Management of a patient 2


Examination of patients with respiratory pathology

By inspection the examiner can reveal diffuse cyanosis in the case of respiratory failure:


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Pay attention to colour of visible mucosa (cyanosis):

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Inspection of the neck shoves svelling of neck veins in elevation of intrathoracic pressure:

You can see swelling of neck veins in superior vena cava obstruction and dilation of superficial veins on the chest


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Patients with chronic hypoxia develop clubbing fingers

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Herpes labialis et nasalis develop in heavy pneumonia

Examination of the chest is done according to a definite plan. Inspection of a chest is divided on static and dynamic one.


Static inspection of the chest

The general configuration of the chest should first beestimated (position of the clavicles, supra- and subclavicular fossae, shoulder blades)$ the next step is to define the type, rrhythm and frequency of breathing, respiratory movements of the left and right shoulder blades, and of the shoulder girgle, and involvement of the accesory respiratory muscles in the breathing act. The patient should be better examined in the upright (standing or sitting) position with the chest being naked. Illumination of the body should be uniform.

Body symmetry is always an important notation during the inspection of the chest. Asymmetry in the chest may indicate serious underlying problems, such as pulmonary dysfunction. However, asymmetry is most often a sign of scoliosis, lateral curvature of the spine. Asymmetry requires further medical investigation.

The shape of the chest may be normal or pathological. A normal chest is characteristic of healthy persons with regular body built. Its right and left sides are symmetrical, the clavicles and the shoulder blades should be at one level and the supraclavicular fossae equally pronounced on both sides. Sinse all people with normal constitution are conventionally divided into three types, the chest has different shape in accordance with its constitutional type.

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Pathological shape of the chest may be the result of congential bone defects and of vatious cjronic diseases (emphysema of the lungs, rickets, tuberculosis).


Normal form of the chest

. 1. Normosthenic (conical) chest in subjects with normosthenic constitution resembles a truncated cone whose bottom is formed by well-developed muscles of the shoulder girdle and is directed upward. The anteroposterior (sterno vertebral) diameter of the chest is smaller than the lateral (transverse) one, and the supraclavicular fossae are slightly pronounced. There is a distinct angle between the sternum and the manubrium (angulus Ludowici); the epigastric angle nears 90. The ribs are moderately inclined as viewed from the side; the shoulder blades closely fit to the chest and are at the same level; the chest is about the same height as the abdominal part of the trunk.

2. Hypersthenic chest in persons with hypersthenic constitution has the shape of a cylinder. The anteroposterior diameter is about the same as the transverse one; the supraclavicular fossae are absent (level with the chest). The manubriosternal angle is indistinct; the epigastric angle exceeds 90;

the ribs in the lateral parts of the chest are nearly horizontal, the intercostal space is narrow, the shoulder blades closely fit to the chest, the thoradc part of the trunk is smaller than the abdominal one.

3. Asthenic chest in persons with asthenic constitution is elongated, narrow (both the anteroposterior and transverse diameters are smaller than normal); the chest is flat. The supra- and subclavicular fossae are distinctly pronounced. There is no angle between the sternum and the manubrium: the sternal bone and the manubrium make a straight "plate". The epigastric angle is less than 90. The ribs are more vertical at the sides, the tenth ribs are not attached to the costal arch (costa decima fluctuens); the intercostal spaces are wide, the shoulder blades are winged (separated from the chest), the muscles of the shoulder girdle are underdeveloped, the shoulders are sloping, the chest is longer than the abdominal part of the trunk.

Pathological chest

1. Emphysematous (barrel-like) chest resembles a hypersthenic chest in its shape, but differs from it by a barrel-like configuration, prominence of the chest wall, especially in the posterolateral regions, the intercostal spaces are enlarged. This type of chest is found in chronic emphysema of the lungs. Active participation of accessory respiratory muscles in the respiratory act (especially m. sternocleidomastoideus and m. trapezius), depression of the intercostal space, elevation of the entire chest during inspiration and relaxation of the respiratory muscles and lowering of the chest to the initial position during expiration become evident during examination of emphysema patients.


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General appearance of a patient with pulmonary emphysema


2. Paralytic chest resembles the asthenic chest. It is found in emaciated patients, in general asthenia and constitutional underdevelopment; it often occurs in grave chronic diseases, more commonly in pulmonary tuberculosis and pneumosclerosis. During examination of patients with paralytic chest, marked atrophy of the chest muscles and asymmetry of the clavicles and dissimilar depression of the supraclavicular fossae can be observed along with typical signs of aslhenic chest. The shoulder blades are not at one level either, and their movements during breathing are asynchronous.

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Paralytic chest


3. Rachitic chest (keeled or pigeon chest). It is characterized by a markedly greater anteroposterior diameter (compared with the transverse diameter) due to the prominence of the sternum (which resembles the keel of a boat.) The anterolateral surfaces of the chest are as if pressed on both sides and therefore the ribs meet at an acute angle at the sternal bone, while the costal cartilages thicken like beads at points of their transition to bones (rachitic beads). As a rule, these beads can be palpated after rickets only in children and youths.

1.     Funnel chest has a funnel-shaped depression in the lower part of the sternum. This deformity can be regarded as a result of abnormal development of the sternum or prolonged compressing effect. In older times this chest would be found in shoemaker adolescents.

5. Foveated chest is almost the same as the funnel chest except that the depression is found mostly in the upper and the middle parts of the anterior surface of the chest. This abnormality occurs in syringomyelia, a rare disease of the spinal cord.

The chest may be abnormal in subjects with various deformities of the spine which arise as a result of injuries, tuberculosis of the spine, rheumatoid arthritis (Bekhterev's disease), etc. Four types of spine deformities are distinguished: lateral curvature of the spine, called scoliosis; excessive forward and backward curvature of the spine (gibbus and kyphosis, respectively); forward curvature of the spine, generally in the lumbar region (lordosis); combination of the lateral and forward curvature of the spine (kyphoscoliosis).

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Different types of chest deformities


The shape of the chest can readily change due to enlargement or diminution of one half of the chest (asymmetry of the chest). These changes can be transient or permanent.

The enlargement of the volume of one half of the chest can be due to escape of considerable amounts of fluid as the result of accumulation of fluid in the pleural cavity, or due to penetration of air inside the chest in injuries (pneumothorax). Levelling or protrusion of the intercostal spaces, asymmetry of the clavicles and the shoulder blades and also unilateral thoracic lagging can be observed during examination of the enlarged part of the chest.

One part of the chest may diminish due to pleural adhesion or complete closure of the pleural slit after resorption of effusion (after prolonged presence of the fluid in the pleural cavity); contraction of a considerable portion of the lung due to growth of connective tissue (pneumosclerosis) after acute or chronic inflammatory processes, such as acute lobar pneumonia (with subsequent carnification of the lung), lung infarction, pulmonary abscess, tuberculosis, etc.;resection of a pan or the entire lung; atelectasis (collapse of the lung or its portion) that may occur due to closure of the lumen in a large bronchus by a foreign body or a tumour growing into the lumen of the bronchus and causing its obturation. The closure of the air passage into the lung with subsequent resorption of air from the alveoli and a decrease in the volume of the lung diminish the corresponding half of the chest. The chest thus becomes asymmetrical, the shoulder of the affected side lowers, the clavicle and the scapula lower as well, and their movements during deep respiration become slower ttnd limited; the supra- and subclavicular fossae become more depressed, the intercostal spaces decrease in size or become invisible. The marked depression of the supraclavicular fossa on one side often depends on the diminution of the apex of a fibrosis-affected lung.


Dynamic inspection. Inspection of the lungs involves primarily observation of respiratory movements, which are discussed. Respirations are evaluated for (1) rate (number per minute), (2) rhythm (regular, irregular, or periodic), (3) depth (deep or shallow), and (4) quality (effortless, automatic, difficult, or labored). The doctor also notes the character of breath sounds based on inspection without the aid of auscultation, such as noisy, grunting, snoring, or heavy.

Movement of the chest wall is noted. It should be symmetric bilaterally and coordinated with breathing. During inspiration the chest rises and expands, the diaphragm descends, and the costal angle increases. During expiration the chest falls and decreases in size, the diaphragm rises, and the costal angle narrows.

Any asymmetry of movement is an important pathologic sign and is reported. Decreased movement on one side of the chest may indicate pneumonia, pneumothorax, atelectasis, or an obstructive foreign body. Marked retraction of muscles either between the ribs (intercostal), above the sternum (suprasternal), or above the clavicles (supraclavicular) is always noted, because it is a sign of respiratory difficulty.

Normal respiratory rate is 16-20 per min. The respiratory rate is always evaluated in relation to general physical status. For example, tachypnea is expected with fever, because for every degree Fahrenheit elevation in temperature, the respiratory rate increases 4 breaths per minute. The usual ratio of breaths to heartbeats is 1:4.

Respiratory movements of the chest should be examined during inspection of the patient. In physiological conditions they are performed by the contraction of the main respiratory muscles: intercostal muscles, muscles of the diaphragm, and partly the abdominal wall muscles. The so-called accessory respiratory muscles (mm. sternocleidomastoideus, trapezius, pectoralis major et minor, etc.) are actively involved in the respiratory movements in pathological conditions associated with difficult breathing.

The type, frequency, depth and rhythm of respiration can be determined by carefully observing the chest and the abdomen. Respiration can be costal (thoracic), abdominal, or mixed type.

Thoracic (costal) respiration. Respiratory movements are carried out mainly by the contraction of the intercostal muscles. The chest markedly broadens and slightly rises during inspiration, while during expiration it narrows and slightly lowers. This type of breathing is known as costal and is mostly characteristic of women.

Abdominal respiration. Breathing is mainly accomplished by the diaphragmatic muscles; during the inspiration phase the diaphragm contracts and lowers to increase rarefaction in the chest and to suck in air into the lungs. The intra-abdominal pressure increases accordingly to displace anteriorly the abdominal wall. During expiration the muscles are relaxed, the diaphragm rises, and the abdominal wall returns to the initial position. This type of respiration is also called diaphragmatic and is mostly characteristic of men.

Mixed respiration. The respiratory movements are carried out simultaneously by the diaphragv and the intercostals muscles.


Respiration rate may be determined by counting the movements of the chest or the abdominal wall, while the patient is being unware of the procedure (during examination of his pulse, for example). In norm the respiration rate is within 16-20 breathing movements a min. It is increased in dyspnea and rises in the case of inhibition of respiratory center.

Respiration rhythm. Respiration of a healthy person is rhythmic, of uniform depth and equal length of the inspiration and expiration phases. Rhythm of the respiratory centre can be inhibited, in some types of oedema. Derangement of the respiratory function can (pause oedema in which a series of respiratory movements alternates with a pronounced (readily detectable) elongation of the respiratory pause (lasting from a few seconds to a minute) or to a temporary arrest of respiration (apnoea). This respiration is known as periodic.

Biot's respiration is characterized by rhythmic but deep respiration movements which alternate (at approximately regular intervals) with 1ong| respiratory pauses (from few seconds to half a minute). Biot's respiration occurs in meningitis patients and in agony with disorders of cerebral circulation.

Cheyne-Stokes' respiration is characterized by periods (from seconds to a minute) of cessation of respiration, followed by noiseless shallow respiration, which quickly deepens, becomes noisy to attain hj maximum at the 5-7th inhalation, and then gradually slows down to end with a new short respiratory pause. During such pauses, the patient often loses his sense of orientation in the surroundings or even faints, to recover from the unconscious condition after respiratory movements are restored. This respiratory disorder occurs in diseases causing acute or chronic insufficiency of cerebral circulation and brain hypoxia, and also in heavy poisoning. More frequently this condition develops during sleep and is more characteristic of aged persons with marked atherosclerosis of the cerebral arteries.

Undulant (wave-like) Groccos respiration somewhat resembles Cheyne-Stokes respiration exept that a weak shallow respiration occurs instead of the respiratory pause with subsequent deepening of the respiratory movement, followed by slowing down. This type of arrhythmic dyspnoea can probably be regarded as the early stages of the same pathological processes which are responsible for resembles Cheyne-Stokes respiration.


Palpation as a method of examination

Palpation involves the use of the doctor's hands to feel texture, size, shape, consistency, and location of certain parts of the client's body and also to identify areas the client reports as being tender or painful. This technique requires the doctor to move into the client's personal space. It is important that the touch is gentle, hands are warm, and nails are short to prevent discomfort or injury to the client. Touch has cultural significance and symbolism. Each culture has its own understanding about the uses and meanings of touch. As a result, it is of utmost importance that doctors tell clients the purpose of their touch (e.g., "I'm feeling for lymph nodes now") and manner and location of touch (e.g., "I'm going to press deeply on your abdomen to feel the organs"). Gloves are worn when palpating mucous membranes or any other area where contact with body fluids is possible.

The palmar surfaces of fingers and finger pads are more sensitive than the fingertips; thus they are better for determining position, texture, size, consistency, masses, fluid, and crepitus. The ulnar surface of the hand extending to the fifth finger is the most sensitive to vibration, whereas the dorsal surface of the hand is better for assessing temperature.

Palpation using the palmar surfaces of the fingers may be light or deep and is controlled by the amount of pressure applied. For example, when examining the abdomen, light palpation is accomplished by pressing to a depth of approximately 1 cm and is used to assess skin, pulsations, and tenderness. Deep palpation, accomplished by using one or both hands to press in up to 4 cm, is used to determine organ size and contour. Light palpation should always precede deep palpation because palpation may cause tenderness or disrupt fluid, which would interfere with collecting data by light palpation. A bimanual technique of palpation uses both hands, one anterior and one posterior, to entrap an organ or mass between the fingertips to assess size and shape. This technique is used to assess the kidneys and uterus.


The sequence and technique of palpation of a chest



Palpation of the chest in user for determination of following:

To locate the pain in the chest and its irradiation carefully press with your fingers along each intercostal space.

Resistance or elasticity of the chest is determined by exerting preassure of the examining hands from the front to the sides and on the back and the , sternum and also by palpation of intercostal spaces.

The strengs of voice conduction to the chest surface (vocal fremitus) The palms of the hands are placed on the symmetrical parts of the chest and the patient is asked to utter loudly words with the letter r in them.

Palpation is used as an additional means of examination to verify findings of inspection (the shape of the chest, its dimensions, respiratory movements(, for determining local or profuse tenderness of the chest, its elasticity (resilience), vocal fremitus, pleural friction and sounds of fluid in the pleural cavity.

Palpation should be done by placing the palms on the symmetrical (left and right) parts of the chest. This examination helps follow the respiratory excursions and deviation of the chest movements from their normal course. During respiration the hands will move with the chest wall. The doctor evaluates the amount and speed of respiratory excursion, noting any asymmetry of movement. Normally the amplitude of movements are equal on both chest parts..

Evaluation of respiratory excursion

The epigastric angle as determined by palpation as well. The thumbs should be pressed tightly against the costal arch, their tips resting against the xiphoid process (ensiform cartilage).

Palpation is used to locate pain in the chest and its irradiation. For example, in rib fracture, pain is located over a limited site, namely at the point of the fracture. Displacement (careful!) of bone fractures will be attended in this case by a specific sound (crunch). Inflammation of the intercostal nerves and muscles also causes pain, but it can be felt during palpation over the entire intercostal space. Such pain is called superficial. It is intensified during deep breathing, when the patient bends to the affected side, or lies on this side.

Resilience or elasticity of the chest is determined by exerting pressure of the examining hands from the front to the sides of the chest or on the back at the sternum, and also by palpation of the intercostal spaces. The chest of a healthy person is elastic, plaint and yields under the pressure. In the presence of pleurisy with effusion, or pleural tumour, the intercostal space over the affected site becomes rigid. Rigidity of the chest increases in general in the aged due to ossification of the costal cartilages, development the lung emphysema, and also with filling of both pleural cavities with fluid. Increased resistance of the chest can then be felt during examining |the chest by compression in both the anteroposterior and lateral directions.

Palpation is used for determining the strength of voice conduction to chest surface {fremitus vocalis s. pectoralis). Vocal fremitus depends on the conduction of voice sounds through the respiratory tract. The palms of the hands placed on the symmetrical parts of the chest and the patient is asked to i loudly a few words (with the letter 'r' in them to intensify vibration). The doctor can ask the patient to repeat words, such as "ninety-nine", "one, two, three," "eee-eee". The patient should speak the words with a voice of uniform intensity. The voice should be as low as possible since voice vibrations are better transmitted by the air column in the trachea and the bronchi to the chest wall in this case. Vibrations are felt as the hands move symmetrically on either side of the sternum and vertebral column.

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Determination of vocal fremitus (position of examiners hands)


In general vocal fremitus is the most intense in the regions of the thorax where the trachea and bronchi are the closest to the surface, particularly along the sternum between the first and second ribs and posteriorly between the scapulae. Progressing downward, the sound decreases and is least prominent at the base of the lungs.

Vocal fremitus is of about the same intensity in the symmetrical parts of the chest of a healthy person. Vocal vibrations are louder in the upper parts of the chest and softer in its lower parts. Moreover, voice conduction is better in men with low voice and thin chest; the vibrations are weaker in women and children with higher voice (and also in persons with the well developed subcutaneous fat tissues). Vocal fremitus can be stronger or weaker (or in some cases it can even be impalpable) in pathological conditions of the respiratory organs. In focal affections, vocal fremitus becomes unequal over symmetrical parts of the chest.

Percussion as a method of examination

Percussion is performed to evaluate the size, borders, and consistency of some internal organs; to detect tenderness; and to determine the extent of fluid in a body cavity. There are two percussion techniques: direct and indirect.

Direct percussion involves striking a finger or hand directly against the client's body. The doctor may use direct percussion technique to evaluate the sinus of an adult by tapping a finger over the sinus, or to elicit tenderness over the kidney by striking the costovertebral angle (CVA) directly with a fist.

Indirect percussion requires both hands and is done by different methods depending on which body system is being assessed. Indirect fist percussion of the kidney, for example, involves placing the nondominant hand palm down (with fingers together) over the CVA and gently striking the fingers with the lateral aspect of the fist of the dominant hand.

Indirect percussion of the thorax or abdomen is performed by placing the distal aspect of the middle finger of the nondominant hand against the skin over the organ being percussed. This finger is sometimes referred to as the pleximeter. The other fingers of that hand are spread apart and slightly elevated off the client's skin so that they do not dampen the vibration. With the tip of the middle finger of the dominant hand (the plexor), the examiner strikes the distal interphalangeal joint, or just distal to the joint, that lies against the client's skin. The tip of the striking finger hits the middle finger, which is against the skin, between the cuticle and first joint. Some examiners use both the index and middle fingers as plexors. The wrist must be relaxed and loose while the . pleximemer remains stationary. Rebound the plexor finger as is it strikes the pleximeter so that the vibration is not lost. Listen for the vibrations created by one finger strikes to-other. Tapping produces a vibration 1.5 to 2 inches (4 to ~ deep in body tissue and subsequent sound waves). Per- two or three times in one location before moving to an-other position. Stronger percussion will be needed for obese or very - obese clients, because thickness of tissue can impair the vibrations; the denser the tissue, the quieter the percussion.

Five percussion tones are described:

- Tympanic isloud, high-pitched sound heard over the abdomen.

- Resonance is heard over normal lung tissue, whereas

-         hyper-resonance is heard in overinflated lungs (as in emphysema).

-         - Dullness is heard over the liver, and

-         - flatness is heard over bones and muscle.

Detecting sound changes is easier when moving from resonance to dullness (e.g., from the lung to the liver). Indirect percussion can be mastered with practice.


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Immediate percussion by different methods: generally adopted method; by Yanovsky; by Obrastsov


The lungs are percussed in order to evaluate the densities of the underlying organs. Resonance is heard over all the lobes of the lungs that are not adjacent to other organs. Dullness is heard beginning at the fifth interspace in the right midclavicular line. Percussing downward to the end of the liver, a flat sound is heard because the liver no longer overlies the air-filled lung. Cardiac dullness is felt over the left sternal border from the second to the fifth interspace medially to the midclavicular line. Below the fifth interspace on the left side, tympany results from the air-filled stomach. Deviations from these expected sounds are always recorded and reported.

Percussion of the chest


In comparative percussing the chest, the anterior lung is percussed from apex to base, usually with the patient in the supine or sitting position. Each side of the chest is percussed in sequence in order to compare the sounds, such as the dullness of the liver on the right side with the tympany of the stomach on the left side. When percussing the posterior lung, the procedure and sequence are the same, although the patient should be sitting. Normally only resonance is heard when percussing the posterior thorax from the shoulder to the eighth or tenth rib. At the base of the lungs dullness is heard as the diaphragm is percussed.

The rules and technique of comparative percussion

A certain sequence is followed in comparative percussion. Percussion sounds over the lung apices (in the front) on the symmetrical points of the chest are first compared; the pleximeter finger is placed parallel to the clavicle. The plexor finger is then used to strike the clavicle which is used as a pleximeter in this case. During percussion of the lungs below the clavicle, the pleximeter finger is placed in the interspace at the strictly symmetrical points of the left and right sides of the chest. The plexor finger is then used to strike the clavicle which is used as a pleximeter in this case. During percussion of the lungs below the clawicle, the pleximeter finger is placed in the interspace at the strictly symmetrical points of the left and right sides of the chest. The percussion sounds are compared only to the level of the 4th rib along the medioclavicular line (and medially). The heart lying below this level changes the percussion sound. For comparative percussion of the axillary region, the patient should raise his arms and clamp the hands at the back of the head. Comparative percussion of the lungs on the back begins with suprascapular areas. The pleximeter finger is placed horizontally, while during percussion of the regions between the scapulae, the pleximeter should be vertical. The patient should cross his arms on the chest to displace the scapulae anteriorly (away from the backbone). During percussion of the points lying below the scapulae, the pleximeter should again be horizontal; in the interspace it should be placed parallel to the ribs


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Topographic percussion

In topographic percussing the chest, the doctor looks for the lungs borders in the main lines, the location of the apex of the lung and width of Kroenigs areas.

In topographic percussion the margin of the lung is assessed from the side of resonance sound.

The upper margin of the lung (the location of the apex of the lung) is determined by percussions from the clavicle to the neck. The apex of each lung rises about 2 to 4 cm above the inner third of the clavicles in front of the body At the back we examine the location of the apex of the lung by percussions from the scapula axis to the seventh cervical vertebra. Normally, the upper border of the lung is in the seventh cervical vertebra at the back.


The width of Kroenigs areas is determined by percussions from the middle of muscle trapezium to each direction (to neck and shoulder) to disappearance of the resonance. Normally, the width of Kroenigs areas is 3-5 cm.

The excursion of the lung is the distance between the lower costal margin of the lungs in the maximum inspiration and maximum expirations. Normally, the excursion of the lung is 2-6 cm.


The rules of the topographic percussion

During topographic percussion of lungs one should apply such rules as follows

-         the finger-pleximeter should be placed parallel to the border of the organ one is seeking for;

-         percussion should be carried out from resonans pulmonary sound to dull one.

-         If the lungs borders has being determined, they should be marked on the edge of the finger-pleximeter from the side of resonans pulmonary sound.

2. Definition of height of the lungs apexes.

The lungs apexes should be determined on anterior and posterior surface of the chest. To find out the height of the lungs apexes anteriorly percuss from the midpoint of each clavicle parallel to their axis in progressive steps downwards as well as quite medially untill dull percussion notes will be heared. Posteriorly percussion should be carried out from the center of suprascapular area in direction to the point, placed on 3-4 cm laterally to the 7th cervical spinous processus. In norm the apex of each lung rises anteriorly about 2-4 cm above the inner third of the clavicle, posteriorly is placed approximately at the level of the 7th cervical spinous processus.

Technique of Kroenigs area width definition

The locations of the lungs apexes can be mentally projected onto the each shoulder so-called Krenigs area. To determine this zone one should use a quiet percussion, moving the finger-pleximeter from the center of trapezoid muscle across the top of each shoulder in direction both to the neck and to the shoulder joint. Percuss across the top of each shoulder to identify the approximately 5-cm band of resonance overlying each lungs apex. In healthy persons the width of dullness makes approximately 3-8 cm.


The upper border of the lung and width of the Kroenigs area can vary depending on the amount of air in the apices. If the amount of air is high (for example, due to emphysema) the apices increase in size and move upwards. The Kroenigs area widens accordingly. The presence of connective tissue in the lungs apex (which usually develops during inflammation as in tuberculosis or pneumonia or inflammatory infiltration) decreases the airness of the pulmonary tissue. The upper border of the lung lowers and the width of the Kroenigs area decreases.


Determination of the lower lungs borders and their mobility

To determine the lower lungs borders one should held the pleximeter finger parallel to the expected border of diaphragmatic dullness, percuss in progressive steps downwards on parasternal, midclavicular, anterior axillary, midaxillary, posterior axillary, scapular and paravertebral lines from the right and left side. Identify the level of diaphragmatic dullness on each side during quiet respiration. This level is often slightly higher on the right. Anteriorly the low border of the left lung on parasternal and midclavicular lines is not distinguished because of heart dullness.

The lower border of the right lung is as a rule at the point of transition of the clear pulmonary resonance to dullness (lung-liver border). In exceptional cases, when air is present in the abdominal cavity (e.g. in perforation of gastric or duodenal ulcer), liver dullness may disappear. The clear pulmonary resonance will then convert to tympany. The lower border of the left lung by the anterior and midaxillary lines is determined by the transition of clear pulmonary resonance to dull tympany. This is explained by the contact between the lower surface of the lung (through the diaphragm) and a small airless organ, such as the spleen and the fundus of the stomach, which give tympany (Traubes space).



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Key points of projection of the lungs low borders on the anterior and posterior chest include the following:


Topographic line

The right lung

The left lung


The Vth intercostal space



The VIth rib


Anterior axillary

The VIIth rib

The VIIth rib


The VIIIth rib

The VIIIth rib

Posterior axillary

The IXth rib

The IXth rib


The Xth rib

The Xth rib


At the level of the 11th thoracic spinous processus

At the level of the 11th thoracic spinous processus


After determining the lower border of the lungs respiratory mobility of pulmonary borders should be determined by percussion during forced inspiration and expiration. The lungs lower borders mobility can be active or passive.

The active mobility is those observed at respiration, passive at changes of patients position. Active mobility is usually measured by the difference in the position of the lower border of the lungs between the two extremes.

The active lower lungs borders mobility can be measured by noting the distance between the levels of diaphragmatic dullness on full expiration and full inspiration, normally around 5-6 cm. Measurements are done by three lines on the right side (midclavicular, axillary, and scapular lines) and two lines on the left side (midaxillary and scapular lines). The normal variation of the lower border of the lungs is described by the figures given in the table. Mobility of the lower border of the left lung by the midclavicular line can not be determined because of the interference of the heart.


Determination of respiratory mobility of the lower lung border


The active mobility of lungs is quite different on different topographic lines and includes following:

Topographic line

The right lung

The left lung


3-4 cm



5-6 cm

5-6 cm


3-4 cm

3-4 cm


Auscultation of lungs

Attention should be paid to the main respiratory sounds, such as vesicular (alveolar) breathing which is heard over the pulmonary tissues, and bronchial (laryngotracheal) breathing which is heard over the larynx, trachea, and large bronchi.

In the presence of pathology in the air ways, in the alveolar tissue or in the pleura, adventitious sounds such as rales, crepitation, and pleural friction, are heard in addition to the main breath sounds during inspiration and expiration. These adventitious sounds should be examined only after the character of the main sounds has been established.

Normal breathing sounds should be better auscultated with the nasal breathing (with the patients mouth closed) while adventitious sounds are better heard with deep respiration through the open mouth.

Prior to listening over any one area of the chest, remind yourself which lobe of the lung is heard best in that region: lower lobes occupy the bottom 3/4 of the posterior fields; right middle lobe heard in right axilla; lingula in left axilla; upper lobes in the anterior chest and at the top 1/4 of the posterior fields. This can be quite helpful in trying to pin down the location of pathologic processes that may be restricted by anatomic boundaries (e.g. pneumonia). Many disease processes (e.g. pulmonary edema, bronchoconstriction) are diffuse, producing abnormal findings in multiple fields.

Put on your stethoscope so that the ear pieces are directed away from you. Adjust the head of the scope so that the diaphragm is engaged. If you're not sure, scratch lightly on the diaphragm, which should produce a noise. If not, twist the head and try again. Gently rub the head of the stethoscope on your shirt so that it is not too cold prior to placing it on the patient's skin.


: : : normal auscultation


Auscultate the lungs, listening to inspiration and expiration at each site.


Vocal resonance (bronchophony)


Place the stethoscope on the chest and ask the patient to say 'ninetynine". Normally the sound produced is 'fuzzy' and seems to come from the chest piece of the stethoscope. The changes in disease should by now be predictable. The sound is increased in consolidation (better transmission through solid lung)and decreased if there is air, fluid or pleural thickening between the lung and the chest wall. The changes of vocal fremitus are the same. Both tests are of little value in themselves, yet a refinement of vocal resonance can be very uscful. Sometimes the increased transmission of sound is so marked that even when the patient whispers, the sound is still heard clearly over the affected lung (whispering pectoriloquy). When this is well developed there is a striking difference between the normal side, where the sound appears to come from the end of the stethoscope and the abnormal side where the syllables are much clearer and seem as if they are being whispered into your ear.Bronchial breathing and whispering pectoriloquy often occur together. Consequently, if you are in doubt about the presence of bronchial breathing then whispering pectoriloquy may confirm it. Like bronchia] breathing, whispering pectoriloquy is characteristic of consolidation but can also occur with lung abscess and above an effusion.



Examination of patients with cardiovascular system diseases.


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Data of general inspection

During examination of a patient you should pay attention to his general condition, posture, motor acivity, gait, skin color, facial expressions. Labored breathing, wheezing, cough are typical for heart decompensation.

The general appearance of the patient, his posture in bed, colour of the skin and visible mucosa, the presence of abcense of edema, the shapes of the terminal finger phalanges (clubbing fingers) and the belly should be assessed.

You should notice the patients forced posture for example, preference for sitting up in the left-sided heart failure. Patients with expressed dyspnea usually lay in bed with high head end, at heavy dyspnea the patient is sitting with the lowered downwards legs (opthopnea). At exudative pericarditis patients prefer to sit, a little having bent forward. At heart dilatation they more often lay on the right side, as in postion on the left side the unpleasant sensations can occur.

: : : angina


Observe facial expressions at rest, during conversation about specific topics, during the physical examination, and in interaction with others. For the heart diseases anxiety, depression, sweading expressions are typical.

In elevation of intrathoracic pressure swelling of neck veins is visible;

: : : 5-4


The colour of the skin is important for diagnosis of some heart diseases. A skin pallor, cyanosis or yellowness may often be revealed in the patients with heart diseases.

Cyanosis. In heart diseases cyanosis is expressed on distant from heart sites (fingers of hands and legs, tip of the nose, lips, ear bowls).

: : : : : : 5-130



In the case if decompensation the central cyanosis can occur. Mitral stenosis can be diagnosed by the violet-red colour of the patient's cheeks, mildly cyanotic colour of the lips, nose, and extremities, rhe skin and visible mucosa of patients with aortal heart diseases are usually pale. Cyanosis in combination with pallor (pallid cyanosis) is characteristic of stenosis of the orifice of the pulmonary trunk or thrombosis of the pulmonary artery. Icteric colour of the sclera and skin is characteristic of grave circulatory insufficiency. The skin of patients with persisting septic endocarditis has a peculiar colour resembling that of coffee with milk.

: : : 5-85 : : : 13-125


Cyanosis in mitral stenosis


Venous insufficiency is characterized by a dark bluish/purple discoloration. Over time, long standing stasis of blood leads to the deposition of hemosiderin, giving the skin a dark, speckled appearance. If the leg is placed in a dependent position, the bluish/purple discoloration may darken dramatically, further suggestive of venous insufficiency. This occurs as a result of gravity working against an already ineffective blood return system. Patients with severe arterial insufficiency, on the other hand, may have relatively pale skin as a result of under perfusion. When their legs are placed in a dependent position, gravity enhances arterial inflow and the skin may become more red as maximally dilated arterioles attempt to bring blood to otherwise starved tissues. In cases of severe ischemia, the affected areas (usually involving the most distal aspect of the foot), can appear whitish or mottled, giving the leg a marbleized appearance. Dead tissue turns black (a.k.a. gangrene)

Oedema frequently attends heart diseases. In gross heart lesions venous congestion in pulmonay ciculation as well as overload of right ventricle develop. They result in venous congestion in systemic ciculation and occurence of edema. Cardiac edema appear only to the evening at first and resolve for night and placed in the area of condilus, crues and back party of feets. In heavier cases the fluid accumulates in abdominal cavity and the patients complain on feeling of weight in the abdomen. If the patient stays out of bed, oedema is localized mainly in the malleolus, the dorsal side of the feet, and the shins, where a pressure of fingers leaves slowly levelling impresions. If the patient lies in bed, oedema is localized in the sacrolumbal region.

Determination of edema


If congestion in portal system develops the pain in the right hypochondrium occurs. At a bed mode edema are located on the back side of patients trunk. At severe heart disease with decompensation of heart failure hydrotorax, ascites or hydropericardiunm develop.

If oedema is significant, it may extend onto the entire body while the ascitic fluid accumulates in various cavities of the body, such as the pleural cavity (hydrothorax), abdominal cavity (ascites), or in the pericardium (hydropericardium). Generalized oedema is called anasarca. The oedematous skin, especially the skin of the extremities, is pallid, smooth, and tense. In persistent oedema, the skin becomes rigid, its elasticity is lost, and the skin acquires a brown tinge due to diapedesis of erythrocytes from the congested vessels. Linear rhexes may develop in the subcutaneous fat of i he abdomen in pronounced oedema, which resemble the scars of pregnancy. In order to assess objectively the degree of oedema, the patient should be weighed regularly and the amount of liquid taken and excreted should foe strictly recorded.

Local oedema sometimes develops in cardiovascular pathology. When the superior vena cava is compressed, for example in exudative pericarditis or aneurysm of the aortal arch, the face, neck, and the shoulder girdle can foe affected by oedema (the collar of Stokes). In thrombophlebitis of the shin or thigh oedema of the affected extremity forms; ascites develops during thrombosis of the portal vein or the hepatic veins.

While edema is a relatively common finding in the lower extremity, it rarely occurs in the arms and hands. This is because the lower extremities are exposed to greater hydrostatic pressure due to their dependent position. Upper extremity edema, when present, usually occurs focally over an area of local inflammation (e.g. cellulitis). Diffuse arm edema can occur if drainage is compromised, as when the lymphatics are disrupted following axillary lymph node surgery for staging and treatment of breast cancer. Upper extremity venous obstruction can also cause edema, though blood clots in this region are much less common then in the lower extremity.

: : : upper extremity edema


Edema is commonly associated with venous insufficiency, a blood return problem. This disorder tends to get worse when the legs are allowed to dangle for prolonged periods below the level of the heart (e.g. towards the end of the day if the patient has been standinag for long periods of time). The fluid builds up preferentially in the most distal aspects of the leg and progress up towards the knee as the process worsens. Arterial insufficiency, on the other hand, rarely causes edema, which makes perfect sense as the problem lies in the delivery of blood to the extremity, not the return from it. On occasion, the conditions may coexist.

Capillary Refill: Push on the tip of the great toe or the nail bed until blanching occurs. Then release and note how long it takes for the red color to return, a reflection of blood inflow to the distal aspect of the lower extremity. Longer then 2-3 seconds is considered abnormal and consistent with arterial insufficiency. Refill may also be delayed in the setting of significant hypovolemia, as decreased blood volume available for perfusion is shunted away from the extremities to feed more vital organs.

Inspection of precordial (heart) region

You should inspect the precordium, assess the apical impulse, identify the jugular venous pulsations.

During the examination the patient should be lying with his upper body somewhat elevated. If you are examining the patients anterior chest, visualize the underlying cardiac chambers and great vessels: the right and left ventricles, the aorta, and the pulmonary artery. Try to detect any abnormal pulsations that they can produce.

You can see cardiovascular pulsations more easy when patients are thin. In contrast, a thick wall can obscure them, and lung tissue can intervene when age or emphysema increases the anteroposterior to detect pulsations. Observe for any pulsation on the aortic, pulmonary area or the right ventricular area (lower half of the sternum and the parasternal area, especially on the left). Observe for diffuse lift or heave. You can reveal pulsation of aortic aneurism or pulsation of increased pressure or flow in the pulmonary artery; in patients with anaemia, hyperthyroidism, fever, where cardiac output is increased, a brief right ventricular impulse may be revealed in epigastrium.


While examining the chest, any obvious bulging is noted, especially on the left side, which may indicate cardiac enlargement. This is best done by observing the patient sitting and looking at the anterior chest wall from an angle, comparing both sides of the rib edge to each other. Normally they should be symmetric. In patients with thin chest walls, the point of maximum impulse, or apical pulse, is sometimes apparent as a pulsation. Noting the location of the impulse may give some indication of the size and positioning of the heart, especially if it deviates from the expected apical site.

Since comprehensive evaluation of cardiac function is not limited to the heart, the doctor also considers other findings, such as presence of all pulses (especially the femoral pulses), distended neck veins, peripheral cyanosis, edema, blood pressure, and respiratory status.


Cardiac hump-back can be seen during inspection of the precordium. This is bulging of the area over the heart. The degree of protrusion depending on the enlargement and hypertrophy of the heart (provided these defects develop in childhood when the chest is liable to changes). General protrusion of the cardiac region and levelling of the costal interspaces are observed in massive effusive pericarditis. The cardiac hump should be differentiated from deformation of the chest caused by changes in the bones, e.g. in rickets.

Apical and heart beat, their peculiarities

In patients with underdeveloped subcutaneous fat and asthenic body build, a limited rhythmic pulsation (the apex beat) can be seen in the fifth interspace, medially of the midclavicular line. This is caused by the thrust of the heart apex against the chest wall. In cardiac pathology, the apex beat may produce a stronger pulsation. If precordial depression is found instead of prominence, the apex beat is said to be negative. It occurs in adhesive pericarditis because of adhesion of the parietal and visceral layers of the pericardium.

Pulsation is sometimes observed to the left of the sternal line over a vast area extending to the epigastric region. This is the so-called cardiac beat. It is due to contractions of the enlarged right ventricle; a synchronous pulsation can also be seen in the upper epigastric region (below the xyphoid process).

Pulsation in the region of the heart base is sometimes observed. Pulsation of the aorta can be felt in the second costal interspace to the right of the sternum; it appears either during its strong dilation (aneurysm of the ascending part and of the arch of the aorta; aortic valve incompetence), or in sclerotic affection of the overlying right lung. In rare cases, the aneurysm of the ascending aorta can destroy the ribs and the sternum. Elastic throbbing tumour is then seen. Pulsation in the second and third costal interspace, that can be seen by an unaided eye, is caused by dilatation of the pulmonary trunk. It occurs in patients with mitral stenosis, marked hypertension in the lesser circulation, patent ductus arteriosus with massive discharge of the blood from the aorta to the pulmonary trunk, and in primary pulmonary hypertension. Pulsation occurring lower, in the third and fourth interspace to the left of the sternum, can be due to the aneurysm of the heart in post-infarction patients.

In at least half of adults the apical impulse may be revealed in the apical or left ventricular area (the 5th intercostal space or just medial to the midclavicular line), especially in thin persons. Normally the apical impulse is just medial to the midclavicular line in either the 5th or 4th interspase.

The apical impulse may be displaced upward and to the left by pregnancy or a high left diaphragm. It may also be displaced by deformities of the chest wall and by heart disease. When cardiac output is increased, as in anaemia, hyperthyroidism, fever, or pregnancy, the apical impulse can have an increased amplitude.

Normally the apical impulse is a light tap, seen in an area about 1 cm to 2 cm in diameter or less.

Look and feel carefully for any extra impulses, such as those that can coincide with S3 to S4.

A rare patients has dextrocardia a heart situated in the right chest. The cardiac impulses will then be found on the right side.

At left ventricular enlargement the apical impulse may be displaced to the left and downward. Its square occupies 3 cm or more, two or more interspaces. When the ventricle is dilated as well as hypertrophied, the apical impulse is also both displaced and enlarged.




Technique of palpation: In order to determine the apex beat, the palm of the right hand is placed on the patient's chest. (The left mammary gland in women is first moved upward and to the right.) The base of the hand should be rested on the sternum, while the fingers should be directed toward the axillary region, between the 3rd and 4th ribs. The terminal phalanges of three fingers should be flexed to form a right angle to the surface of the chest, and moved slowly along the interspaces toward the sternum until the moderately pressing fingers feel the movement of the heart apex. If the apex beat is felt over a considerable area, its borders are outlined hy locating the extreme left and lower points of the protruding area, which is considered to be the point of the apex beat. The apex beat can be better detected if the patient slightly leans forward, or by palpation during a deep expiration: in this position the heart is pressed closer to the chest wall.



A normal apex beat is found in the fifth interspace, 1-1.5 cm toward the sternum from the left midclavicular line. When the patient lies on his left side, the beat is displaced 3-4 cm to the left, and 1-1.5 cm to the right when the patient lies on the right side.


Properties of the apex beat: Stable displacement of the apex beat may depend on the changes in the heart itself or the adjacent organs. For example, if the left ventricle is enlarged, the apex beat is displaced to the left to the axillary line, and downwards to the 6th and 7th interspace. If the right ventricle is dilated, the apex beat may be displaced to the left as well because the left ventricle is moved to the left by the distended right ventricle. In cases with abnormal congenital heart position, e.g. in dextrocardia, the apex beat is felt in the fifth costal interspace, 1-1.5 cm toward the sternum from the right midclavicular line The position of the apex beat depends also on the diaphragm. Increased pressure in the abdominal cavity (in pregnancy, ascites, meteorism, tumours) displaces the apex beat upward and to the left because the heart is not only lifted but also turned to the left to assume a horizontal position. If the diaphragm is low (after childbirth, wasting, visceroptosis), the apex beat is displaced downward and slightly to the right to assume the more vertical position.

In the presence of effusion or gas in the right pleural cavity, the apex beat is displaced to the left accordingly. Pleuropericardial adhesions and sclerotic affection of the lungs due to growth of connective tissue in them displace the heart to the involved side. In patients with left-sided pleurisy with effusion and in accumulation of the fluid in the pericardial region, the apex beat disappears. In about one third of cases the apex is impalpable (covered by the rib).



The relative and absolute heart dullness, the sequence of percussion of heart dullness borders, their normal indicies

The right contour of dullness of the heart and the vascular bundle is formed (from top to bottom) by the superior vena cava to the upper edge of the 3rd rib and by the right atrium at the bottom. The left contour is formed by the left part of the aortic arch at the top, then by the pulmonary trunk, by the auricle of the left atrium at the level of the 3rd rib and downward by a narrow strip of the left ventricle. The anterior surface of the heart is formed by the right ventricle. Being an airless organ, the heart gives a dull percussion sound. But since it is partly covered on its sides by the lungs, dullness is dual in its character, i.e. it is relative (deep) and absolute (superficial). The relative cardiac dullness is the projection of its anterior surface onto the chest. It corresponds to the true borders of the heart, while the absolute dullness corresponds to the anterior surface of the heart that is not covered by the lungs. Percussion can be done with the patient in both erect and lying position. It should, however, be remembered that the area of cardiac dullness in the vertical position is smaller than in the horizontal. This is due to mobility of the heart and the displacement of the diaphragm as the patient changes his posture.

Determining relative cardiac dullness. When determining the borders of relative cardiac dullness, interspaces should be percussed in order to avoid lateral distribution of vibrations along the ribs. The percussion stroke should be of medium strength. The pleximeter-inger should be tightly pressed against the chest so that the percussion vibration might penetrate deeper regions.

When determining the border of relative dullness, the remotest points of the cardiac contour are first found on the right, then on the left, and finally at the top. Since the border of cardiac dullness depends on the position of the diaphragm, the lower border of the right lung is first determined in the midclavicular line; its normal position is at the level of the 6th rib. The position of the lower border of the lung indicates the level of the diaphragm. The pleximeter-finger is then moved one interspace above the lower border of the right lung and placed parallel to the right border of the heart being determined (normally, in the 4th costal interspace). Percussion is continued by moving the pleximeter-finger gradually along the interspace toward the heart until the percussion sound dulls. The right border of the heart is marked by the outer edge of the finger directed toward a clear resonant sound. Its normal position is 1 cm laterally of the right edge of the sternum.

: : :


The left border of the relative cardiac dullness is determined in the interspace, where the apex beat is present. The apex beat is therefore first determined by palpation, and the pleximeter-fmger is then placed laterally of this point, parallel to the sought border, and the interspace is percussed toward the sternum. If the apex beat cannot be determined, the heart should be percussed in the 5th interspace from the anterior axillary line toward the sternum. The left border of relative cardiac dullness is located 1-2 cm medially of left midclavicular line; it coincides with the apex beat.

The upper border of the relative cardiac dullness is determined 1 cm to the left of the left sternal line. To that end, the pleximeter-fmger is placed perpendicularly to the sternum, near its left margin, and then moved downward until dullness appears. The normal upper border of the relative cardiac dullness is in the 3rd interspace.


Once the area of relative cardiac dullness of the heart has been established, its transverse length is measured by a measuring tape, from the extreme points of the relative dullness to the anterior median line. The normal distance from the right border of relative cardiac dullness (usually in the 4th interspace) to the anterior median line is 3 or 4 cm, while the distance from the left border of relative cardiac dullness (usually in the 5th interspace) to the same line is 8 or 9 cm. The sum of these lengths is the transverse length of relative cardiac dullness (normally 11-13 cm).



: : :


The shape of the heart can be determined by percussion of the borders of the vascular bundle in the 2nd intercostal space on the right and left, and of relative cardiac dullness in the 4th or 3rd interspace on the right, and in the 5th, 4th, or 3rd interspace on the left. The pleximeter-finger is moved parallel to the borders of expected dullness and the elicited points of dullness are marked on the patient's skin. The points are then connected by a line to mark the contours of the relative cardiac dullness. Normally, an obtuse angle is formed by the lines of the left heart contour between the vascular bundle and the left ventricle. The heart is of normal configuration in such cases. In pathological conditions, when the chambers of the heart are dilated, mitral and aortal configurations are distinguished.

Determining absolute (superficial) cardiac dullness. The anterior wall of the heart is not covered by the lungs and the area of absolute cardiac dullness corresponds to the area of the heart. Percussion of this area gives dullness. To determine absolute dullness of the heart, light percussion strokes are needed. The right border uf absolute cardiac dullness is first elicited. The pleximeter-finger is placed on the right border of relative (deep) cardiac dullness, parallel to the sternum, and then moved medially, to the left, to dullness. The border is marked by the outer edge of the finger directed toward resonance. In normal subjects this border parses along the left edge of the sternum.

To outline the left border of absolute cardiac dullness, the pleximeter-finger is placed slightly outside the border of relative cardiac dullness, and then moved medially to dullness. The left border of absolute cardiac dullness is normally 1-2 cm medially of the border of relative cardiac dullness. To elicit the upper border of absolute cardiac dullness, the pleximeter-finger is placed on the upper border of relative cardiac dullness and then moved downward to dullness. The superior border of absolute cardiac dullness is normally at the level of the 4th rib. It is sometimes difficult to differentiate between absolute and relative cardiac dullness, if percussion is done from the lungs to the heart. The pleximeter-finger should in such cases be placed at the centre of absolute dullness and then moved to its borders (from dullness to diminished dullness). The first sign of the admixed pulmonary resonance indicates the transition from the area of absolute dullness to the area of relative dullness.


Borders of cardiac dullness


Border s of absolute cardiac dullness



left sternal line (4th intercostal space)


The upper edge of the III rib (at the left parasternal line)


1-2 cm medialy of left border of relative heart dullness (5th intercostal space)


The width of vessel bundle, normal indicies and pathologiocal changes

The borders of the vascular bundle are determined by light percussion in the second intercostal space, to the right and left from the midclavicular line, toward the sternum. When the percussion sound dulls, a mark should be made by the outer edge of the finger. The right and left borders of vascular dullness are normally found along the edges of the sternum; the transverse length of dullness is 56 cm.


The square of heart dullness, normal indicies and pathologiocal changes

The heart transverse diameter is the sum of shortest distances between the left and right borders of the relative heart dullness to the medial line. It is about 11-13 cm in a healthy person.

The area of cardiac dullness can be modified by extracardiac factors. At high position of the diaphragm, the heart assumes a horizontal position and its transverse dimensions thus increase. When the diaphragm is low, the heart assumes the vertical position and its transverse diameter is thus diminished. Accumulation of liquid or air in one pleural cavity displaces cardiac dullness toward the healthy side; in atelectasis and pneumosclerosis, or in the presence of pleuropericardial adhesion the borders of cardiac dullness are displaced to the affected side. The area of absolute cardiac dullness markedly diminishes or disappears in pulmonary emphysema, while it increases in pneumosclerosis. The area of absolute dullness is also enlarged in the anterior displacement of the heart (e.g. by a mediastinal tumour, due to accumulation of fluid in the pericardium, or in dilatation of the right ventricle). The borders of relative dullness are displaced in the presence of enlarged heart chambers. Displacement to the right is due to dilatation of the right atrium and the right ventricle. If the left atrium or the conus of the pulmonary trunk is enlarged, the area of relative dullness is displaced upwards. Dilatation of the left ventricle displaces the area of relative dullness to the left. It should be remembered that a markedly enlarged and hypertrophied right ventricle displaces the left ventricle and can also displace the border of relative dullness to the left. Aortic dilatation increases the dullness area in the second interspace.


Examination of a pulse

A pulse is a rhythmic fluctuations of arteries walls, caused by emission of blood into arterial bed and changes of blood pressure in it during systole and diastole. With each contraction the left ventricle ejects a volume of blood (a stroke volume) into the aorta and then into the arterial tree. A pressure wave moves rapidly through the arterial system where it can be felt as the arterial pulse. The spreading of a pulse wave depends on the ability of arteries walls to elastic extension and contraction.

Perypheric arterial pulse nay be assessed at carotic, axillary, cubital, radial, femoral, popliteal arteries, arteries of the foot and abdominal aorta.







: : : A doctor checks a patient's pulse at the bilateral radial artery. (Photograph by Dagmar Ehling. Science Source/Photo Researchers. Reproduced by permission.)

A doctor checks a patient's pulse at the bilateral radial artery. (Photograph by Dagmar Ehling. Science Source/Photo Researchers. Reproduced by permission.)

Popliteal arteries. Move down to the level of the knee allowing it to remain slightly bent. Place your hands around the knee and push the tips of your fingers into the popliteal fossa in an effort to feel the popliteal pulse. Note whether it feels simply pulsatile (normal) or enlarged and aneurysmal (uncommon). This artery is covered by a lot of tissue and can be difficult to identify, so you may need to push pretty hard. Even then, it may not be palpable, which is not clinically important if you can still identify the more distal pulses (see below).

: : : Popliteal Artery Palpation : : : Popliteal Artery Palpation




Properties of the pulse are assessed at the radial artery.

First the examiner should determine if the pulse can be equally felt on both arms. To that end both radial arteries should be palpated simultaneously he magnitude of pulse waves on both hands compared (normally it is the same). The pulse on one arm may happen to be lower (in unilateral structural abnormalities in peripheral course of the artery, its constriction, compression by a tumor etc.). Pulse may also be different when similar changes occur in in the brachial or subclavial artery, or due to compression of large arterial trunk by the aortic aneurism, mediastinal tumor, retrosternal goiter, or markedly enlarged left atrium.

Rrhythm. In healthy individuals cardiac contractions and pulse waves follow one another at regular intervals: the pulse is said to be rrhythmic or regular. Some pulse waves nat be missed or they may appear prematurely (in extrasystole) or pulse waves follow one another at irregular intervals ( fibrillation).

Pulse rate in normal conditions corresponds to the rate of cardiac contractions and is 60-80 per min.

If the pulse is arrhythmic the heart bets should be counted and compared with the pulse rate. During the frequent and irregular contractions of the heart, some systoles of the left ventricle can be so weak that the blood is not ejected into the aorta or the amount of blood is very small and the pulse wave does not reach the peripheral arteries. The difference between heart and pulse rate is called the pulse difficit while the pulse itself is called pulsus defcicens.

Pulse pressure is determined by the force that should be applied to the pulsating artery to compress it completely. This property depends on the magnitude of the systolic arterial pressure. If arterial pulse is normal, the artery can be compressed bya moderate pressure. A normal pulse is therefore of moderat tension. The higher the pressure, the more difficult is it to compress the artery (dull pulse or pulsus durus). If the arterial pressure is small, the artery is easy to compress and the pulse is called soft (pulsus mollis).

Volume of pulse. Pulse volume shows the artery filling with blood, which is turn depends on the amount of blood that is ejected during systole into the arterial system and which produses variations in the artery volume. Pulse volume depends on the stroke volume, on the total amount of circulating blood, and its diatribution in the body. If the stroke volume is normal and the artery is sufficiently filled with blood, the pulse is said to be full (pulsus plenus). In abnormal circulation and blood loss, pulse volume decreases (pulsus vacuus).

Pulse size implies filling and tension.

If the pulse pressure and filling are high the pulse is called large-volume pulse or pulsus magnus or pulsus altus. (characteristic for aortic valse incompetence). Decreased pulse pressure and filling are typical for amall pulse (pulsus parvus)/ It occurs in aortic asenosis.

The pulse wave my be quite insignificant in shock, acute cardiac failure and massive loss of blood. This pulse is called thready (pulsus filiformis).


Assessment of blood pressure

A minimum systolic value can be roughly estimated by palpation, most often used in emergency situations, but should be used with caution. It has been estimated that, using 50% percentiles, carotid, femoral and radial pulses are present in patients with a systolic blood pressure > 70 mmHg, carotid and femoral pulses alone in patients with systolic blood pressure of > 50 mmHg, and only a carotid pulse in patients with a systolic blood pressure of > 40 mmHg.

A more accurate value of systolic blood pressure can be obtained with a sphygmomanometer and palpating the radial pulse. The diastolic blood pressure cannot be estimated by this method. The American Heart Association recommends that palpation be used to get an estimate before using the auscultatory method.

Auscultatory method aneroid sphygmomanometer with stethoscope

The auscultatory method (from the Latin word for "listening") uses a stethoscope and a sphygmomanometer. This comprises an inflatable (Riva-Rocci) cuff placed around the upper arm at roughly the same vertical height as the heart, attached to a mercury or aneroid manometer. The mercury manometer, considered the gold standard, measures the height of a column of mercury, giving an absolute result without need for calibration and, consequently, not subject to the errors and drift of calibration which affect other methods. The use of mercury manometers is often required in clinical trials and for the clinical measurement of hypertension in high-risk patients, such as pregnant women.

A cuff of appropriate size is fitted smoothly and snugly, then inflated manually by repeatedly squeezing a rubber bulb until the artery is completely occluded. Listening with the stethoscope to the brachial artery at the elbow, the examiner slowly releases the pressure in the cuff. When blood just starts to flow in the artery, the turbulent flow creates a "whooshing" or pounding (first Korotkoff sound). The pressure at which this sound is first heard is the systolic blood pressure. The cuff pressure is further released until no sound can be heard (fifth Korotkoff sound), at the diastolic arterial pressure.

The auscultatory method is the predominant method of clinical measurement.


uscultation of a heart

Auscultation involves listening for heart sounds with the stethoscope, similar to the procedure used in assessing breath sounds.

The heart is usually auscultated by a stethoscope or a phonendoscope, but direct (immediate) auscultation is also used. The condition of the patient permitting, the heart sounds should be heard in various postures of the patient: erect, recumbent, after exersice (e.g. after repeated squatting). Sounds associated with the mitral valves pathology are well heard when the patient lies on his left side, since the heart apex is at its nearest position to the chest wall; aortic valve defects are best heard when the patient is in the upright posture or when he lies on his right side. The heart sounds are better heard if the patient is asked to inhale deeply and then exhale deeply and keep breath for short periods of time so that the respiratory sounds should not interfere with auscultation of the heart. The valve sounds should be heard in the order of decreasing frequency of their affection. The mitral valve should be heard first (at the heart apex); next follows the aortic valve (in the second intercostal space to the right of the sternum), the pulmonary valve (in the second intercostal space, to the left of the sternum), tricuspid valve (at the base of the xiphoid process), and finally the aortic valve again at the Botkin-Erb point. If any deviations from normal sounds have been revealed at these points, the entire heart area should be auscultated thoroughly.

The sites of projections of the valves on the anterior chest wall are very close to one another. The mitral valve projects to the left of the sternum, at the 3rd costosternal articulation, and the tricuspid valve, on the sternum midway between the 3rd left and 5th right costosternal articulations The valve of the pulmonary trunk is projected in the 2nd intercostal space, to the left of the sternum, the aortic valve is projected in the middle of the sternum, at the level of the 3rd costosternal articulation. Since all heart valves are projected on a small area of the chest, it is difficult to decide which of them is damaged if the valves are auscultated at sites of their actual projections.

Where to place your stethoscope

As with palpation of the heart, auscultation should proceed in a logical manner over 4 general areas on the anterior chest, beginning with the patient in the supine position.  The 4 percordial areas are examined with diaphragm, including:

1.     Aortic region (between the 2nd and 3rd intercostal spaces at the right sternal border) (RUSB right upper sternal border).

2.     Pulmonic region (between the 2nd and 3rd intercostal spaces at the left sternal border) (LUSB left upper sternal border).

3.     Tricuspid region (between the 3rd, 4th, 5th, and 6th intercostal spaces at the left sternal border) (LLSB left lower sternal border).

4.     Mitral region (near the apex of the heard between the 5th and 6th intercostal spaces in the mid-clavicular line) (apex of the heart).

The auscultatory areas are as follows: (1) the area of the apex beat for the mitral valve because the vibrations are well transmitted by the muscle of the left ventricle and the cardiac apex is at the nearest distance to the anterior chest wall during systole; (2) the lower part of the sternum near its junction with the xiphoid process (the right-ventricular area); for the tricuspid valve; (3) the valve of the pulmonary trunk is best heard at its anatomical projection onto the chest, i.e. in the second intercostal space, to the left of the sternum; (4) the aortal valve is best heard in the second intercostal space, to the right of the sternum where the aorta is the nearest to the anterior chest wall. Moreover, the heart sounds which are associated with the contractions of the aortic valve or which develop during its affections can be heard to the left of the sternum at the 3rd and 4th costosternal articulation (the so-called fifth listening post at the Botkin-Erb point).

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video: auscultation_of_a_heart


Examination of patients with digestive system diseases

General inspection

Mouth and throat.

The doctor asks the patient to open his mouth wide, requests that he move his tongue in different directions for full visualization, and has him say ahh in order to depress the tongue for full view of the back of the mouth (tonsils, uvula, oropharynx). For a closer look at the buccal mucosa or lining of the cheeks, the doctor can ask the patient0 to use his fingers to move the outer lip and cheek to one side. The tongue blade is placed along the side of the tongue, not the center back area where the gag reflex is elicited.

: normal mouth : normal mouth


All areas lined with mucous membranes (inside the lips and cheeks, gingiva, underside of tongue, palate, back of pharynx) are inspected, noting color, any areas of white patches or ulceration, bleeding, sensitivity, and moisture. The membranes should be bright pink, smooth, glistening, uniform, and moist. Any deviations are noted. For example, reddened areas with white ulcerated centers may be canker sores (aphthae), which may be caused by trauma to the gums during toothbrushing or chewing.

As the doctor observes the lining of the mouth, any odor (halitosis) is noted. Mouth odors are characteristic of a number of important health problems, such as poor dental hygiene, gingival disease, chronic constipation, dehydration, malnutrition, or systemic illness. A sudden, foul odor in the mouth may indicate a foreign body in the nose, particularly a bean or pea. The doctor should inspect the nose carefully and, if possible, remove the object with tweezers.

The teeth are inspected for number in each dental arch, hygiene, and occlusion or bite.. Discoloration of tooth enamel with obvious plaque (whitish coating on the surface of the teeth) is a sign of poor dental hygiene and indicates a need for dental counseling. Brown spots in the crevices of the crown of the tooth or between the teeth may be caries. Teeth that appear greenish black may be stained from oral ingestion of supplemental iron. Although unsightly, this disappears after the iron is no longer given.

The gums surrounding the teeth are examined. The color is normally coral pink, and the surface texture is stippled, similar to the appearance of orange peel. In dark-skinned individuals the gums are more deeply colored and a brownish area is often observed along the gum line.

The tongue is inspected for the presence of papillae, small projections that contain several taste buds each and give the tongue its characteristic rough appearance. Changes in the surface texture are noted, such as (1) geographic tongue, unusual patterns of papillae formation and denuded areas, (2) coated tongue, such as in thrush, or (3) an exceptionally beefy red and swollen tongue, which is a sign of various systemic diseases.

The doctor also notes the size and mobility of the tongue, especially protrusion, which is frequently seen in children with mental retardation. Normally the tip of the tongue should extend to the lips. If the patient is unable to move the tongue forward to this point, the frenulum, or central band of mucous membrane, which attaches the tongue to the floor of the mouth, may be too short. Tongue-tie can result in speech problems.

The roof of the mouth consists of the hard palate, near the front of the cavity, and the soft palate, toward the back of the pharynx, which has a small midline protrusion called the uvula. Both are carefully inspected to be sure that they are intact. Sometimes there is a pinpoint cleft in the soft palate, which may go undetected unless carefully inspected. Such a cleft is especially important if the uvula is bifid or separated into two appendages. A submucosal cleft may result in speech problems later on, since air cannot be effectively trapped for vocalization. The arch of the palate should be dome shaped. A narrow-flat roof or high-arched palate affects the placement of the tongue and can cause feeding and speech problems. Movement of the uvula is tested by eliciting a gag reflex. It moves upward to close off the nasopharynx from the oropharynx.

As the recesses of the oropharynx are inspected, the size and color of the palatine tonsils are also noted. They are normally the same color as the surrounding mucosa, glandular, rather than smooth in appearance, and barely visible over the edge of the palatoglossal arches. Enlargement, redness, and white patches on the tonsils and surrounding area are recorded. Such signs are indicative of suppurative tonsillitis or pharyngitis.


: normal mouth

Left Peritonsilar Abscess. Note deveiation of uvula towards right.

The roof of the mouth consists of the hard palate, near the front of the cavity, and the soft palate, toward the back of the pharynx, which has a small midline protrusion called the uvula. Both are carefully inspected to be sure that they are intact. Sometimes there is a pinpoint cleft in the soft palate, which may go undetected unless carefully inspected. Such a cleft is especially important if the uvula is bifid or separated into two appendages. A submucosal cleft may result in speech problems later on, since air cannot be effectively trapped for vocalization. The arch of the palate should be dome shaped. A narrow-flat roof or high-arched palate affects the placement of the tongue and can cause feeding and speech problems. Movement of the uvula is tested by eliciting a gag reflex. It moves upward to close off the nasopharynx from the oropharynx.

As the recesses of the oropharynx are inspected, the size and color of the palatine tonsils are also noted. They are normally the same color as the surrounding mucosa, glandular, rather than smooth in appearance, and barely visible over the edge of the palatoglossal arches. Enlargement, redness, and white patches on the tonsils and surrounding area are recorded. Such signs are indicative of suppurative tonsillitis or pharyngitis.

Exam of the Abdomen

The major components of the abdominal exam include: observation, auscultation, percussion, and palpation. While these are the same elements which make up the pulmonary and cardiac exams, they are performed here in a slightly different order (i.e. auscultation before percussion) and carry different degrees of importance. Pelvic, genital, and rectal exams, all part of the abdominal evaluation, are discussed elsewhere.

Quadrants of the Abdomen

: normal abdomen

Topical Anatomy of the Abdomen

: normal internal anatomy

By convention, the abdominal exam is performed with the provider standing on the patient's right side.


Much information can be gathered from simply watching the patient and looking at the abdomen. This requires complete exposure of the region in question, which is accomplished as follows:

Ask the patient to lie on a level examination table that is at a comfortable height for both of you. At this point, the patient should be dressed in a gown and, if they wish, underwear.

Take a spare bed sheet and drape it over their lower body such that it just covers the upper edge of their underwear (or so that it crosses the top of the pubic region if they are completely undressed). This will allow you to fully expose the abdomen while at the same time permitting the patient to remain somewhat covered. The gown can then be withdrawn so that the area extending from just below the breasts to the pelvic brim is entirely uncovered, remembering that the superior margin of the abdomen extends beneath the rib cage.

The patient's hands should remain at their sides with their heads resting on a pillow. If the head is flexed, the abdominal musculature becomes tensed and the examination made more difficult. Allowing the patient to bend their knees so that the soles of their feet rest on the table will also relax the abdomen.

Keep the room as warm as possible and make sure that the lighting is adequate. By paying attention to these seemingly small details, you create an environment that gives you the best possible chance of performing an accurate examination. This is particularly important early in your careers, when your skills are relatively unrefined. However, it will also stand you in good stead when examining obese, anxious, distressed or otherwise challenging patients.

While observing the patient, pay particular attention to:

Appearance of the abdomen. Is it flat? Distended? If enlarged, does this appear symmetric or are there distinct protrusions, perhaps linked to underlying organomegaly? The contours of the abdomen can be best appreciated by standing at the foot of the table and looking up towards the patient's head. Global abdominal enlargement is usually caused by air, fluid, or fat. It is frequently impossible to distinguish between these entities on the basis of observation alone (see below for helpful maneuvers). Areas which become more pronounced when the patient valsalvas are often associated with ventral hernias. These are points of weakening in the abdominal wall, frequently due to previous surgery, through which omentum/intestines/peritoneal fluid can pass when intra-abdominal pressure is increased.

Presence of surgical scars or other skin abnormalities.

Patient's movement (or lack thereof). Those with peritonitis (e.g. appendicitis) prefer to lie very still as any motion causes further peritoneal irritation and pain. Contrary to this, patients with kidney stones will frequently writhe on the examination table, unable to find a comfortable position.

The contour of the abdomen is inspected while the patient is erect and supine. The usual male and female contours of the pelvic cavity change the shape of the abdomen to form characteristic curves, especially in the female.The size and tone of the abdomen also give some indication of general nutritional status and muscular development. A large, prominent, flabby abdomen is often seen in obese patients, whereas a concave abdomen is frequently suggestive of undernutrition.


Draping the Abdomen

: abdomen draping


However, careful note is made of a protruding abdomen, which may indicate pathologic states such as abdominal distention, ascites, tumors, or organomegaly. A protuberant abdomen with spindly extremities and flat, wasted buttocks suggests severe malnutrition that may occur from inadequate nutritional intake such as kwashiorkor or from diseases such as cystic fibrosis. Likewise, a scaphoid abdomen may indicate dehydration or diaphragmatic hernia, in which the abdominal organs rise into the thoracic cavity, or a scaphoidlike abdomen that only appears sunken in relationship to pneumothorax or high intestinal obstruction. A midline protrusion from the xiphoid to the umbilicus or pubic symphysis is usually diastasis recti, or failure of the rectus abdominis muscles to join in utero. A tense, boardlike abdomen is a serious sign of paralytic ileus and intestinal obstruction.

The doctor also notes the condition of the skin covering the abdomen. It should be uniformily taut, without wrinkles or creases. Sometimes silvery, whitish striae are seen, especially if the skin has been stretched as in obesity or with distention resulting from ascites. Any scars, ecchymotic areas, excessive hair distribution, or distended veins are noted.

Movement of the abdomen is observed. Visible peristaltic waves most often indicate pathologic states, particularly intestinal obstruction such as pyloric stenosis.

A doctor may observe pulsation of the descending aorta in the epigastric region (midline and below the xiphoid). Although visible pulsations are normally seen, especially in thin patients, the doctor should auscultate and palpate the aorta for any evidence of an aneurysm, a saclike enlargement of the vessel.

If a hemiation is present in umbilical region, the sac is palpated for abdominal contents and the approximate size of the opening is estimated. ernias are common in infants, especially in black children. Hernias are looked for elsewhere on the abdominal wall, such as in the inguinal or femoral region. An inguinal hernia is a protrusion of peritoneum through the abdominal wall in the inguinal canal. It most often occurs in males, is frequently bilateral, and may be visible as a mass in the scrotum. It is palpated by sliding the little finger into the external inguinal ring at the base of the scrotum and asking the child to cough. If a hernia is present, it will hit the tip of the finger.

A femoral hernia is felt or seen as a small mass on the anterior surface of the thigh just below the inguinal ligament in the femoral canal (a potential space medial to the femoral artery). Its location can be estimated by placing the index finger of the right hand on the patients right femoral pulse (left hand for left pulse) and the middle ring finger flat against the skin toward the midline. The ring finger lies over the femoral canal, where the hemiation occurs. Palpation of hernias in the pelvic region, particularly inguinal ones, is often part of the examination of genitalia.

Various Causes of Abdominal Distension

: obese abdomen

Obese abdomen

: hepatomegaly abdomen


Splenomegaly: Massively enlarged spleen, the result of extramedullary hematopoiesis, is outlined above. This patient's left upper quadrant appears more full than the corresponding area on the right.

: ascites

Auscultation. Each of the four quadrants should be auscultated using the diaphragm and bell chestpieces. Unlike listening to the heart or lungs, in which the stethoscope rests gently on the skin, to hear bowel sounds the stethoscope must be pressed firmly against the abdominal surface. With the diaphragm chestpiece this usually presents no difficulty, but with the bell chestpiece, especially one with a short cone, the skin may occlude the opening and prevent transmission of sound.

The most important sound to listen for is peristalsis, or bowel sounds, which sound like short metallic clicks and gurgles. Loud grumbling noises, known as borborygmi, are the familiar stomach growls usually denoting hunger. A sound may be heard every 10 to 30 seconds and its frequency per minute should be recorded (for example, 5 bowel sounds/minute). However, the nurse may need to listen for several seconds before audible peristalsis can be heard. Bowel sounds may be stimulated by stroking the abdominal surface with a fingernail. Absent bowel sounds or hyperperistalsis is recorded and reported, since either usually denotes abdominal disorder.

Various other sounds may be heard in the abdominal cavity. Normally the pulsation of the aorta is heard in the epigastrium. Sounds that resemble murmurs (called bruits), hums, or rubs are always referred for further evaluation.


Abdominal Auscultation

: abdominal auscultation

What exactly are you listening for and what is its significance? Three things should be noted:

1.                 Are bowel sounds present?

2.                 If present, are they frequent or sparse (i.e. quantity)?

3.                 What is the nature of the sounds (i.e. quality)?

As food and liquid course through the intestines by means of peristalsis noise, referred to as bowel sounds, is generated. These sounds occur quite frequently, on the order of every 2 to 5 seconds, although there is a lot of variability. Bowel sounds in and of themselves do not carry great significance. That is, in the normal person who has no complaints and an otherwise normal exam, the presence or absence of bowel sounds is essentially irrelevant (i.e. whatever pattern they have will be normal for them). In fact, most physicians will omit abdominal auscultation unless there is a symptom or finding suggestive of abdominal pathology. However, you should still practice listening to all the patients that you examine so that you develop a sense of what constitutes the range of normal. Bowel sounds can, however, add important supporting information in the right clinical setting. In general, inflammatory processes of the serosa (i.e. any of the surfaces which cover the abdominal with peritonitis) will cause the abdomen to be quiet (i.e. bowel sounds will be infrequent or altogether absent). Inflammation of the intestinal mucosa (i.e. the insides of the intestine, as might occur with infections that cause diarrhea) will cause hyperactive bowel sounds. Processes which lead to intestinal obstruction initially cause frequent bowel sounds, referred to as "rushes." Think of this as the intestines trying to force their contents through a tight opening. This is followed by decreased sound, called "tinkles," and then silence. Alternatively, the reappearance of bowel sounds heralds the return of normal gut function following an injury. After abdominal surgery, for example, there is a period of several days when the intestines lie dormant. The appearance of bowel sounds marks the return of intestinal activity, an important phase of the patient's recovery. Bowel sounds, then, must be interpreted within the context of the particular clinical situation. They lend supporting information to other findings but are not in and of themselves pathognomonic for any particular process.

After you have finished noting bowel sounds, use the diaphragm of your stethoscope to check for renal artery bruits, a high pitched sound (analogous to a murmur) caused by turbulent blood flow through a vessel narrowed by atherosclerosis. The place to listen is a few cm above the umbilicus, along the lateral edge of either rectus muscles. Most providers will not routinely check for bruits. However, in the right clinical setting (e.g. a patient with some combination of renal insufficiency, difficult to control hypertension and known vascular disease), the presence of a bruit would lend supporting evidence for the existence of renal artery stenosis. When listening for bruits, you will need to press down quite firmly as the renal arteries are retroperitoneal structures. Atherosclerosis distal to the aorta (i.e. at the take off of the Iliac Arteries) can also generate bruits. Blood flow through the aorta itself does not generate any appreciable sound. Thus, auscultation over this structure is not a good screening test for the presence of aneurysmal dilatation.

Percussion: The technique for percussion is the same as that used for the lung exam. First, remember to rub your hands together and warm them up before placing them on the patient. Then, place your left hand firmly against the abdominal wall such that only your middle finger is resting on the skin. Strike the distal interphalangeal joint of your left middle finger 2 or 3 times with the tip of your right middle finger, using the previously described floppy wrist action (see under lung exam). There are two basic sounds which can be elicited:

1.     Tympanitic (drum-like) sounds produced by percussing over air filled structures.

2.     Dull sounds that occur when a solid structure (e.g. liver) or fluid (e.g. ascites) lies beneath the region being examined.

*Special note should be made if percussion produces pain, which may occur if there is underlying inflammation, as in peritonitis. This would certainly be supported by other historical and exam findings.


: livertop: percuss: liverbot

Abdominal Percussion

: abdomen-percussion

What can you really expect to hear when percussing the normal abdomen? The two solid organs which are percussable in the normal patient are the liver and spleen. In most cases, the liver will be entirely covered by the ribs. Occasionally, an edge may protrude a centimeter or two below the costal margin. The spleen is smaller and is entirely protected by the ribs. To determine the size of the liver, proceed as follows:

1.                 Start just below the right breast in a line with the middle of the clavicle, a point that you are reasonably certain is over the lungs. Percussion in this area should produce a relatively resonant note.

2.                 Move your hand down a few centimeters and repeat. After doing this several times, you will be over the liver, which will produce a duller sounding tone.

3.                 Continue your march downward until the sound changes once again. This may occur while you are still over the ribs or perhaps just as you pass over the costal margin. At this point, you will have reached the inferior margin of the liver. The total span of the normal liver is quite variable, depending on the size of the patient (between 6 and 12 cm). Don't get discouraged if you have a hard time picking up the different sounds as the changes can be quite subtle, particularly if there is a lot of subcutaneous fat.

4.                 The resonant tone produced by percussion over the anterior chest wall will be somewhat less drum like then that generated over the intestines. While they are both caused by tapping over air filled structures, the ribs and pectoralis muscle tend to dampen the sound.

5.                 Speed percussion, as described in the pulmonary section, may also be useful. Orient your left hand so that the fingers are pointing towards the patients head. Percuss as you move the hand at a slow and steady rate from the region of the right chest, down over the liver and towards the pelvis. This maneuver helps to accentuate different percussion notes, perhaps making the identification of the liver's borders a bit more obvious.

Palpation: First warm your hands by rubbing them together before placing them on the patient. The pads and tips (the most sensitive areas) of the index, middle, and ring fingers are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures. You may use either your right hand alone or both hands, with the left resting on top of the right. Apply slow, steady pressure, avoiding any rapid/sharp movements that are likely to startle the patient or cause discomfort. Examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel.

: xiphoid and ribs


It is necessary that the abdominal cavity should be accessible to palpation, i.e. that its muscles (prelum) be relaxed and that the examiner should not provoke their straining by his manipulations. The patient should relax in his bed. (The bed should not be too soft.) His legs should be stretched and the arms flexed on the chest. The patient's breathing should not be deep; his head should rest against a small firm pillow. This position ensures relaxation of the abdominal muscles. The physician takes his place by the right side of the bed, facing the patient. The chair should be firm and level with the patient's bed. The ambient temperature should be comfortable for the patient, and the hands of the doctor should be warm and dry.

The examining movements should be careful and gentle so as not to hurt the patient. Touching the abdomen roughly with cold hands will cause reflex contraction of the prelum to interfere with palpation of the abdomen. The patient with distended abdomen should first be given cathartics or enema to empty the bowels. These are the conditions for palpation of the patient in the recumbent position. But some organs or their parts can only be palpated when they hang by gravity with the patient in the erect position. Thus the left lobe of the liver, the lesser curvature of the stomach, the spleen, the kidneys, the caecum, or tumours can become palpable. The epigastrium and the lateral parts of the abdominal cavity should also be palpated with the patient in the erect position.

Palpation is used to establish normal topographic relations between the abdominal organs and their normal physical condition; the other object is , to detect any possible pathology that changes the morphological condition of the organs and their topographic relations responsible for their dysfunction, to locate the defect, and to determine its nature. Surface and deep palpation are used. Deep palpation gives information on the physical and sometimes functional condition of the organs and also on their position in the abdominal cavity. In other words, deep palpation gives information on the topography of the abdominal cavity (topographic palpation).

Surface tentative palpation. The physician assumes his position by the bedside as described above and places his right hand flat on the abdomen of the patient (the fingers may be slightly flexed) to examine carefully and gradually the entire abdomen without trying to penetrate the deep parts of the abdomen. By this examination the physician should establish the strain of the prelum, its tenderness, and location of the painful site. The left inguinal area should be examined first, provided the patient does not complain of pain in this region. Palpation is then continued by examining symmetrical points of the abdomen on its left and right sides to end in the epigastric region. If the patient complains of pain in the left inguinal area, the sequence of palpation should be so changed that the least painful site on the anterior abdomen should first be examined. The physician should simultaneously assess the condition of the abdominal skin and subcutaneous connective tissue, the strain of the abdominal wall, the zones of superficial and deeper painful areas to locate them accurately. Hernial separation of muscles and protrusions, and also other anatomical changes should be revealed, if any. Resistance and marked strain of muscles of the abdominal wall are usually palpated over the organ affected by inflammation, especially so if the peritoneum is involved. In the presence of acute inflammation of the peritoneum (local inflammation included, e.g. in purulent appendicitis, cholecystitis, and the like), local pressure causes strong pain but it becomes even more severe when the pressure is released (Shchetkin-Blumberg symptom). In the presence of pronounced enlargement of the parenchymatous organs, in strained abdomen or intestinal loops, and also in the presence of large tumours, even surface palpation can give much diagnostic information. But only deep systematic palpation can give full information about the condition of the abdominal cavity and its organs, as well as their topography.

Deep sliding palpation (according to Obraztsov and Strazhesko). When starting deep palpation the examiner should always be aware of the anatomical relations in the abdominal cavity, the shape and physical properties of the organs, their supporting structures and possible deviations in topographical relations that may depend on the constitution of the patient, his special condition, nutrition, relaxation of the abdominal muscles, etc.

Obraztsov used the double-checking principle in his examinations. For example, in order to make sure that a given section of the intestine is actually ileum terminale it is necessary to locate the caecum; to determine the size of the stomach, the palpatory findings are checked by percussion and percussive palpation of the stomach. Respiratory excursions of the organs should be taken into consideration during palpation according to a strictly predetermined plan, beginning with more readily accessible parts. The following sequence is recommended: the sigmoid, the caecum with the appendix, pars coecalis ilii, the ascending and descending colon, the stomach with its parts, the transverse colon, the liver, the spleen, the duodenum, the pancreas, and the kidneys.

Success of palpation depends on strict observation of the rules. The posture of the patient and the physician should be the same as in surface palpation. Palpation should be carried out by the apt hand. In some cases the other hand should be placed on the examining hand to increase pressure. Palpation can also be bimanual (palpation with both hands simultaneously). If only one hand is used,, the other hand presses the prelum laterally to the palpated zone in order to lessen or overcome resistance of the abdominal wall and hence to promote relaxation of the prelum in the palpated zone. The other hand can be used to move the palpated organ closer to the examining hand or in order to perform bimanual palpation.

The palpation technique includes the following four steps. First: proper positioning of the physician's hands. The right hand is placed flat on the anterior abdominal wall, perpendicular to the axis of the examined part or the edge o\ the examined organ. Second: formation of a skin fold to facilitate further movements of the examining hand. Third: moving the hand inside the abdomen. Deep palpation is when the fingers are moved gradually, with each expiration, into the abdomen when the abdominal wall is relaxed. The examining hand thus reaches the posterior wall of the abdomen or the underlying organ. Fourth: sliding movement of the fingertips in the direction perpendicular to the transverse axis of the examined organ. The organs pressed against the posterior wall and the examining finger? continue moving over the examined intestine or the stomach curvature, depending on the position of the organ, the sliding movement should be either from inside, in the outward direction (the sigmoid, caecum) or in the downward direction (the stomach, transverse colon); the movements should then be more oblique in accordance with the deviation of the organ from the horizontal or-vertical course. The examining hand should always move together with the skin and not over its surface.

By palpating the intestine, the physician establishes its localization, mobility, tenderness, consistency-, diameter, the condition of the surface {smooth, tubercular), the absence or presence of rumbling sounds during palpation. Ail these signs indicate the presence or absence of pathology.

The sigmoid is palpated from top right to medial left, downward and laterally, perpendicularly to the axis of the intestine which runs obliquely in the left iliac space at the border of median and the outer third of the linea umbilico-iliacae. Palpacion is carried out by four fingers, placed together and slightly flexed, or by the ulnar edge of the right little finger. The fingers are immersed medially of the expected position of the intestine and as soon as the posterior wall of the abdomen is reached, the fingers slide along the intestine in the given direction, i.e. laterally and downward. The intestine is pressed against the posterior wall and first slides along it (to the extern allowed by the mesenteric length) but later it slips from under the examining fingers. The sigmoid can be palpated by the described technique in 90-95 % of cases.


Palpation of the sigmoid



The sigmoid is only impalpated in excess inflation of the abdomen and in obese patients. If the sigmoid is not found where it belongs, it may be displaced to some other location because of long mesenterium which accounts for the high sigmoid mobility. It is then usually displaced closer to the navel and to the right. The sigmoid can usually be found by deep palpation of the infraumbilical and suprapubic areas. Normally the sigmoid can be palpated over the length of 20-25 cm as a smooth firm cylinder, its thichness being that of a thumb or an index finger; the sigmoid is painless to palpation, it does not produce rumbling sounds, its peristalsis is rather flaccid and infrequent. The sigmoid can be displaced 3-5 cm to either side.

The caecum is palpated by the same technique, except that the direction is different. Since the caecum is situated at the border of the median and lateral third of the umbilico-iliac line (5 cm by the iliac spine), the palpation is carried along this line or parallel to it. Palpation is used not only to locate the caecum but also a certain part of the ascending colon (10-12 cm of its length), i.e. the part of the large intestine which is known in the clinic as typhlon. A normal caecum can be palpated in 80-85 per cent of cases as a moderately strained cylinder (widening to the round bottom), 2-3 cm in diameter; when pressed upon, it rumbles. Palpation is painless. It reveals a certain passive mobility of the caecum (to 23 cm).

Palpation of the caecum



The lower edge of the caecum is 0.5 cm above the bi-iliac in man and 11.5 cm below it in women. Further palpation of the right iliac region gives (in 8085 per cent of cases) information on the 15-20 cm length of the ileum which ascends from the small pelvis to the right, to be connected with the large intestine (ileum terminate). This section of the intestine extends mostly upward and to the right and palpation should therefore be carried out almost parallel to the umbilico-iliac line (but below it). The terminal end of the ileum can be palpated in the depth of the right iliac space as a soft, easily peristalting and passively mobile cylinder, the thickness of the little finger (or a pencil); it slips out from under the examining fingers and rumbles distinctly. When the terminal end of the ileum is found, the vermiform process can be found above or below it. It is found easier if the belly of the psoas muscle is first found. The location of this muscle is facilitated when the patient slightly raises his straight right leg. The vermiform process then becomes more pronounced over the contracted belly of the psoas muscle. The vermiform process can be palpated in 2025 per cent of cases. This is a thin (goose-feather thick) painless cylinder. When palpated the process does not change its consistency; nor does it rumble. Once the cylinder has been felt above or below the ileum, the examiner cannot be quite sure that he has found the vermiform process because it can be simulated by mesenteric duplicature and a lymph bundle. It is difficult to find the vermiform process also because its position varies with respect to the caecum. It becomes impalpable at all when located behind the caecum. When the process is inflamed it becomes much easier to find it because of its thickening, fixation, and consolidation. The caecum, the terminal part of the ileum, and the vermiform process are palpated by four fingers of the right hand; the fingers should be held together and slightly flexed. If the prelum is tense, the muscles in the palpation zone can be relaxed by pressing the umbilical area with the radial edge of the left hand.

The ascending and descending colons are palpated by two hands. The left hand is placed under the left and then the right lumbar side, while the fingers of the right hand press on the anterior wall of the abdominal cavity until the examiner feels his right and left hands meet. The examining fingers slide laterally, perpendicularly to the axis of the intestine.


Palpation of the descending colon



The transverse colon is palpated by four fingers of the right hand held together and slightly flexed. Bimanual palpation can also be used. Since the position of the transverse colon is unstable, it is useful first to determine by percussive palpation (after Obraztsov) the lower border of the stomach, and only then to search for the colon some 2-3 cm below this border. The right hand (or both hands) is placed on the sides of the linea alba and the skin is moved slightly upwards. The examining hand is then immersed gradually during relaxation of the prelum at expiration until the posterior wall of the abdomen is felt. Once the posterior wall is reached, the examining hand should slide down to feel the intestine: this is an arching (transverse) cylinder of moderate density (22.5 cm thick), easily movable up and down, painless and silent. If the intestine is impalpable in this region, the same technique should be used to examine the lower and lateral regions, the position of the palpating hands being changed accordingly. Normal transverse colon can be palpated in 60-70 per cent of cases.

Palpation of the transverse colon



In addition to the mentioned portions of the intestine, the horizontal parts of the duodenum and the curvature of the colon can in rare cases be palpated; an occasional loop of the small intestine that may happen in the iliac cavity can also be palpated. But the small intestine is usually impalpable because of its deep location, high mobility, and thin walls; it cannot be pressed against the posterior abdominal wall, which is the necessary condition for palpation of normal intestine.

The rectum can be probed by a finger after cleansing it with enema. The patient should assume the knee-chest position. The examining index finger should first be coated with vaseline oil and then introduced carefully into the rectum to the maximum possible depth. If the patient is especially sensitive, or the rectum and the ampulla are affected with inflammation or fissures, the sphincter and the ampulla should be anaesthetized below intervention. As the examining finger passes the sphincter, it feels anteriorly the prostate in men and the vaginal part of the uterus in women. The finger should be moved upwards to pass the sacrococcygeal plica and to reach, if possible, the terminal rectal plica that closes the entrance to the sigmoid (11-13 cm above the anus). Palpation of the rectum can be facilitated if the patient squats and strains (makes evacuatory efforts) After examination of the anterior wall, the posterior wall of the rectum is felt by the finger. The finger is turned through 180 and the posterosacral and then lateral walls are examined. The examiner should get an idea of the mucosa (the presence of papilloma, polyps, varicose nodes, oedema and swelling of the mucosa, cicatricial narrowings, newgrowths, etc.) and the connective tissue surrounding the rectum, Douglass space, the prostate, the uterus and its appendages, and the pelvic bones.


Palpation of the liver

Surface palpation in diseases of the liver can reveal a tender zone in the right hypochondrium and epigastrium. Especially severe local pain (caused even by a slight touch on the anterior abdominal wall in the zone overlying the gall bladder) is observed in acute cholecystitis and biliary colic. In chronic cholecystitis slight or moderate tenderness is only revealed at the point of projection of the gall bladder fundus onto the anterior abdominal wall. In healthy subjects this point is found immediately below the right costal arch by the lateral edge of the right rectus abdominis muscle.

The liver is palpated by the Obraztsov and Strazhesko method. As the lower edge of the liver descends to meet the examining fingers during a deep inspiration it slides over the fingers and thus becomes detectable. It should be remembered that the respiratory mobility of the liver is the highest compared with that of the other abdominal organs because the liver is the closest to the diaphragm. It follows therefore that during palpation of the liver, the active role belongs to its respiratory mobility rather than to the palpating fingers (as is the case with palpation of the intestine).

The patient should stand or lie during palpation of the liver and the gall bladder. But in certain cases the liver can be easier palpated if the patient lies on his left side: the liver hangs by gravity from under the hypochondrium and its inferio-anterior edge can thus be better palpated. Common rules should be followed during palpation of the liver and the gall bladder. Special attention should be paid to the antero-inferior margin of the liver whose properties (outlines, form, tenderness, consistency) are indicative of the condition of the liver, its position, and configuration. In many cases (especially if the liver is enlarged or lowered) the liver can be palpated not only from the left hypochondrium to the right hypochondrium, but its superio-anterior surface becomes palpable as well.


Palpation of the liver.

: normal palpation

The examiner sits by the right side, facing the patient. He places four fingers of his left hand on the right lumbar region of the patient and uses his left thumb to press on the costal arch to move the liver closer to the palpating fingers of the right hand and to prevent expansion of the chest during inspiration. This stimulates greater excursions of the right cupola of the diaphragm. The palm of the right hand is placed flat on the abdomen below the costal arch in the midclavicular line. The slightly flexed fingers press lightly on the abdominal'wall. The patient is asked to take a deep breath; the liver descends to touch the palpating fingers and then slides to bypass them. The examiner's hand remains motionless. The procedure is repeated several times, pie position of the liver margin varies depending on conditions. It is therefore necessary first to determine the lower margin of the liver by percussion before positioning the palpating fingers.

According to Obraztsov, normal liver can be palpated in 88 per cent of cases. Physical properties of the liver can be determined by palpating its lower edge (it can be soft, firm, rough, sharp, rounded, tender, etc.). The margin of an unaffected liver palpated at the height of a deep inspiration is 1-2 cm below the costal arch. It is soft, sharp, readily bending, and insensitive.


Palpation of the liver.

The lower edge of a normal liver is usually palpated in the right midclavicular line; the liver is impalpable to the right of this line because it is located behind the costal arch; the liver is hardly palpable to the left of the line because of the abdominal muscles. An enlarged or consolidated liver can be palpated in all lines. The liver of patients with pronounced distension of the abdomen should be examined with the empty stomach to facilitate palpation. In accumulation of much fluid in the abdominal cavity (ascites) the liver is not always palpable if the patient is lying. The patiei should then be examined in the erect position, or he may lie on his left side. If the amount of fluid in the abdomen is very large, it should be released paracentesis.

In accumulation of much fluid in the abdominal cavity, ballotment should be used to palpate the liver. To that end the right hand (two or four flexed fingers) should be placed on the lower right part of the abdomen, perpendicularly to the expected lower edge of the liver. The abdominal wall is given a sharp tap from the palpating fingers which move upward to meet the firm object, the liver, which is first tossed to the deeper parts of the abdominal cavity but is then returned back to strike the fingers.

Palpation is painful if the liver is inflamed and the affection extends to the liver capsule; the liver is also tender when it is distended (e.g. blood congestion due to heart failure). The liver of a healthy subject (if it is accessible to palpation) is soft; it becomes firmer in hepatitis, hepatosis and cardiac congestion. The liver is especially firm in cirrhosis. Its edge becomes sharp and the surface smooth or covered with small tubercles. The liver is also firm in the presence of tumour and multiple metastases of cancer. Its surface then becomes covered with rough tubercles (surface metastases) and the lower margin is rough. The liver is firm in amyloidosis. Comparatively small tumours and echinococcosis can sometimes be palpated. Protrusion of the lower margin of an enlarged liver is assessed with respect to the costal arch in the right anterior axillary line, right midclavicular line, right parasternal line, anterior median line, and left parasternal line. Palpation verifies the findings obtained by percussion of the liver.

The gall bladder cannot be palpated in healthy subjects because of its soft consistency and the insignificant protrusion. But if the gall bladder is enlarged (hydrops, stones in the bladder, cancer, etc.) it becomes palpable. The position of the patient for palpation of the gall bladder is the same as in palpation of the liver. After the margin of the liver has been found, the gall bladder should be palpated at the lateral edge of the right rectus abdominis muscle. The palpation technique is the same as that for palpation of the liver. The gall bladder can easier be found by moving the palpating fingers in the direction perpendicular to the axis of the gall bladder. The bladder is felt like a pear of variable size, firmness and tenderness depending on the character of pathology in the gall bladder proper or the surrounding organs (e.g. the gall bladder is enlarged, soft, and elastic in tumour-obstructed bile duct: Courvoisier- Terrier sign; the bladder is firm and tuberous in the presence ot newgrowths in its wall, in overfilling with stones, in inflammation of the wall, etc.).



Hooking Edge of the Liver

: normal hooking

Palpation of the pancreas

Surface palpation of the abdomen of a patient with acute pancreatitis icveals tenderness and strain of the prelum muscles in the epigastrium, .'inetimes in the left hypochondrium or over the pancreas (Korte symp-10m).

Palpation of the pancreas is very difficult because of the deep position .ind soft consistency of the gland. Normal pancreas can only be palpated in 1-5 per cent of women and 1-2 per cent of men affected by cachexia with iclaxed prelum and ptosis of the internal organs. The pancreas is only palpable when enlarged considerably. Consolidated pancreas affected by cirrhosis, newgrowth, or cyst can be easier palpated.

The pancreas should be palpated in the morning, after giving purgatives (with the empty stomach). The greater curvature should first be palpated; then the position of the pylorus should be determined and the right knee of the transverse colon palpated. The horizontal portion of the duodenum should preferably be outlined by palpation in order to find the point where the head of the pancreas might be better palpated. The head of the pancreas is easier to palpate than its body or tail because of its greater size and frequent consolidation. Palpation is deep and sliding, usually above the right pan of the greater curvature of the stomach. The Obraztsov-Strazhesko rule should be followed during palpation. The palpating hand is placed horizontally, 2-3 cm above the preliminarily found lower border of the stomach. The skin is pulled upwards and then the palpating hand presses gradually into the abdominal cavity with each expiration. As soon as the posterior wall is reached, the hand should slide in the downward direction.

A normal pancreas is a soft transverse cylinder, 1.5-3 cm in diameter. The organ is immobile and painless. In the presence of chronic pancreatitis and tumour of the pancreas, it can sometimes be palpated as a firm, irregular, and slightly tender band. Conclusions should be derived very carefully, because part of the stomach, the transverse colon, a pack of lymph nodes and some other formations can easily be mistaken for the pancreas.



PALPATION of kidneys

The posterior location of the kidneys, and also the absence of anterior. Upproach to them due to the interference of the costal arch, rrakes palpa-fiiun of the kidneys difficult. Relaxation of the prelum and pronounced cachexia can be attended by certain ptosis of the kidneys and make them accessible to palpation even in healthy subjects. But the results of palpation can only be reliable in considerable enlargement of the kidneys (at least 1.52 times, e.g. due to formation of a cyst or a tumour), or their displacement by a tumour, or in cases with a floating kidney. Bilateral enlargement of the kidneys is observed in polycystosis.

It is necessary to remember that the kidneys can move about in the range of 23 cm in the proximal and distal directions when the subject changes his position from horizontal to vertical, and also during respiratory movements of the diaphragm. Passive movements of the kidneys transmitted from the diaphragm during inspiration and expiration should be taken into consideration during palpation: the Obraztsov-Strazhesko palpation method should be used. The patient should be palpated in the lying or standing position. When the patient is in the horizontal position, his kidneys are better palpated because the strain of the prelum is absent. The movable kidney can be palpated in the standing patient because the hangs by gravity and is displaced downward by the pressure of the low diaphragm.

During palpation of the patient in the lying position, his legs should be stretched and the head placed on a low pillow; the prelum is relaxed and the arms are freely placed on the chest. The physician should assume his position by the right side of the patient with his left hand under the patient's loin, slightly below the 12th rib so that the finger tips be near the spinal column. During palpation of the left kidney, the physician's hand should be moved further, beyond the vertebral column, to reach the left part of the lumbar region. The right hand should be placed on the abdomen, slightly below the corresponding costal arch, perpendicularly to it and somewhat outwardly of the rectus abdominis muscles. The patient is asked to relax the abdominal muscles as much as possible and breathe deeply and regularly. The physician's right hand should press deeper with each expiration to reach the posterior abdominal wall, while the left hand presses the lumbar region to meet the fingers of the right hand. When the examining hands are as close to each other as possible, the patient should be asked to breathe deeply by "the abdomen" without straining the prelum. The lower pole of the kidney (if it is slightly descended or enlarged) descends still further to reach the fingers of the right hand. As the physician feels the passing kidney, he presses it slightly toward the posterior abdominal wall and makes his fingers slide over the anterior surface of the kidney bypassing its lower pole. If ptosis of the kidney is considerable, both poles and the entire anterior surface of the kidney can be palpated. The physician should assess the shape, size, surface (smooth or tuberous), tenderness, mobility, and consistency of the kidneys. Bimanual palpation of the kidney can also be done with the patient lying on his side.

In contrast to other organs, an enlarged or ptosed kidney can be examined by ballottement (Guyon's sign): the right hand feels the kidney while the fingers of the left hand strike rapidly the lumbar region in the angle between the costal arch and the longissimus thoracic muscles: the fingers of the right hand feel vibration of the kidney. In deranged urine outflow through the ureter and in pronounced distension of the renal pelvis by the accumulated urine or pus, liquid fluctuation can be felt during palpation of the kidney.

If the physician palpates some formation where he expects to find a kidney, he must check reliably if this is actually a kidney because it is easy to mistake for the kidney an overfilled and firm part of the large intestine, tumor of perirenal cellular tissue (lipoma, fibroma), an enlarged right lobe of the liver, the gall bladder (during palpation of the right kidney), or an enlarged or displaced spleen (during palpation of the left kidney). The kidney is a bean-shaped body with a smooth sin face, slipping upwards from under the palpating fingers and returning to normal position, tossed up by ballottment and giving tympany during percussion over the kidney (by overlying intestinal loops). Protein and erythrocytes appear in the urine after palpation. But all these signs are of only relative importance. For example, if a malignant tumour develops, the kidney may lose its mobility due to proliferation of the surrounding tissues; its surface becomes irregular and the consistency more firm; if the tumour is large, the kidney moves apart the intestinal loops and percussion gives dullness. But the kidney can nevertheless be identified by the mentioned signs by difl tiating it from the neighbouring organs and other formations.

Palpation of the kidneys in the standing patient was propose S. Botkin. During palpation the patient stands facing the physicnui j sits on a chair. The prelum muscles should be relaxed and the trunk -,11 inclined forward.

Palpation can be used to diagnose ptosis of the kidneys. Three iU of nephroptosis can be distinguished: the lower pole of the kidney < palpated in cases with ptosis of the first degree; the entire kidney > palpated in the second degree; and the kidney freely moves aboui directions to pass beyond the vertebral column, to the side of thr kidney, and to sink downwards to a considerable distance, in the degree ptosis.

Palpation is also used to examine the bladder. If it contains much i especially in persons with thin abdominal wall, the urinary bladdei palpated over the pubic bone as an elastic fluctuating formation bladder is markedly distended, its superior border reaches the umlnli|

Tenderness in palpation of the ureter along its course and sensitivil over the kidneys (sensitive to pressure exerted in the angle between ih# [ rib and the longissimus thoracic muscles) is of certain diagnostic h tance. The area overlying the ureter extends on the anterior abdomiiw between the superior ureter point (at the edge of the rectus abdominuj cle at the level of the umbilicus) and the inferior point (at the inter if of the bi-iliac line and the vertical line passing the pubic tubercle).

View: Location of the Kidneys : Location of Kidneys


Gross Retroperitoneum Anatomy

: Gross Retroperitoneum Anatomy