Prof. R. Sukumar MD Institute of Internal Medicine MMC & GGH


Dr. Leopold Auenbrugger was the inventor of percussion He got the idea by observing a wine merchant percussing out a half-full barrel Later, he began to practice this technique on his patients History tells us that he percussed immediately with one hand, using all four fingertips

PERCUSSION OF THE ABDOMEN      Liver Spleen Kidneys Urinary bladder Free fluid .

midaxillary and midscapular line .PERCUSSION OF LIVER    Percuss downwards from the right 5th intercostal space in the midclavicular line to locate the upper border of the liver Patient's breath held in full expiration Measure the distance from the upper border of dullness to the palpable liver edge in the midclavicular .

LIVER SPAN Normal span is 12-15 cm at midclavicular line .

Interposition of the transverse colon between the liver and the diaphragm (Chilaiditi's sign) .Loss of normal Liver Dullness       Emphysema Large right pneumothorax Hollow viscus perforation Post Laparotomy/ Laparoscopy Massive hepatic necrosis.

PERCUSSION OF SPLEEN  Nixon s method Castell s method Traube s space percussion   .

NIXON S METHOD      The patient is placed on the right side so that the spleen lies above the colon and stomach Percussion begins at the lower level of pulmonary resonance in the posterior axillary line Proceeds diagonally along a perpendicular line toward the lower midanterior costal margin The upper border of dullness is normally 6 8 cm above the costal margin Dullness >8 cm in an adult is presumed to indicate splenic enlargement .

CASTELL S METHOD      Patient is poitioned supine Percuss in the lowest intercostal space in the anterior axillary line (8th or 9th) Resonant note is produced if the spleen is normal in size This is true during expiration or full inspiration Dull percussion note on full inspiration suggests splenomegaly .



it can be mapped by dropping perpendicular lines from the sixth rib at the costochondral junction and the ninth rib at the anterior axillary line to the costal margin Tympanic on percussion Percussed in sitting or supine posture . superiorly by the left lung resonance and inferiorly by left costal margin On the surface.TRAUBE S SPACE       Described by Ludwig Traube It is a semilunar space over the fundus of stomach Bounded medially by the left lobe of the liver. laterally by the spleen.

Obliteration of Traube s Space       Left sided Pleural Effusion Massive Splenomegaly Enlarged Left lobe of Liver Full Stomach Fundal Growth Massive Pericardial effusion .

KIDNEYS     Percussion over a right or left subcostal mass To distinguish hepatic or splenic from renal masses Resonant area is percussed over renal mass because of overlying bowel Sometimes a very large renal mass may displace overlying bowel .

URINARY BLADDER  Percussion in the suprapubic region Helpful in determining whether an ill-defined mass is an enlarged bladder (dull) or distended bowel (resonant)  .


DEMONSTRATION OF FREE-FLUID  Fluid thrill Shifting dullness Puddle s sign   .

. massive ovarian cyst or a pregnancy with hydramnios.FLUID THRILL     An assistant (or the patient) to place the medial edge of palm firmly on the centre of the abdomen The examiner flicks the side of the abdominal wall Pulsation (thrill) is felt by the hand placed on the other abdominal wall Positive in massive ascites (>2L).


a dull percussion note in the flanks Even with gross ascites an area of central resonance will always persist .SHIFTING DULLNESS     The percussion note over most of the abdomen is resonant. the influence of gravity causes this to accumulate first in the flanks in a supine patient When at least 1 litre of fluid have accumulated. due to air in the intestines When ascites collects.

Repeat percussion moving laterally to central over your mark The fluid(dull note) will now be moved by gravity away from the marked spot and the previously dull area will be resonant .SHIFTING DULLNESS       Percuss centrally and laterally until dullness is detected Keep your finger pressed there Ask the patient to roll onto the opposite side Ask the patient to hold the new position for about half a minute.


gradually moving it from the periphery toward the stethoscope A positive sign consists of an abrupt perceived increase in the intensity and clarity of the note just as the flicking finger moves beyond the edge of the pool of fluid Detects as little as 120 mL of ascites .PUDDLE S SIGN       Ausculto percussion method Have the patient lie prone for 5 minutes and then raise himself up to a knee elbow position Place the diaphragm of the stethoscope over the most dependent portion of the abdomen. Flick with your finger.


Sir William Osler (1849-1919) THANK YOU . Medicine is learned by the bedside and not in the classroom.

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