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Stanford Medicine 25AN INITIATIVE TO REVIVE THE CULTURE OF BEDSIDE MEDICINE


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Percussion
The "5-7-9 rule"

The upper border of liver dullness is defined by:


o 5th intercostal space in the midclavicular line
o 7th intercostal space in the midaxillary line
o 9th intercostal space in the scapular line
Note: 9th intercostal space is located approximately at the inferior
border of the scapula
Hyperresonance that continues below these boundaries can be suggestive of
hyperinflation (e.g. emphysema)

Cardiac dullness

Be able to outline the area of "absolute" cardiac dullness a fist sized area just
to the left of the sternum. If it is not there it suggests emphysema.

Traube's space

Surface markings:
o Superiorly: Left 6th rib
o Inferiorly: Left costal margin
o Laterally: Anterior axillary line
Usually, traube's space is hyperresonant due to the location of the gastric bubble,
however, loss of this hypersonance can be seen in following conditions:
o Left pleural effusion (however NOT in left lower lobe pneumonia without
effusion as it is the effusion that falls into the costophrenic recess that is
above the gastric bubble)
o Splenomegally (less reliable compared to Castells Sign)
o Very full colon
o Recently eaten (i.e. stomach is full)

Click here to read an article on the Ludwig Traube.

Tidal Percussion

Percuss down the back until the normal hyperresonance of the lungs becomes
dull over the diaphragm. Then simply have the patient breath in and out deeply
while continuing to percuss. The sound should wax and wane.
Loss of tidal percussion:
o Pleural effusion
o Hyperinflation such as emphysema from a maximally contracted
diaphragm

Major and Minor Fissures

The major fissure can be located by drawing a line from the T2 spinous process
to where the 6th rib meets the sternum. The minor fissure can be approximated
by drawing a horizontal line from the 4th rib attachment of the sternum to the
major fissure.
Easier method: Simply ask the patient to put their hands over their head. The
scapula will rotate externally and its medial border will outline the major fissure
(see figure below).

Historical Perspective
Percussion was first described by Dr. Josef Leopold Auenbrugger, an Austrian
physician who first observed his father tapping on wine barrels in the cellar of his hotel to
determine how much wine was left. The son applied this technique to patients when he became
a physician. He is credited with bringing the technique of percussion to the field of medicine.
Much of his work occurred around 1760 where he described that by percussing the thorax he
could accurately predict the contents of what was inside, as confirmed with post-mortum studies
he conducted.

Inspection
Signs of COPD

Inspiratory descent of trachea.


Use of accessory muscles.
Pursed lips on exhalation (provides a small amount of PEEP).
Increased AP diameter (barrel chest).
o Normal in infancy and increased with aging.
Prominent angle of Louis (or sternal angle).
Flaring of the lower costal margins.
Dahl Sign: Above the knee, patches of hyperpigmentation or bruising caused by
constant 'tenting' position of hands or elbows.
Hoover's sign: briefly, during inspiration a paradoxical medial movement of the
chest.
o The "subcostal angle" is the angle between the xiphoid process and the
right or let costal margin. Normally, during inhalation the chest expands
laterally, increasing this angle. When the diaphragms are flattened (as in
COPD), inhalation paradoxically causes the angle to decrease.

Harrison's sulcus: a horizontal grove where the diaphragm attaches to the ribs;
associated with chronic asthma, COPD, & Rickets.

REMEMBER : "The side that moves less, is the side of disease!"

Look for signs of volume loss (or gain) on the side that moves less (hollow
supraclavicular fossae, intercostal spaces prominent, shoulder droopy, scapula
outline more prominent).

Dr. Peadar Noone trained in Galway, Dublin, Boston, the UK and Chapel Hill,
where he is now Associate Professor of Medicine and Medical Director of the Lung
Transplant Program at the University of North Carolina, Chapel Hill.

Clinical Pearl:

Insert (in a normal individual) three fingers vertically in the space under the cricoid
cartilage, and above the sternal notch. As the person breathes in, the space may reduce
to two fingers at most (i.e. the fingers get "squeezed" as the sternum rises with
inspiration).
In a patient with severe hyperinflation, the crico-sternal distance is much shorter
(because the sternum is elevated), maybe 1-2 fingers at most
With inspiration one's fingers get "squeezed" out as the already "high" sternum rises up
to the level of the cricoid, thus, in many cases, obliterating the crico-sternal distance
altogether.
o Some clinicians label this sign "tracheal shortening" but strictly speaking, the
actual tracheal length does not get shorter.
Classically this is seen with severe emphysema / hyperinflation, or severe air trapping.
Often accompanied by reduced hepatic and cardiac dullness on percussion, a widened /
flared costal angle, and Hoover's sign.

Consult the Expert

Other Findings in the Chest

Pectus Excavatum (Funnel Chest): depression of sternum; in severe cases


may compress heart and great vessels.
Pectus Carinatum (Pigeon chest): anterior displacement of sternum, usually
benign.
Flail Chest: secondary to multiple rib fractures, depression of diaphragm causes
injured area to cave inward producing a "paradoxical thoracic movement" in
breathing.

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