Post on 16-May-2018
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