Percussion

The chest is percussed to confirm the

cardiac borders, size, contour and position
in the thorax.
Relative cardiac dullness( )
Absolute cardiac dullness(
)

Method of percussion for heart

Patient should lie supine on an
examining table or sit on the chair,
with the physician at his right side.
Usually we employ indirect
percussion( ) for
percussing heart borders.

Many beginners, in attemptng to

outline the cardiac dullness, strike too
forcibly and thus fail to hear the slight
change in the percussion note caused
by the thin layer of overlying lung.

One should use the lightest percussion

possible and, with experience, rely
more and more upon the vibratory
sense.

Percussion with finger parallel

to cardiac outlines

Percussion with finger at right

angle to cardiac outline

The orthopercussion(
) method of Plesch is
carried out by flexing the left
middle finger to a right angle,
placing the pulp of the finger
on the area to be percussed,
and then striking the flexed
finger at the distal end of the
first phalanx.

This method is recommended in the

percussion of absolute cardiac dullness,
and give excellent results comparing
with ordinary methods.

It is outlined by percussing in the 5th,

4th, 3rd and 2nd interspace on the left
sequentially, starting near the axilla
and moving medially until cardiac
dullness is encountered.

Percussion
The beginner should mark with a skin
pencil where the note changes. The
distance from midsternal line to the left
border should be measured and
recorded, measurement should be made
along a straight line paralleled to the
transverse diameter in the thorax.

Heart borders
Right border of the heart
formed by
sup vena( ),
ascending aorta( ), right
atrium( )

Left border of the heart

formed by
aorta arch( ), pulmonary
arterial trunk( ), left atria
appendage( ), LV( )

Inferior border of the heart

formed by
RV( ), lesser extent LV

Normal heart dullness

right(cm) ICS,MSL left(cm)
2-3
2-3
3-4

2-3
3.5-4.5
5-6
7-9

Normally from midsternal line to MCL is about 8-10cm

Physiologic changes in the area

of cardiac dullness
The position of the heart, and with it
the area of cardiac dullness, is
influenced by the level of the
diaphragm.

In deep inspiration the diaphragm

descends, producing a decrease in
cardiac dullness, while in forced
expiration the diaphragm rises and
produces an increase in the cardiac
dullness.

In the later months of pregnancy the

diaphragm is pushed upward, causing
the heart to lie more horizontally and
closer to the chest wall, thus increasing
the area of cardiac dullness.

Cardiac dullness in
abdominal distention
A variety of pathologic conditions such
as ascites, an ovarian cyst( ),
or peritonitis( ) may cause an
elevation of the diaphragm with an
increase in the area of cardiac dullness.

Changes in position of
cardiac dullness
A left-sided pleural effusion(
) will push the heart to the right, and
increase the cardiac dullness to the right
of sternum, the left border in such cases
can usually not be made out. A rightsided pleural effusion increase the
cardiac dullness on left side.

In pneumothorax the heart is displaced

toward the normal side, but in massive
collapse of the lung( ) the heart
is displaced toward the affected side.

Pleural adhesions( ) may

pull the heart to the affected side with
resulting changes in cardiac dullness
similar to those produced by collapse
of the lung.

Decrease in the area of

cardiac dullness
A decrease in the relative cardiac
dullness may occur in pulmonary
emphysema( ). The absolute
cardiac dullness is usually decreased in
such cases, since the lung is increased
in size and covers a greater area of the
heart than normal.

Increase in the area of

cardiac dullness
An increase in the area of cardiac
dullness is most strikingly seen in
patients with cardiac disease. we cannot
detect by percussion an appreciable
increase of the cardiac dullness in
hypertrophy of the heart unless there is
an accompanying dilatation.

Cardiac enlargement
Enlargement of the left ventricle
produces an increase in the relative
cardiac dullness to the left and often
downward on this side.

The heart silhouette looks like a shoe

Enlargement of the left ventricle

appears in aortic insufficiency, in aortic
stenosis, in mitral insufficiency, in
longstanding hypertension and in
chronic nephritis( ). It is
called aortic heart( ).

Right ventricular enlargement, the

cardiac dullness will extended to left
and upward. If the right ventricular is
severely enlarged, the right border of
the heart will extend to the right. It is
seen in cor pulmonale, in mitral
stenosis, in tricuspid insufficiency etc.

Both the left atrium and pulmonary

artery enlarged, the pulmonary artery
will be exaggerated to leftward. The
cardiac silhouette is like a pear and
called mitral heart( ), it is
frequently seen in mitral valve
stenosis.

The heart silhouette is like a pear

Aortic dilation( ),
aneurysm of aorta( ),
pericardial effusion, all those diseases
may cause the base border of heart
enlargement, so that the base border of
the heart will be widened.

Congestive heart failure, severe

myocarditis, Keshan disease( ),
dilated myocardiopathy(
) may cause the heart silhouette
extending both to right and left(
).

Pericardial effusion
The cardiac dullness is increased in all
directions and assumes the form of a
triangle with the apex at the level of
the first or second intercostal space or a
general globular enlargement.

The heart silhouette is like a flask

The heart silhouette is like a globe

Adhesive pericarditis
The degree of enlargement depends on
the extent of the adhesive process. The
relative, and especially the absolute,
cardiac dullness are both markedly
increased to left and to the right.

Increase in the absolute

cardiac dullness
Increase in the absolute cardiac
dullness without demonstrable cardiac
enlargement occurs when the left lung
is retracted and a larger area of the
ventricle is exposed.

It also occurs in mediastinal tumors

when the heart is pushed up against the
chest wall and a large area of the
ventricle comes into direct contact with
the anterior surface of the chest.


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