Percussion of the Chest (Stanford Medicine 25)

Percussion of the Chest (Stanford Medicine 25)


in this session we’re going to focus on percussion percussion is a technique discovered fairly recently by Leopold Olin bruger the story is that he was an innkeeper son and he watched his father tapping on casa wine to see how much wine was left and from that when he became a physician in the late 1700s he discovered percussion and everything we know about percussion he described he used an instrument that they laid on the chest and a tiny hammer in fact the present-day knee hammer has its genesis from that instrument but we found that we perk us much better when our finger is the plexi meter and our other hand is the hammer I know that there are many different ways to do this I favor your putting your hand firmly against the patient’s chest not keeping the other fingers up because I think it’s harder to form a good seal so push the fingers in seated nicely in the intercostal spaces and you’re trying to aim for the middle of this phalanx and it’s important to keep your fingernails short in order to perk us successfully your wrists must be loose and if you get all these things going you will have a nice percussion stroke that will serve you very well you’re detecting a slight difference between left and right and that is quite normal that is the area of superficial cardiac Dominus and now we’re going to go over the surface anatomy of the right side of the lung because if you think about it there’s no point in percussing and encountering an abnormality dulness say if you don’t know the normal anatomical boundaries and don’t know if that’s liver or lung so I’m going to point out some of the surface markings and I’m going to draw them for you if you were to put your finger in the suprasternal notch and bring your hand down you would encounter the angle of Louie it’s a very important landmark this is a super strong notch because lots of exciting things happen there it’s the level of the right atrium the trachea bifurcates the thoracic duct crosses over.the as Lucas vein joins that’s the lower border of t4 and for us it’s very helpful because the second rib joins right there and therefore the space right below it is the second intercostal space now and percussing on the right side we we must be conscious of the location of the major fissure because the major fissure will divide us divide things into the upper and lower lobes and the minor fissure and I’m going to show you an easy way to do that without having to remember too many landmarks and so on so let me let me demonstrate by having Jeff turn around for me a second now this is the medial edge of Jeff’s scapula with his arm at his side so if you if you remember this this is where his scapula is I’m now gonna have him put his hand on top of his head and a really exciting thing happens is the moment he puts his hand on his head the lower border of the scapula becomes a wonderful landmark for the major fissure so this is the lower border of the scapula and if I continue it up and then continue it through the side like so it will eventually come meet the costal margin at about the sixth rib right about there and then median fissure or the horizontal fissure is found by drawing a line from the fourth rib and if you follow that line it eventually intersects with the other line and as you can see the axilla is the only place where you can see all three lobes of the lung upper lobe middle lobe lower lobe when you’re examining the patient from the back you’re largely dealing with lower lobe with a little smidgen of upper lobe and when you examine the patient from the front you’re mostly seeing upper lobe with a little silver of the middle lobe and a tiny silver of the lower lobe in percussing the right side it’s terribly important again to know where the liver is and especially to know the upper border of Liberty on us because the liver is here it is dull when you perk us over it you need to know the upper border so that you can say any dumbness above that is fluid or consolidation and the magic numbers to remember are five seven nine five seven nine the fifth rib in the midclavicular line so here’s the second rib third fourth fifth right about there’s a fifth rib in the midclavicular line the seventh rib in the mid-axillary line I’m going to turn Jeff a little bit and have you put your hand on your head and I’m going to find my landmark again here’s the seventh rib in the mid-axillary line and the ninth rib if I can turn you all the way put your hand down the ninth rib in the mid scapular line the ninth rib which is about there so remember the magic numbers five seven nine representing the midclavicular line the mid-axillary line the mid scapular line if you have down list below that that’s normal that’s liver if you have dauntless above that especially if it’s considered me about that it’s quite abnormal and percussing the left side of the chest it’s really quite different from the right side on the right side you have the solid organ of the liver to contrast its darkness with the resonance of the lung on the left side there’s a slightly different situation so on the left side you have the heart and as I mentioned before you have an v sized area of dumbness which we call the area of superficial cardiac dullness everybody should be dull there and if they’re not it suggests hyper-inflated lung the pulmonary ii space again should always be resonant and if it’s not it suggests perhaps an enlarged pulmonary artery but the very interesting phenomenon here has to do with the gastric bubble that sits under the ribcage here is the lower margin of the ribcage and the gastric bubble sits underneath there in an area called trop space which I’m going to outline drop space spelled tra ube is formed by dropping a perpendicular on the sixth rib in the middle avicularia so here’s a metal bicular line here is the second rib third fourth fifth sixth so perpendicular from the sixth rib in the midclavicular line and another perpendicular from the ninth rib in the anterior axillary line and what you then get is an irregular quadrilateral representing the stomach bubble sitting quite high up don’t forget the diaphragm is quite a dome even though the costal margin is here and when we perk us the lung and go down this way we go from resonance typically to timpani from that large solitaire bubble so listen to this you hear how it became a much fuller boxy sound unlike this sound and that represents the stomach bubble it’s a useful sign because if you have a pleural effusion on the left lung it will seep into the costophrenic angle and it will obliterate throb space whereas if you have a consolidation of the lung the lung will be consolidated the lung sound will be flat dull and when you come here trough space will be preserved because the lung boundaries over there this represents the costophrenic recess and so it’s a useful sign in that situation the preceding program is copyrighted by the Board of Trustees of the Leland Stanford junior University please visit us at med.stanford.edu

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