Thursday, 11 October 2012

Percussing the heart

Does any of you still do cardiac percussion? We Indonesian medical students are still trained to do it, our physical exam books still explain how to do it, but I seldom see foreign resources doing likewise. Sure, in the fast-paced modern medicine, we have plenty of diagnostic tools like the X-ray that are more accurate, but sometimes we need a handy bedside examination for a quick assessment of, say, a pleural effusion. So I wonder if thoracic, and more specifically cardiac, percussion has become a lost art.

In cardiac examination, percussion is performed to determine the borders of the heart, which in turn will determine if there is a cardiomegaly. It is a rough estimation, but the more you do it, the more trained your ears will become, and I believe the more accurate the results will be, just like any other things in life.

Here's how you do it on an adult patient:


In case you've forgotten.


1. Have the patient lie supine on the examination table.

2. Start from the right side of the chest. Percuss the intercostal spaces (ICS) down the right midclavicular line until you reach the dull sound of the liver. Go up one ICS and start percussing towards the sternum until you reach a weak dull sound. That is the right border of the heart. Normally it is found on the 4th ICS at the right parasternal line.

3. Now we move to the left side. Percuss the ICS down the left parasternal line until you reach a weak dull sound. That is the conus pulmonalis or the "cardiac waist" as they say it in radiology. Normally it is found on the 2nd-3rd ICS at the left parasternal line.

4. Still on the left side. Percuss the ICS down the anterior axillary line until you reach the tympanic sound of the stomach. Go up one ICS and start percussing towards the sternum until you reach a weak dull sound. That is the left border of the heart. Normally it is found on the 4th-5th ICS at the left midclavicular line.


Normal chest radiography.
Blue circle is the "cardiac waist", formed by the pulmonary trunk and left atrium.
Original image source: Life in the Fast Lane. Circle by me.


Some sources are more detailed, although they do not explain precisely how one should percuss.


Upper right border: 2nd ICS at the right parasternal line
Lower right border: 4th ICS at the right parasternal line
Upper left: 2nd ICS at the left parasternal line
Lower left: 4th ICS at the left midclavicular line

Hope this helps! :)

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