Measure the vertical span of liver dullness in the right midclavicular line after carefully locating the midclavicular line to improve accurate measurement. Use a light to moderate percussion strike, because a heavier strike can lead to underestimates of liver size. Starting at a level well below the umbilicus in the RLQ (in an area of tympany, not dullness), percuss upward toward the liver. Identify the lower border of dullness in the midclavicular line.

Next, identify the upper border of liver dullness. Starting at the nipple line, percuss downward in the midclavicular line until lung resonance shifts to liver dullness. Gently displace a woman's breast as necessary to be sure that you start in a resonant area. The directions of percussion are shown in Figure 1.

FIGURE 1. Percuss for liver dullness.

Now, measure in centimeters the distance between your two points—the vertical span of liver dullness. Normally, the liver span, shown in Figure 2, is greater in men than in women and in taller compared to shorter individuals. If the liver seems enlarged, outline the lower edge by percussing medially and laterally

FIGURE 2. Measure the liver span.

Measurements of liver span by percussion are more accurate when the liver is enlarged with a palpable edge.

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