PERCUSSION

AUSCULTATION

Emese Mihaly MD, PhD Semmelweis University

2nd Department of Internal Medicine

Palpation

Tenderness

Mass or swelling

Position of the trachea

Tactile fremitus

Chest expansion

Tenderness

Inflamed pleura

Injury of the chest

Intercostal muscular pain

Herpes Zoster

Rib fracture

Pleurosy

Mass/swelling

Tumor

Rubor

Calor

Functio laesa

Site/surface /consistency/size/mobility

Trachea position

Normally: on midline, may slightly deviate to

the right

Abnormal:

Deviation to the same side: lung collapse or

fibrosis

Diveation to the opposite side: PTX, pleural

effusion

No tracheal deviaton in lung consolidation

Tactile (Pectoral) Fremitus

Palpable vibrations transmitted

through the broncho-pulmonary tree

from the larynx to the chest wall

Ask the patient to say: 99/HUN33

Palpate and compare symmetrical

areas

For presence or absence of simmetry

of TF

Tactile (Pectoral) Fremitus

TF Increased: lung consolidation

lung fibrosis

TF Decreased or missing:

Hydrothorax

Pleural thickening

PTX

Chest expansion

Chest expansion

Place the fingertips of both hands on either

side of the lower chest so that the tips of the

thumbs meet in the mid line

Ask the patient to breath deeply

If on thumb remains closer to the mid line

indicates that there is a diminished

expannsion of the chest on the same side

In healthy man > 5cm

In emphysema < 1 cm

Percussion

First used by Avicenna, Ibn Sina,

(980-1030)

One of the greatest intellects of

Islam’s Golden Age

Best known for his contributions to

medicine

His works, after being translated

into Latin became deeply influential

in Medieval and renaissance

Europe.

Percussion Direct percussion:

to perform direct percussion, tap directly on

the patient's skin

tapping movement should originate from your

wrist, not your elbow

best for percussing the paranasal sinuses.

Indirect percussion

Two fingers: pleximeter and striking finger

Used for most parts on the body

Percussion

Method of tapping on a surface to determine

the underlying structure

To assess the condition of the thorax or

abdomen

Hyperextend the middle finger of one hand

and place firmly against the patient’s chest

(nonstriking finger, pleximeter)

With the tip of the opposite middle finger use

a quick flick of the wrist to strike the first

finger

Percussion

Percussion

Percuss simmetrical areas of both sides

From upper to lower part

From left to the right

And from right to the left

Find the level of diaphragmatic dullness on both sides

Percussion

There are four types of percussion sounds:

resonant, hyper-resonant, stony dull or dull.

Dull sound indicates the presence of a solid

mass under the surface, pleural effusion.

Resonant sound indicates hollow, air-

containing structures.

Hyper-resonant sound: emphysema

Tympanic sound if there is a pneumothorax

Diaphragmatic excursion

Percuss along the scapular line until the level of the diaphragmatic dullness

Ask the patient to inspire deeply and hold his breath

Proceed to percuss down from the marked point to determine the diaphragmatic excursion in deep inspiration

Repeat on the opposite side

Measure the distance between the upper-lower points on each side

Normally is 3-5 cm bilaterally (symmetrically)

Auscultation

Breath sounds

Added-adventitious- sound

Vocal resonance

Auscultation Normal breathing sound:

Over the lung tissue: vesicular-soft and low

pitched

Over the trachea: tracheal-loud, high pitched

Over the manubrium: bronchial- loud, high

pithced

Between the scapulae, and 1st-2nd interspace:

bronchovesicular-inter mediate intensity and

pitch

Air entry-Intensity

Normal

Decreased / absent:

Pleural effusion, PTX

Increased: Consolidation

Vocal resonance

Bronchophony: Ask patient to say 99 while auscultating the

chest wall

Normally the sound is muffled and indistinct

In pneumonia: normal speech is heard clearly

Vocal resonance

Egophony:

Ask the patient to say „ee” continuously

Ausculatate symmetrical areas

Mulffled EE sound should be head

If „ee” is heard as „ay” , change „E-A”

refers to consolidation

Vocal resonance

Whispered Pectoriloquy: Ask patient to whisper 99

Auscultate symmetrical areas

Whispered sound is normally heard faintly or

indistinctly

When louder and clearer whispered sound

are heard: whispreded pectoriloquy-refers to

consolidation

Added-adventitious sounds

Crackles/rales

Wheezes/ronchi

Pleural friction rub

Stridor

Added sounds Atypical-added, adventitious-sounds

Superimposed on breath sounds

Are not alterations in breath sounds

Patient should clear his or her secretion

Crepitation: short, discrete, interrupted crackling

sound at the end of inspiration

Fine crackles: soft, high pitched, brief 5-10

msec/fibrosing alveolitis, congestive heart failure

Course crackles: louder, lower in pitch, 20-30

msec-bronchiectasis

Added sounds Ronchi

Continuous sounds produced by the movements of air in the

presence of free fluid in the airway lumen

Wheezes

Often audible at the mouth as well at the chest wall

More prominent during expiration than inspiration

Oscillation of airway walls that occurs when there is airflow

limitation

Stridor: Interily or predominantly inspiratory

Louder in the neck

Due to larynx or trachea obstruction, demands immediate

attention (foreign body, epiglottitis, external obstruction)

Pleural friction rub

Creaking noise like to that emitted by

compression of new leather

Indicates inflammed pleural surfaces rubbing

against each other

Heard in both respiratory cicles (insp and exp)

Pleurisy from adjacent pneumonia, pulmonary

infaction or tbc

Confined to relatively small area of the chest

Pneumonia

Hydrothorax

Ellis-Damoiseau line

Inspection

Careful inspection of the anterior chest may reveal the location of the apical impulse

Systolic retraction at the site of apical impulse indicates pericardial accretio (a form of adhesive pericarditis in which adhesions extend from the pericardium to the chest wall)

Percussion of the heart

Heart borders

1. Lower border: percussion the position of the diaphragma on the right side. 5-6th interspace in the midclavicular line.

2. Right border: does not exceed the right border of the sternum.

3. Upper border: 3d interspace parasternally on the left side

4. Left border: 7-9 cm from the midline

Heart sounds

Closure of the mitral and tricuspid valve

produces the first heart sound (S1).

Aortic and pulmonary valve closure

produces the second heart sound (S2).

Normally, the mitral valve closes just prior

to the tricuspid valve. Thus, M1 is audible

before T1 (a difference that is often not

detectable). If this difference is more

prominent=Split S1.

Thank You!