Having said all this, we would agree that cardiac percussion for the purpose of determining the cardiac borders is prone to error. Indeed, as early as 1899 Williams1 noted the errors of ordinary percussion as opposed to roentnographic determination for this purpose, particularly in small hearts. What we propose is the elucidation of abnormal areas of dullness, whose determination allow us to obtain quick information at the bedside. Indeed, in his popular A Primer of Medicine,2 and based on work by Dressler, Papworth alludes to at least fifteen cardiac pathologies that may be diagnosed on the basis of cardiac percussion. By dullness in this instance we mean an extremely flat note. Of course percussion around the praecordium will inevitably reveal a dull note, but an element of resonance is always noted.
In the healthy individual such an area of marked dullness is normally found adjacent to the sternal margin, beneath the fourth rib on the left. This dull area is approximately two inches wide and merges with hepatic dullness at the level of the sixth rib caudally. Enlargement of the heart results in more proximate apposition of its chambers to the chest wall, so causing a flatter percussion note above this vicinity and extension of the normal area of marked dullness. As the anterior aspect of the heart is primarily right ventricle, it is right heart dilation that is most readily amenable to detection by this method. It is characterized by extension of marked dullness to the left and right of the normally dull area, such that there is substernal dullness and left-sided flattening extending more than the two inches described. Areas of abnormality should be compared to the normal area of dullness to judge the tone as being definitively dull.
The above-mentioned features of extended areas of dullness were posited by Dressler3,4 to be particularly useful in determining cases of mitral stenosis and tricuspid regurgitation. However, perhaps the greatest value of the cardiac percussion method lies in appreciation of the more diffuse pattern of marked dullness that accompanies pericardial effusion. Here, the finding of a flat percussion note over the lower half or two-thirds of the sternum in the absence of evidence for mitral stenosis is suspicious of pericardial effusion. In moderate effusions dullness often extends to both sides of the sternum, especially the left side where the second and third interspaces are involved. In our experience, however, we have discovered that the extremely dilated hearts of chronic mitral stenosis, dilated cardiomyopathy and heart failure can mimic this picture, so the clinical context is important.
If the borders between tympanitic (resonant) and dull notes remain the same, the person probably does not have ascites, or has less than 2 litres of free fluid present. If the fluid causing the dullness was not free, then the air-fluid level would not move. Shifting dullness is usually present if the volume of ascitic fluid is up to 500 mL ml. If low volume ascites is suspected, then an attempt to elicit the puddle sign may be performed.
Upper Limit of Fluid can be recognized by: Percussion
The upper limit of dullness of pleural effusion is a straight line around chest.It was believed, one should elicit a higher level of dullness in axilla compared toanterior and posterior chest in pleural effusion. Now it is recognized that it is anoptical illusion and our perceived dullness being high in the axilla is a prejudicedfinding. Shifting Dullness When there is air and fluid, the fluid shifts easily to dependent position. The lung and air floats up. If dullness was elicited in lower axilla, by having patient assume a lateral decubitus position return of resonance can be demonstrated at the previous site of dullness. In prone position the previously dull pleural gutter will become resonant as the fluid shifts and lung floats up. Shifting dullness is demonstrable with ease when there is hydropneumothorax.Radiologically it is easy to demonstrate shifting of fluid in pleural effusion also, but however it is not easy to demonstrate shifting dullness, as one can do with hydropneumothorax. This may be because of the capillary action, there is always fluid even in upper portion of chest.
Begin percussion over the lungs and move from the area of resonant lung sounds to the areas of dullness. Mark the area of change. Repeat the same process from below, moving again from resonance over the bowel to dullness and again mark the area of change. Start in the lower right quadrant so as to not miss a greatly enlarged liver. Measure the vertical distance from the top to the bottom. You can also use palpation to determine the lower border.
Case description: A 75-year-old man with hypertension had constipation and variable abdominal pain symptoms for a long time. He had no fever or abdominal pain at that time. Physical examination of the abdomen revealed high-pitched bowel sounds and hypertympanic percussion with absent liver dullness. An abdominal CT scan revealed coincidentally a left-sided liver, gallbladder and portal system. This was an explanation for the absent liver dullness.
A novel procedure is described to establish knife steeling schedules for poultry and meat- processing operations based on increased force due to knife dullness from repetitive use to minimize operator exertions and physical stress associated with work-related musculoskeletal disorders. Knife dullness was quantified using a novel apparatus described in this article that measures the area cut by a knife into a carrageenan gel target for a controlled dynamic load at the knife handle. Two meat-cleaning jobs in a poultry-processing plant were studied. One job required significantly more force and a greater number of cuts than the other. Eight experienced operators participated in the study. Four freshly ground and honed knives were randomly used by each operator for 4, 45, 75, or 125 cutting cycles, measured for dullness and reconditioned by the operator using a steel sharpening rod. An empirical model for knife dulling and reconditioning was developed, and the corresponding increase in force was predicted for various cutting and reconditioning frequencies. The model showed that it took 57 and 125 cutting cycles for the high- and low-force jobs, respectively, to achieve a similar reduction in target surface area of 30%. This reduction in target surface area corresponded to a similar percentage increase in force needed for the same cut in carrageenan gel as compared to a freshly honed knife as measured using strain gages. This method may be used in meat processing plants for determining effective reconditioning schedules that reduce operator exertions with minimum effect on quality and productivity.
After cleansing, reach for a brightening toner to soothe your skin and remove any leftover residue or excess oil. For dull skin, we recommend Clearly Corrective Brightening & Soothing Treatment Water. This gentle toning liquid with illuminating minerals immediately soothes and hydrates while imparting the skin with a subtle, healthy-looking glow. This daily toner helps diminish the appearance of dullness for a visibly clearer, more even-looking appearance with continued use.
As an added defense against environmental aggressors that can cause dullness, wash your face thoroughly morning and night to remove any impurities lingering on your skin. We recommend using the cult-classic Ultra Facial Cleanser to keep your skin clean and healthy-looking. This best-selling cleanser with olive-derived squalane cleanses the skin without stripping away its natural oils for a clean, balanced appearance.
Earnestness is the opposite of spiritual dullness, laziness, apathy, complacency. Like all believers, the earnest experience seasons of doubt and struggle and discouragement, but even then (maybe especially then), the flame of their faith burns warmer and brighter than expected.
Dullness is pretty much the opposite of glowing skin. Dull skin looks lackluster, tired, and pretty blah overall. We also group other signs of uneven skin tone within the dullness category too, such as dark spots, discoloration, undereye circles (for which we recommend our Vacation Eyes Brightening Eye Gel), and post-acne scars and marks.
The shifting dullness refers to a sign, elicited on physical examination, for ascites. If, on percussion, the region of dullness shifts when the patient is turned from supine position to side-lying, they probably have fluid in the abdomen. If the borders between tympanic and dullness remain the same, the person likely does not have ascites.