany is the predominant sound heard over the region. Increased liver span on percussion indicates an enlarged liver, which can underlie a variety of pathological processes. It is essential to identify both the lower and the upper borders of the liver dullness to distinguish between an enlarged liver which has an increased span , and a liver displaced downwards as a result of chronic obstructive pulmonary disease in which case the liver span is normal.

The spleen is located slightly posterior to the left midaxillary line and produces an oval area of dullness between the 9 th and 11 th ribs. Only a small surface of a normal spleen is superficial enough to be detected, and the splenic dullness is often obscured by gastric or colonic tympany.

Percussion is helpful to diagnose the causes of a protuberant abdomen. Tympany over a protuberant abdomen indicates air accumulation that could be due to an intestinal obstruction. When percussion over the flanks of a protuberant abdomen produces a dull note, it is consistent with fluid accumulation or ascites. Figure 2. Shifting dullness test. If ascites is present, the point at which tympany changes to dullness over the abdominal flanks is shifted upward towards the umbilicus when the patient is in lateral decubitus position.

Percussion is a critical part of the abdominal examination; therefore, learning the correct technique is essential for any physician aiming to make quick, yet accurate diagnosis of gastrointestinal pathologies. As you might know, medical percussion is based on the difference in pitch between the sounds elicited by tapping on the body wall.

The sounds produced during abdominal percussion can help detect pathologies like organomegaly, intra-abdominal masses, and fluid accumulation. This video will illustrate the major anatomical areas to be percussed during an abdominal exam, and the steps and findings of this procedure.

First, let's talk about the expected abdominal percussion sounds and their interpretations. As the air-filled bowel loops are positioned in the closest proximity to the abdominal wall, percussion over most parts of the abdominal cavity elicits a predominantly tympanic sound… Notice that this sound is relatively long, high pitched, and loud.

Percussion over dense organ tissues, like the spleen or the liver, produces a dull sound… Therefore, the contrast between dullness versus tympany allows for determination of the margins of these organs and thus help in detection of conditions like hepatomegaly or splenomegaly.

Dull sounds are also produced on percussing areas filled with fluid and feces. Therefore, by percussing one can predict the cause of protuberant abdomen, which helps in diagnosis of conditions like ascites.

With this background in mind, let's review a detailed step-wise procedure for abdominal percussion. Explain the procedure to the patient and obtain their consent before starting with the exam. Drape the patient appropriately to expose the torso area and perform light percussion over each of the nine abdominal regions. Listen to the intensity, pitch, and duration of the percussion note. Normally, tympanic sound produced by air in the bowel loops will be heard As you percuss, watch the patient's face for any signs of discomfort.

Ask the patient if they are experiencing any tenderness. Tenderness on percussion is abnormal and can indicate peritoneal inflammation. After abdominal area, percuss the lower anterior chest, above the costal margins. Dull sound on the right, over the liver is expected On the left, one should hear tympany over the gastric air bubble and the splenic flexure of the colon Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors.

Hyperresonant sounds that are louder and lower pitched than resonant sounds are normally heard when percussing the chests of children and very thin adults. Hyperresonant sounds may also be heard when percussing lungs hyperinflated with air, such as may occur in patients with COPD, or patients having an acute asthmatic attack.

An area of hyperresonance on one side of the chest may indicate a pneumothorax. Tympanic sounds are hollow, high, drumlike sounds. Tympany is normally heard over the stomach, but is not a normal chest sound.

Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax.