Palpation

Expansion of the Chest:

• It is measured by placing the hands in lower part of the chest (also in middle part), fingers are placed on the side of chest keeping the thumbs in midline and close to each other (can also be measured using tape at the level of nipple). Ask the patient to take deep breath in and out. Normal expansion is .5 cm.

Causes of reduced expansibility:

• Emphysema (in severe emphysema, it is ,1 cm).

• Pleurisy.

• Ankylosing spondylitis.

• Respiratory muscle paralysis.

Trachea:

• Normally, it is slightly deviated to the right. Causes of shifting of trachea:
  

1. Same side (on the side of lesion):

• Collapse.
•  Fibrosis.
•  Pneumonectomy.
•  Agenesis of one lung.

2. Opposite side (opposite to the side of lesion):

•  Pleural effusion.
•  Pneumothorax.

Apex Beat:

May be shifted, causes are as in trachea (see above). Apex beat is also shifted in kyphoscoliosis, pectus excavatum and cardiac cause.

Vocal Fremitus:

• May be normal, or increased or decreased (it is less practiced now a day, as vocal resonance is seen, which is more sensitive).

Causes of increased vocal fremitus (3 C’s):

• Consolidation.
  
• Collapse with patent bronchus.
• Cavity (large).

• Also in fibrosis.

Causes of decreased vocal fremitus:

•  Pleural effusion.
•  Thickened pleura.
• Pneumothorax.
•  Collapse with complete bronchial obstruction.
• Mass lesion (bronchial carcinoma, hydatid cyst).