Palpation
• Use the index finger to feel the trachea and to determine whether the trachea feels central or is deviated.
• The trachea is deviated away from pneumothorax and effusion and towards collapse and consolidation.
• The trachea may also be deviated by a mass, eg enlarged lymph nodes.
• Chest expansion:
• Usual chest expansion in an adult is 4-5 cm and should be symmetrical.
• Asymmetrical reduction of chest wall expansion: absent expansion (eg empyemaand pleural effusion) or reduced expansion (eg pulmonary consolidation and collapse).
• Tactile vocal fremitus:
• To assess tactile vocal fremitus, use the ulnar side of the hand, by the hypothenar eminence with the palms facing upwards. Place it at various levels over the back, each time asking the patient to say "ninety-nine". Note how the sound is transmitted to the hand.
• Tactile vocal fremitus is increased over areas of consolidation and decreased or absent over areas of effusion or collapse.
• Feel for the apex beat of the heart; it will be displaced if the mediastinum is displaced or distorted.