What percussion sound would you expect to hear when percussing the stomach?

Percussion is a method of tapping on a surface to determine the underlying structures, and is used in clinical examinations to assess the condition of the thorax or abdomen. It is one of the four methods of clinical examination, together with inspection, palpation, auscultation, and inquiry. It is done with the middle finger of one hand tapping on the middle finger of the other hand using a wrist action. The nonstriking finger (known as the pleximeter) is placed firmly on the body over tissue. When percussing boney areas such as the clavicle, the pleximeter can be omitted and the bone is tapped directly such as when percussing an apical cavitary lung lesion typical of tuberculosis.

There are two types of percussion: direct, which uses only one or two fingers; and indirect, which uses only the middle/flexor finger. Broadly classifying, there are four types of percussion sounds: resonant, hyper-resonant, stony dull or dull. A dull sound indicates the presence of a solid mass under the surface. A more resonant sound indicates hollow, air-containing structures. As well as producing different notes which can be heard they also produce different sensations in the pleximeter finger.

Percussion was at first used to distinguish between empty and filled barrels of liquor, and Dr. Leopold Auenbrugger is said to be the person who introduced the technique to modern medicine, although this method was used by Avicenna about 1000 years before that for medical practice such as using percussion over the stomach to show how full it is, and to distinguish between ascites and tympanites.

Of the thorax[edit]

It is used to diagnose pneumothorax, emphysema and other diseases. It can be used to assess the respiratory mobility of the thorax.

Of the abdomen[edit]

It is used to find whether any organ is enlarged and similar (assessing for organomegaly). It is based on the principle of setting tissue and spaces in between at vibration. The sound thus generated is used to determine if the tissue is healthy or pathological.

Inspection of the abdomen gives clues to the diagnosis of intra-abdominal pathology. Combined with the patient's history, inspection can often provide a preliminary diagnosis that can be confirmed by auscultation and palpation. Despite the current popularity of various noninvasive and invasive diagnostic tests, the experienced surgeon can usually make an accurate diagnosis of intra-abdominal pathology by history and physical examination. This is demonstrated by the patient with a several-day history of right upper quadrant and back pain with associated nausea, vomiting, fever, and a visible mass in the right upper quadrant. Such a patient almost certainly has acute cholecystitis with hydrops of the gallbladder. The remainder of the physical examination merely confirms this and detects additional disease. Though inspection alone never provides a clear diagnosis, it should not be overlooked.

Generalized distention of the abdomen is usually from obesity, bowel distention by gas or liquid, or ascites. Obesity can cause generalized distension by either fat in the abdominal wall or intra-abdominal fat in the omentum or viscera. Generalized abdominal distention can also be related to ascites, particularly when associated with an everted umbilicus. Distention of the upper half of the abdomen only may be due to pancreatic cyst or tumor or to acute gastric dilatation. Distention of the lower half of the abdomen may be due to pregnancy, ovarian tumor, uterine fibroids, or bladder distention. A scaphoid abdomen is due to malnutrition.

Skin abnormalities detected on inspection of the abdominal wall need to be correlated with the clinical history. Bruising should be correlated with a history of trauma to determine the possible organs injured. Cullen's and Grey Turner's signs (bluish discoloration of the umbilicus and flanks, respectively) are related to intra-abdominal and retroperitoneal bleeding, and it is believed the blood dissects along fascial planes to reach these areas. Thus, one would want to question the patient diligently for causes of such bleeding—severe pancreatitis, trauma, or ruptured ectopic pregnancy.

Striae of the abdominal wall are a result of rupture of the reticular dermis that occurs with stretching. This is seen clinically in pregnancy, obesity, ascites, abdominal carcinomatosis, and Cushing's syndrome.

Surgical scars should be examined carefully, both as to their position and their characteristics. Often patients are unsure of what kinds of surgery they have had, but the position of the incision may give the examiner a clue. Even though a transverse right lower quadrant incision suggests appendectomy, however, it in no way proves it, and one must be circumspect in making any such assumptions. The scar tells the examiner about the surgery. All scars are initially raised and red; they gradually fade to pink and by 6 months are generally flat and skin colored or gray. Wounds that heal cleanly by first intention are thin and regular, whereas those that are infected and heal by secondary intention are wider and irregular. Keloids are wide, irregular scars with abundant hypertrophic tissue outside the field of normal scarring. Keloid formation tends to recur in certain individuals and is particularly common in blacks.

Enlarged veins are seen in three clinical situations: emaciation, portal hypertension, and inferior vena cava obstruction. In emaciation there is loss of subcutaneous fat so that the normally invisible veins become prominent. These veins become more prominent in the presence of portal hypertension. In portal hypertension the umbilical vein becomes an outflow tract of the portal system and forms collaterals with the veins of the abdominal wall. This is responsible for the caput medusa that is diagnostic of portal hypertension. The direction of blood flow in these veins in portal hypertension is normal (i.e., upward in those above the umbilicus and downward in those below) as the blood is flowing from the high-pressure portal system to the low-pressure systemic system. Finally, the veins of the abdominal wall may be dilated due to obstruction of the inferior vena cava. This occurs because the abdominal wall becomes a collateral, or bypass, around the obstruction of the cava. In this situation the direction of blood flow will be reversed below the umbilicus as the blood flows from the femoral vein to the superior vena cava. Obstruction of the inferior vena cava can occur as a result of a hepatic malignancy, as an extension of hepatic vein obstruction (Budd–Chiari syndrome), as a result of thrombophlebitis, or as a result of trauma or surgical intervention.

Masses noted on inspection of the abdomen may be related to organs in that area. Thus, a mass in the right upper quadrant may represent hepatomegaly from hepatitis or hepatic tumor, a distended gallbladder from cholecystitis or pancreatic cancer, or a carcinoma in the head of the pancreas. An epigastric mass is likely to be from acute gastric distention. pancreatic pseudocyst, pancreatic cancer, or aneurysm of the abdominal aorta (which will be pulsatile). Masses in the left subcostal region are generally due to splenomegaly, although carcinoma of the spenic flexure of the colon is also a possibility.

Masses in the lumbar region are generally of renal origin. Renal cysts, polycystic kidneys, and renal malignancies may all be visible in asthenic patients.

Masses in the lower quadrants may result from inflammatory or neoplastic disorders of the intestine. In the right lower quadrant appendiceal abscess and cecal carcinoma are most likely, while in the left lower quadrant diverticular abscess or carcinoma of the sigmoid colon is most likely.

Hypogastric masses are the result of pelvic pathology. Acute urinary retention is the most common cause of such a mass in males. In females, uterine or ovarian neoplasms may cause visible midline abdominal masses.

Visible intestinal peristalsis is usually the result of intestinal obstruction. This can be seen in the stomach of the newborn with hypertrophic pyloric stenosis and in the small intestine of patients with small bowel obstruction from various etiologies.

What percussion sound does the stomach make?

Which percussion tone should the nurse expect to hear over the stomach?

When percussing the abdomen the expected findings are?

What are the sounds you may hear during percussion?