Percussion

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Percussion

• The chest is percussed to confirm the cardiac
  borders, size, contour and position in the
  thorax.
• Relative cardiac dullness(??????)
• Absolute cardiac dullness(??????)

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Method of percussion for heart

• Patient should lie supine on an examining
  table or sit on the chair, with the physician at
  his right side. Usually we employ indirect
  percussion(?????) for percussing heart borders.

3

• Many beginners, in attemptng to outline the
  cardiac dullness, strike too forcibly and thus
  fail to hear the slight change in the percussion
  note caused by the thin layer of overlying lung.

4

• One should use the lightest percussion
  possible and, with experience, rely more and more
  upon the vibratory sense.

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• Percussion with finger parallel
• to cardiac outlines

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• Percussion with finger at right
• angle to cardiac outline

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• The orthopercussion(?????) method of Plesch is
  carried out by flexing the left middle finger to
  a right angle, placing the pulp of the finger on
  the area to be percussed, and then striking the
  flexed finger at the distal end of the first
  phalanx.

8

• This method is recommended in the percussion
  of absolute cardiac dullness, and give excellent
  results comparing with ordinary methods.

9

• It is outlined by percussing in the 5th, 4th,
  3rd and 2nd interspace on the left sequentially,
  starting near the axilla and moving medially
  until cardiac dullness is encountered.

10
Percussion

• The beginner should mark with a skin pencil
  where the note changes. The distance from
  midsternal line to the left border should be
  measured and recorded, measurement should be made
  along a straight line paralleled to the
  transverse diameter in the thorax.

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Heart borders

• Right border of the heart
• formed by
• sup vena(????), ascending
  aorta(????), right atrium(???)

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• Left border of the heart
• formed by
• aorta arch(????), pulmonary arterial
  trunk(????), left atria appendage(???), LV(???)

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• Inferior border of the heart
• formed by
• RV(???), lesser extent LV

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• Normal heart dullness
• right(cm) ICS,MSL left(cm)
• 2-3 ? 2-3
• 2-3 ? 3.5-4.5
• 3-4 ? 5-6
• ? 7-9
• Normally from midsternal line to MCL is about
  8-10cm

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Physiologic changes in the area of cardiac
dullness

• The position of the heart, and with it the
  area of cardiac dullness, is influenced by the
  level of the diaphragm.

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• In deep inspiration the diaphragm descends,
  producing a decrease in cardiac dullness, while
  in forced expiration the diaphragm rises and
  produces an increase in the cardiac dullness.

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• In the later months of pregnancy the diaphragm
  is pushed upward, causing the heart to lie more
  horizontally and closer to the chest wall, thus
  increasing the area of cardiac dullness.

21
Cardiac dullness in abdominal distention

• A variety of pathologic conditions such as
  ascites, an ovarian cyst(????), or
  peritonitis(???) may cause an elevation of the
  diaphragm with an increase in the area of cardiac
  dullness.

22
Changes in position of cardiac dullness

• A left-sided pleural effusion(????) will push
  the heart to the right, and increase the cardiac
  dullness to the right of sternum, the left border
  in such cases can usually not be made out. A
  right-sided pleural effusion increase the cardiac
  dullness on left side.

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• In pneumothorax the heart is displaced toward
  the normal side, but in massive collapse of the
  lung(???) the heart is displaced toward the
  affected side.

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• Pleural adhesions(????) may pull the heart to
  the affected side with resulting changes in
  cardiac dullness similar to those produced by
  collapse of the lung.

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Decrease in the area of cardiac dullness

• A decrease in the relative cardiac dullness
  may occur in pulmonary emphysema(???). The
  absolute cardiac dullness is usually decreased in
  such cases, since the lung is increased in size
  and covers a greater area of the heart than
  normal.

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Increase in the area of cardiac dullness

• An increase in the area of cardiac dullness is
  most strikingly seen in patients with cardiac
  disease. we cannot detect by percussion an
  appreciable increase of the cardiac dullness in
  hypertrophy of the heart unless there is an
  accompanying dilatation.

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Cardiac enlargement

• Enlargement of the left ventricle produces an
  increase in the relative cardiac dullness to the
  left and often downward on this side.

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• The heart silhouette looks like a shoe

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• Enlargement of the left ventricle appears in
  aortic insufficiency, in aortic stenosis, in
  mitral insufficiency, in longstanding
  hypertension and in chronic nephritis(????). It
  is called aortic heart(?????).

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• Right ventricular enlargement, the cardiac
  dullness will extended to left and upward. If the
  right ventricular is severely enlarged, the right
  border of the heart will extend to the right. It
  is seen in cor pulmonale, in mitral stenosis, in
  tricuspid insufficiency etc.

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• Both the left atrium and pulmonary artery
  enlarged, the pulmonary artery will be
  exaggerated to leftward. The cardiac silhouette
  is like a pear and called mitral heart(?????), it
  is frequently seen in mitral valve stenosis.

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• The heart silhouette is like a pear

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• Aortic dilation(?????), aneurysm of
  aorta(????), pericardial effusion, all those
  diseases may cause the base border of heart
  enlargement, so that the base border of the heart
  will be widened.

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• Congestive heart failure, severe myocarditis,
  Keshan disease(???), dilated myocardiopathy(??????
  ) may cause the heart silhouette extending both
  to right and left(???).

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Pericardial effusion

• The cardiac dullness is increased in all
  directions and assumes the form of a triangle
  with the apex at the level of the first or second
  intercostal space or a general globular
  enlargement.

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• The heart silhouette is like a flask

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• The heart silhouette is like a globe

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Adhesive pericarditis

• The degree of enlargement depends on the
  extent of the adhesive process. The relative, and
  especially the absolute, cardiac dullness are
  both markedly increased to left and to the right.

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Increase in the absolute cardiac dullness

• Increase in the absolute cardiac dullness
  without demonstrable cardiac enlargement occurs
  when the left lung is retracted and a larger area
  of the ventricle is exposed.

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• It also occurs in mediastinal tumors when the
  heart is pushed up against the chest wall and a
  large area of the ventricle comes into direct
  contact with the anterior surface of the chest.

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