Chest and abdominal percussion
The percussion method is based on analyzing the sound produced when tapping body parts. Using it, the physician determines organ boundaries and the presence of pathological contents (fluid or gas).
In the chest region, heart borders are identified by percussion. Their displacement may indicate fluid or gas accumulation in one of the pleural cavities, causing mediastinal shift. When exudate or pus is present in the pleural cavity, a dull sound is determined. The Ellis-Damoiseau line is formed — the oblique upper boundary of fluid, the highest point of which projects along the posterior axillary line. If pyopneumothorax develops (simultaneous accumulation of both fluid and air), the fluid level becomes strictly horizontal.
When percussing the abdomen, the liver zone is assessed. Reduction or complete disappearance of hepatic dullness is a critically important symptom in hollow organ perforation. To search for free fluid (ascites, peritonitis), the dependent (lateral) areas of the abdomen are percussed, revealing dullness. The fluid shift phenomenon is used for confirmation:
- The patient lies supine — a dull sound is determined in the flanks.
- The patient is turned onto their side.
- The dull sound shifts to the lower half (on which the patient is lying), while tympanites appears on the opposite (upper) side.
Additionally, in inflammatory processes (peritonitis), percussion reveals local tenderness and a tympanic sound caused by intestinal bloating (meteorism).
Heart and lung auscultation
Auscultation involves assessing acoustic phenomena occurring during the vital activity of organs. When listening, it is necessary to describe in detail the nature of sounds and tones.
- Heart: The physician evaluates the presence of tones, their loudness (enhancement or attenuation), and rhythm. Pathological changes may manifest as systolic or diastolic murmurs.
- Lungs: The character of basic breathing is assessed — it can be vesicular, weakened, harsh, or bronchial. Adventitious breath sounds, such as dry or moist rales, as well as crepitation, are recorded.
Gastrointestinal tract auscultation
In abdominal surgery, auscultation is necessary to assess intestinal peristalsis. The acoustic picture allows differentiation of various acute conditions:
- «Dead silence»: Complete absence of peristaltic sounds. This indicates intestinal atony, which is extremely characteristic of severe peritonitis.
- Enhanced peristalsis: Vigorous, loud bowel sounds are typical of mechanical intestinal obstruction in the early stages.
- Pathological murmurs: The specific falling-drop murmur is also a sign of developing intestinal obstruction.
Assessment of vessels and musculoskeletal system
Auscultation is used as an additional diagnostic method in traumatology and vascular surgery.
The musculoskeletal system is auscultated for intra-articular injuries, aneurysms, and long bone fractures. Fractures reveal bone crepitation (crunching) and impaired bone sound conduction: when tapping one of the bone fragments, the sound is not conducted across the fracture line to the other fragment.
When auscultating blood vessels, all projection points of major conduit arteries must be auscultated. Normally, the conducted tone of the pulse wave impact is determined over them. Pathological sounds include:
- Systolic murmur: Heard during arterial narrowing (atherosclerotic lesion, stenosis) or dilation.
- Systolic-diastolic murmur: Occurs during pathological blood shunting from the arterial to the venous bed.
- «Top murmur»: A specific acoustic phenomenon heard over an aneurysm.
Briefly: answers to topical questions
At which points on the chest is heart valve auscultation performed?
Heart valve auscultation is performed at five standard points on the chest.
- Mitral valve — apex of the heart (usually the fifth intercostal space 1–1.5 cm medial to the left midclavicular line).
- Tricuspid valve — lower part (third) of the sternal body or base of the xiphoid process.
- Aortic valve — second intercostal space on the right at the sternal margin.
- Pulmonary valve — second intercostal space on the left at the sternal margin.
- Fifth point (Botkin-Erb point) — third intercostal space on the left at the sternum (for auscultation of the diastolic murmur in aortic regurgitation).
What percussion zones (triangles) are formed in exudative pleurisy, besides the Ellis-Damoiseau line?
In exudative pleurisy, besides the Ellis-Damoiseau line, two specific percussion triangles are determined.
- Garland's triangle — located on the affected side above the Damoiseau line (the compressed lung area closer to the spine). Percussion over it reveals a dull-tympanic sound (tympanites).
- Rochard-Grocco triangle — located on the healthy side in the lower part adjacent to the spine. Formed due to mediastinal organ displacement. Percussion over it reveals dullness.
What variants of vesicular breathing exist in normal and pathological states?
The sources indicate the following breathing variants:
- Puerile breathing — a normal variant for this age in children.
- Weakened breathing — heard in the initial and final stages of pneumonia, as well as in alveolar pulmonary edema.
- Harsh and bronchial breathing are also listed among the respiratory character variants during lung auscultation.
The link between weakened vesicular breathing and normality in premature newborns is not directly supported by the provided materials.
What types are moist rales divided into during lung auscultation?
During lung auscultation, moist rales are divided into several types depending on their caliber.
- Fine moist rales — heard in interstitial pulmonary edema, homologous blood syndrome, and over pneumonia foci.
- Medium moist rales — found in alveolar pulmonary edema.
- Coarse moist rales — heard during the progression of pulmonary edema (including alveolar).
Additionally, moist rales can be characterized by their resonance (e.g., non-resonant rales are distinguished).
To memorize fluid shift in the abdomen: «Where it's lower, it's duller». When turning the patient onto their side, the dull sound (fluid) always «flows» down, while tympanites (gas) rises up.
Class and exam questions
What does a horizontal fluid level indicate upon percussion of the pleural cavity?
The horizontal level indicates pyopneumothorax — the simultaneous accumulation of fluid (pus, exudate) and free air in the pleural cavity.
How does the percussion sound over the liver change in hollow viscus perforation?
Hepatic dullness during percussion decreases or completely disappears due to the accumulation of free gas under the diaphragmatic dome.
What does the "grave silence" sign mean?
This is the complete absence of peristaltic sounds during abdominal auscultation, which indicates intestinal atony resulting from severe peritonitis.
How to use auscultation to confirm a tubular bone fracture?
When tapping one fragment, the sound is not conducted across the fracture line to the other fragment (impaired bone conduction), and bone crepitation may also be heard.
What else to study on this topic
- Mechanism of formation of the Ellis-Damoiseau line in pleurisy
- Differential diagnosis of systolic and diastolic heart murmurs
- Physical differences between vesicular and bronchial breath sounds
- Pathogenesis of the "falling drop" sound in intestinal obstruction
- Technique of auscultation of major vessels and their projection points
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