Percussion, auscultation

Dr. Szathmári Miklós

Semmelweis University

First Department of Medicine

21. Sept. 2015

The physical principles of the

percussion

• Percussion sets the body surface (chest wall) and underlying tissues into motion.

• The motion of the surface and underlying tissues produce audible sounds and palpable vibration

• Helps to determine whether the underlying tissues are:

– Air-filled

– Fluid-filled

– Solid

organs give rise to sounds of different

- loudness (intensity)

- pitch (high or low)

- duration

These differences in sound quality allow

- to establish organ size (boundaries ) = topographic

percussion

- to recognize abnormal formations (fluid, growth etc,) =

comparative percussion

- to check movements of organs and abnormal formations

The sound quality of percussion depends on

- the mode of percussion

- air contents of the organ

- the elasticity of the superficial structures

The aims of the percussion

I. On percussion, air-filled organs (abnormal formations, lesions etc.) give rise to

• resonant sound if tissues (structures) are present;

• this may become hyperresonant when the amount of tissue decreases;

• tympanic sound if only air is present

II. On percussion, solid organs(abnormal formations, lesions etc.) give rise to

• flat sound if they are close to the surface

• dull sound if they are not immediately beneath the surface;

Percussion notes and their

characteristics

Percussion notes and their characteristics

Relative

intensity

Relative pitch Relative

duration

Example location Pathologic examples

Flatness Soft High Short Thigh Large pleural effusion

Dullness Medium Medium Medium Liver Lobar pneumonia

Resonance Loud Low Long Normal lung Bronchitis

Hyper-

resonance

Very loud Lower Longer None normal Emphysema

Tympany Loud High Musical

timbre

Gastric air bubble Large pneumothorax

The technique of percussion

• Hyperextend the middle finger of your left hand

• Press its distal interphalangeal joint firmly on the surface to be percussed. Avoid contact by any other part of the hand.

• The right middle finger should be partially flexed, relaxed, and poised to strike.

• With a quick, sharp, but relaxed wrist motion, strike the pleximeter with the right middle finger (plexor finger). Aim at your distal interphalangeal joint.

• Use the tip of your plexor finger, not the finger pad.

• Withdraw your striking finger quickly.

• Thump about twice in one location.

The technique of percussion

The plexor finger

The pleximeter finger

The longer the pleximeter finger pad

touched the body surface, the larger

the percussed area. The power of the

percussion is proportional with the

depth of the percussion

Szarvas F, Csanády M:: Belgyógyászati fizikális diagnosztika, Semmelweis Kiadó, 1993.

Modification of the percussion

technique according to the expected

physical finding

Deeply localized

solid organ gives

relative dullness

Superficial solid

organ, that gives

absolute dullness

Small power, short

pleximeter

Szarvas F, Csanády M:: Belgyógyászati fizikális diagnosztika, Semmelweis Kiadó, 1993.

Larger power, longer

pleximeter

AUSCULTATION

Laënnec: De l'auscultation médiate" (1819)

Stethoscope – Phonendoscope

Physical principle:

Sounds are generated in the body by:

- movement of air (bronchi)- movement of fluid (bronchial secretion)- movement of tissues (alveoli)- movement of organs (friction rub)- movement of blood (turbulence: murmurs)- movement of cardiac valves (heart sounds)- movement of bowels (bowel sounds)

The methods of auscultation

Use of the stethoscope

• Listen to the breath sounds with the diaphragm of the stethoscope as the patient breathes somewhat more deeply than normal through an open mouth.

• Auscultation of the abdomen with the diaphragm– Before percussion and palpation, because these

manoeuvres may alter the frequency of bowel sounds

• Auscultation of the heart:– The bell is more sensitive to low pitched sounds (S3,

S4, mitral stenosis)

– The diaphragm is better for picking up relatively high-pitched sounds (S1, S2, murmurs of aortic and mitral regurgitation, pericardial friction rub)

Normal breathing sounds

1. Vesicular breath sounds- arise from the alveoli. Vibrations of the alveolar wall

during inspiration

- soft, low-pitched

- fade away during expiration - normal breathing sound

2. Bronchial breath sounds- arise in the bronchi- coars, high-pitched, tubular sound- longer duration during expiration - usually pathological

3. Broncho-vesicular breath sounds- intermediate between 1. and 2.- normal between the scapulae

4. Tracheal breath sound- arises in the trachea- very coarse- normal over the trachea in the neck

Adventitious sounds of

breathing 1.

• Discontinuous sounds ( crackles, rales)

– short intermittent

– non-musical

– typically inspiratory sound

– they result from a series of tiny explosions when small

airways deflated during expiration, pop open during

inspiration.

– it can be simulated by rolling a lock of hair between

your fingers close to the ear

– Fine crackles: produced in the alveoli (late inspiratory,

repeat themselves from breath to breath) Coarse

crackles (early inspiratory) : arise in the bronchioli

Adventitious sounds of

breathing 2.• Continuous sounds are generated in the bronchi

– long in duration

– musical character

– occur when air flows rapidly through bronchi that are narrowed nearly to the point of closure

• Wheezing: high-pitched, hissing (whistle)

• Rhonchi: low-pitched, snoring (organ pipe)

• Stridor: very coarse inspiratory sound, that represents flow through a narrowed upper airway (goitre, croup). Audible without the stethoscope.

• Pleural rub: coarse, loud, grating sound, indicates inflamed pleural surfaces rubbing against each other. Appears close under the stethoscope

Abnormal Sounds

increased or decreased- in loudness- in pitch- in frequency- in duration

extra sounds – heart

crackleswheezingronchi

lung

murmurs - heart

bruits - vessels

clicksgurglesborborygm

bowel

friction rub - pleurapericardiumperitoneum

Palpation; general rules

• Cut your fingernails short

• Have warm hands

– If not, warm them by rubbings, washing in hot water

or start palpating through the gown of the patient

• Use the pads of your fingers

• Use both hands

• Move them smoothly

• Palpate first lightly, than perform deep palpation

• Avoid causing pain to the patient

Palpation of the skin

• Moisture– Dryness – hypothyroidism

– Sweating - hyperthyroidism

• Temperature– Generalized warmth in fever or hyperthyroidism

– Local warmth of inflammation

– Coolness in hypothyroidism

• Mobility and turgor– Lift a fold of skin and note the ease with which it lifts

up (mobility- decreased in oedema)

– The speed with which it returns into place (turgor –decreased in dehydration)

Characteristics of palpable mass

• Size:

– head of the pin, pepper, bean, peanut, green nut, apple, fist of child or of an adult, head of a child or of an adult etc.

• Surface:

– Smooth, nodular (micro/macro), lobulated, irregular

• Consistency:

– Soft, glandular, rubbery, firm, hard (like cartilage, wood, stone), fluctuating

Characteristics of palpable mass

• Mobility

– Freely moving (movable, shifting), attached to skin or underlying tissue, matted together (lymph nodes)

• Other palpable characteristics

– Pulsation

– Resonance

– Tenderness

– Bruise

Cervical adenopathy

Massive right side cervical adenopathy due to

metastatic, intraoral squamous cell cancer.

Palpation of lymph nodes

• Using the pads of your index and middle fingers, move the skin over the underlying tissues in each area

– The patient should be relaxed, with neck flexed slightly forward and slightly toward the side being examined.

– Note the size, shape, mobility, consistency and any tenderness. Small, mobile, discrete, non tender nodes are frequently found in normal persons.

• Tender nodes suggest inflammation

• Hard or fixed nodes suggest malignancy