Chapter 4:	Examination of the Chest
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Palpation

Palpation involves touching the chest wall in order to evaluate underlying structure and function, and is used to confirm or rule out suspected problems identified by the interview, history, and initial inspection. Palpation is generally performed to:

• evaluate vocal fremitus

• estimate thoracic expansion

• assess the chest’s skin and subcutaneous tissues

The term fremitus refers to the vibrations that are transmitted through lung tissues and the chest wall whenever a vocal sound is made. When these vibrations are felt on the chest wall during palpation, they are called tactile fremitus. A comparison of these vibrations between both lungs is performed. There are differences in fremitus between men and women, and fat and thin people, but a comparison of fremitus within an individual is what needs to be noted.

To palpate for fremitus, the RCP places palmar aspect of the fingers or the ulnar aspect of the hand against the chest and has the patient repeat the number "99." All areas of the chest should be compared, both front and back. Fremitus should be equal over all areas of normal lung tissue except over the right upper lobe, where it increases because the bronchus is closer to the chest wall. Tactile fremitus increases in intensity whenever the density of lung tissue increases, such as in consolidation or fibrosis, and will decrease when a lung space is occupied with an increase of fluid or air (e.g., pleural effusion, pneumothorax and emphysema). The causes of abnormal tactile fremitus include:

Increased:

• Pneumonia
• Lung tumor or mass
• Pulmonary fibrosis
• Atelectasis

Decreased

• Bronchial obstruction with mucus plug or foreign object
• Pleural effusion
• Pneumothorax

• Muscular or obese chest wall
• Chronic obstructive lung disease

Palpable vibrations referred to as rhonchial fremitus may be produced by the passage of air through airways containing thick secretions. Rhonchial fremitus often identified during inhalation and exhalation may clear if the patient produces an effective cough. It is frequently associated with a low-pitched, coarse sound that can be heard without using a stethoscope.