Interactive Guide to Physical Examination
Thorax & Lungs

Advanced Techniques

Abnormal pulmonary findings can be further evaluated via palpation and auscultation of the patient's voice through the chest wall.

Tactile fremitus:

Feeling the vibrations generated from the spoken voice is termed tactile fremitus. Tactile fremitus:

  • Is evaluated by having the patient say "ninety-nine" or "one-two-three", and feeling the transmitted vibrations with the hands.
  • Is more prominent in the interscapular regions, less prominent at the lung bases.
  • Provides information about the density of underlying lung tissue and chest cavity.
  • Is decreased or absent in conditions that impede transmission of sound (such as an obstructed bronchus, COPD, pleural fluid, or a very thick chest wall).
  • Is increased in conditions that increase transmission of sound (such as consolidated lobar pneumonia).
View video Click on the video icon for further demonstration of tactile fremitus examination techniques.

Vocal fremitus:

Evaluating speech through the stethoscope is termed vocal fremitus. Vocal fremitus:

  • Is evaluated by having the patient say "ninety-nine" while listening with the stethoscope over various portions of the lungs.
  • Is an indistinct low-pitched mumble over normal lung.
  • Is increased over areas where the lung has become airless (e.g. consolidation or atelectasis) and results in louder, clearer voice sounds (bronchophony).
  • Is particularly notable if the patient whispers a message, and it is clearly audible through the stethoscope over the airless portion of lung (whispered pectoriloquy).
  • Is decreased when there is a decrease in lung density such as hyperinflation, or focally when the lung tissue is separated from the chest wall (for example in pneumothorax or pleural effusion).

When voice sounds increase in intensity and take on a "bleating" quality, this is described as egophony. Egophony is present when "e-e-e" spoken by the patient is heard through the stethoscope as "a-a-a." Egophony is generally found over consolidated lung where bronchophony is also present.

These signs are most easily appreciated when various areas of lung are compared to each other.

View video Click on the video icon for further demonstration of egophony and whispered pectoriloquy examination.