Identify tender areas. Carefully palpate any area where pain has been reported or where lesions or bruises are evident.
Unilateral impairment or lagging of respiratory movement suggests disease of the underlying lung or pleura.
Intercostal tenderness over inflamed pleura
Assess any observed abnormalities such as masses or sinus tracts (blind, in- Although rare, sinus tracts usually flammatory, tubelike structures opening onto the skin) indicate infection of the underlying pleura and lung (as in tuberculosis, actinomycosis).
Test chest expansion. Place your thumbs at about the level of the 10th ribs, with your fingers loosely grasping and parallel to the lateral rib cage. As you position your hands, slide them medially just enough to raise a loose fold of skin on each side between your thumb and the spine.
Ask the patient to inhale deeply. Watch the distance between your thumbs as they move apart during inspiration, and feel for the range and symmetry of the rib cage as it expands and contracts.
Feel for tactile fremitus. Fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall when the patient speaks. To detect fremitus, use either the ball (the bony part of the palm at the base of the fingers) or the ulnar surface of your hand to optimize the vibratory sensitivity of the bones in your hand. Ask the patient to repeat the words "ninety-nine" or "one-one-one." If fremitus is faint, ask the patient to speak more loudly or in a deeper voice.
Use one hand until you have learned the feel of fremitus. Some clinicians find using one hand more accurate. The simultaneous use of both hands to compare sides, however, increases your speed and may facilitate detection of differences.
Causes of unilateral decrease or delay in chest expansion include chronic fibrotic disease of the underlying lung or pleura, pleural effusion, lobar pneumonia, pleural pain with associated splinting, and unilateral bronchial obstruction.
Fremitus is decreased or absent when the voice is soft or when the transmission of vibrations from the larynx to the surface of the chest is impeded. Causes include an obstructed bronchus; COPD; separation of the pleural surfaces by fluid (pleural effusion), fibrosis (pleural thickening), air (pneumothorax), or an infiltrating tumor; and also a very thick chest wall.
Palpate and compare symmetric areas of the lungs in the pattern shown in the photograph. Identify and locate any areas of increased, decreased, or absent fremitus. Fremitus is typically more prominent in the interscapular area than in the lower lung fields, and is often more prominent on the right side than on the left. It disappears below the diaphragm.
Tactile fremitus is a relatively rough assessment tool, but as a scouting technique it directs your attention to possible abnormalities. Later in the examination you will check any suggested findings by listening for breath sounds, voice sounds, and whispered voice sounds. All these attributes tend to increase or decrease together.
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