As you palpate the chest, focus on areas of tenderness or bruising, respiratory expansion, and fremitus.
■ Identify tender areas. Carefully palpate any area where the patient reports pain or has visible lesions or bruises. Note any palpable crepitus, defined as a crackling or grinding sound over bones, joints, or skin, with or without pain, due to air in the subcutaneous tissue.
■ Assess any skin abnormalities such as masses or sinus tracts (blind, inflammatory, tube-like structures opening onto the skin).
■ 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 (Fig.1). As you position your hands, slide them medially just enough to raise a loose fold of skin between your thumbs over 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. This movement is sometimes called lung excursion.
FIGURE 1. Assess lung expansion.
■ Palpate both lungs for symmetric tactile fremitus (Fig.2). Fremitus refers to the palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking and is normally symmetric. Fremitus is typically more prominent in the interscapular area than in the lower lung fields and easier to detect over the right lung than the left. It disappears below the diaphragm.
FIGURE 2. Locations for palpating fremitus.
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." Initially practice with one hand until you feel the transmitted vibrations. Use both hands to 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. If fremitus is faint, ask the patient to speak more loudly or in a deeper voice.
Tactile fremitus is a somewhat imprecise assessment technique, but does direct your attention to possible asymmetries. Confirm any disparities by listening for underlying breath sounds, voice sounds, and whispered voice sounds. All these attributes should increase or decrease together.
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