PERCUSSION OF THE CHEST
What is percussion
Is tapping of the body structure to produce audible sound &
palpable vibration.
Aims of percussion
 To determine limits of lung resonance.
 To determine state of lungs as regard to quantity of air.
 To determine any fluid or gas in pleural cavity or thickened
pleura.
Rules of percussion
1. From resonant to dull or less resonant area except in Kronig’s isthmus.
2. The pleximeter finger should be in firm contact with chest wall.
3. The long axis of the pleximeter finger should be parallel to the edge of the organ to be per
cussed and the line of percussion should be perpendicular to the edge.
4. Light percussion is meant for the lungs.
5. Heavy or deep percussion is meant for deeper organs e.g. liver.
6. The chest is percussed along the mid- clavicular, the mid axillary and the scapular lines space
by space and rib by rib comparing both sides on front and back.
Types and technique of percussion
Immediated percussion (Direct percussion)
5. The right middle finger (plexor) should be partially flexed,
Strikes the chest either by the palmer aspect of the middle finger or tips of four fingers
relaxed and ready to strike.
held tightly together. Clavicles & Sternum
6. With a quick, sharp but relaxed wrist motion strike the left
middle finger with the right middle finger
Mediated percussion (Indirect percussion)
7. Striking at distal interphalangeal joint.
1. Hyperextension of the middle finger of the left hand (the pleximeter finger).
8. We use the tip of the plexor finger not the finger pad.
2. Press its distal interphalangeal joint firmly on the surface wanted to be per cussed. 9. The striking finger should be at right angles with the pleximeter
3. We must avoid contact by any other part of the hand.
finger.
4. The right forearm quit close to the surface with the hand cocked upward.
10. Thump about twice in one location and then move to another.
Flatness
Dullness
Resonance
Hyper-resonance
Tympany
Intensity
Soft
Medium
Loud
Very loud
Loud
Percussion notes
Pitch
High
Medium
low
lower
High
Location
Thigh
Medium
Lung
None normally
Over stomach
Pathology
Large effusion
Liver
Bronchitis
Emphysema Pneumothorax
Large Pneumothorax
Steps of chest percussion


1. Upper border of the liver
Heavy percussion on the right MCL.
The upper border of the liver
normally present in the 5th ICS
Emphysema: encroachment on liver
dullness.
Right border
1. Starting by ICS above the upper border of the
liver.
2. Percuss from outside inwards towards the heart.
3. Normally no dullness is found to the right of the
sternum.
2. Heart
Base of heart

In the 2nd right
and 2nd left
spaces

Left border
started from a left position away from the
apex beat and towards it.
Also, from a left position away from the left
border of the heart and towards it for each
intercostal space.
Thug’s
3. Percussion of the chest proper
Patient lying down
Patient sitting
Direct percussion of clavicles normally: resonant note.
Percuss the lateral chest wall along anterior, mid and posterior axillary lines
Direct percussion of the sternum & manubrium normally cancellus resonance.
while the patients raises his hands above his head and compare both sides.
Percuss the lung anteriorly along parasternal and midclavicular lines and
Percuss posterior chest wall while the patient sit sits with his arms folded
comparing both sides.
across the front of the chest.
Percuss Traube’s area.
Percuss Kronig’s isthmus.
Percuss bare area of the heart.
Tidal percussion
Special Areas
Kronig’s isthmus
Bare area of the heart
Traube’s area
Resonance
Impaired note
Hyper-resonance (tympanitic resonance)
By light percussion give over 4th and 5th spaces.
It’s a lozenge Shaped area of tympanitic
 supra clavicular band
Part of heart not covered by lung
on the left basal region overlying the fundus of the stomach.
 apex of the lung
 In emphysema there is encroachment on bare area.
 In cardiomegaly there is broadening of the area
which is referred to as ‘superficial dullness’
 Sternoclavicular joint to
 Rt border: middle line
 Rt border: Lt 6th ribs – Lt 8th costal cartilage
7th cervical
 Lt border: middle line opposite 4th rib to 6th rib in
 Lt border: Lt 9th – 11th in MAL
 Jx of medial 2/3 & lat 1/3
parasternal line
 Upper Border: Lt 9th to Lt 6th rib in MCL
th
of clavicle to spine of
 Inf border: concave border joining 4-6 ribs
 Lower Border: Lt 8th costal cartilage – 11th rib in MAL
scapula
Dullness
Widened resonance
Apical TB
RVH & pericardial effusion
Splenomegaly
Left basal lung collapse
Apical Fibrosis
Hepatomegaly
After basal pneumonectomy
Hyperresonant
Apical pneumonia
Left
pleural
effusion
Splenectomy
 Emphysema
Apical Tumor(pancoast)
Pericardial Effusion
Liver cirrhosis
 Pneumpthorax
Apical pleural thickening
Full
stomach
&
gastric
tumor
Dilatation of the stomach
 Pneumomediastinum
Massive pleural effusion
Infradiaphragmatic causes: ascites,
Pneumothorax
 Compensatory emphysema of left lung
Collapsed rt upper lobe
pregnancy & subphrenic abscess
Tidal percussion
The lower border of lung resonance at the back is carefully noted in full inspiration and full expiration.
The distance between both represents approximately the range of movement of the diaphragm.
Normally around 4cm to 7cm or about 2 spaces.
Thug’s