hello I'm Sandra Adams a pulmonologist in the founder of the white diseases foundation this is the third in a series of videos the first one on tactile fremitus why it's increased and decreased in different conditions the second one was on percussion learning the best technique now let's see if you can apply what you've learned about percussion and tactile fremitus to identify different clinical conditions based on these examination findings now what if a patient had the following physical exam findings normal breath sounds tactile fremitus and percussion throughout his entire left lung but in the lower two-thirds of his right lung he has dullness to percussion in increased tactile fremitus what do you think he has so this is dullness to percussion on the right side in increased tactile fremitus on the right side so does he have chronic obstructive pulmonary disease does he have a pleural effusion pneumonia and pneumothorax pulmonary edema or pulmonary fibrosis what do you think well the correct answer is pneumonia he has dullness to percussion because the pneumonia or consolidation is liquid from the pus and exudative material and it's increased tactile fremitus because that fluid is inside the lung so therefore the sound waves travel through the bronchus hit the fluid in the lung and take off to your hand therefore the tactile fremitus is increased if fluid is inside the lung or consolidation like pneumonia now let's talk about another patient normal breath sounds tactile fremitus and percussion throughout the entire left lung again but this time the lower two-thirds of his right lung he has reduced tactile fremitus and this time hyper resonance to percussion what do you think he has same set of options decreased from addis and hyper resonance to percussion what do you think the correct answer is pneumothorax why is fremitus decreased in pneumothorax well there's a pocket of air there and we know that sound doesn't travel very well through air and so because the air is between the visceral and parietal pleura when you feel on the patient's chest the tactile fremitus will be decreased why is it hyper resonance to percussion well again there's air there and we know that the lung is resonant and if there's extra air there then you call that hyper resonance so the correct answer would be pneumothorax now we've got another patient same thing on the left normal breath sounds tactile fremitus and percussion throughout his entire left lung but now on the lower two-thirds of his right lung he has reduced tactile fremitus and dullness to percussion so decreased tactile fremitus and dullness to percussion what do you think in this scenario well the correct answer is pleural effusion so again why is the tactile fremitus decrease there's fluid there but remember this time the fluid is outside the lung so the sound travels down the bronchus through the lung hits the visceral pleura kind of stops then it has to go through a layer of fluid so by the time it gets to your hand the tactile fremitus feel is markedly decreased in dullness to percussion makes sense because it's fluid so it's going to be very dull when you percuss so the correct answer for this one would be pleural effusion now what if yet another patient had the following bilateral physical examination findings throughout both lungs decreased breath sounds decreased tactile fremitus and hyper resonance to percussion throughout everywhere so what do you think on this one well the correct answer here is chronic obstructive pulmonary disease but the exam findings are bilateral therefore it's almost impossible to hear this and feel this clinically if you had performed these maneuvers on a patient over time and you could remember how it sounded and felt before then it's possible that you could pick this up but otherwise when it's really hard to tell that somebody has hyper resonance or decreased tactile fremitus because it's equal bilaterally in a situation like this what about the findings of patients with pulmonary edema and pulmonary fibrosis well these are both usually diffuse and bilateral conditions affecting the interstitial of the lungs and sometimes spilling out into the alveoli therefore the most common exam findings include crackles that can be heard in the lungs and other extra pulmonary physical exam findings patients with pulmonary edema will often have other signs of volume overload such as lower extremity edema elevated jugular venous pressures in the neck and sometimes you can hear a third heart sound patients with pulmonary fibrosis often have clubbing of their fingers and toes in addition to the crackles in their lungs you can often figure out what a patient's chest radiographs will demonstrate based on the patient's physical exam findings particularly when you perform a complete physical exam and take a careful history as well thank you for watching this video please let us know if it was helpful also please check back often for future educational offerings thank you very much you