Physical Exam

Tactile Fremitus

also known as Vocal fremitus

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Video coming September 2026

How to Perform

Place the ulnar edge or palmar surface of your hands on symmetric areas of the chest wall and ask the patient to repeat a resonant phrase such as ‘ninety-nine.’ Compare the intensity of the vibrations felt side to side, noting any area of increased or decreased fremitus.

How to Interpret

Pleural Effusion

Decreased tactile (vocal) fremitus over the affected hemithorax

Rule in

Helpful

Rule out

Somewhat helpful

Evidence:Limited

References

Heckerling PS, Tape TG, Wigton RS, Hissong KK, Leikin JB, Ornato JP, Cameron JL, Racht EM. Clinical prediction rule for pulmonary infiltrates. Ann Intern Med. 1990;113(9):664-670. doi:10.7326/0003-4819-113-9-664. PMID: 2221647. Closest study: a five-variable prediction rule for pneumonia that does not include tactile fremitus and reports no operating characteristics for this sign.
Kalantri S, Joshi R, Lokhande T, Singh A, Morgan M, Colford JM Jr, Pai M. Accuracy and reliability of physical signs in the diagnosis of pleural effusion. Respir Med. 2007;101(3):431-438. doi:10.1016/j.rmed.2006.05.017. PMID: 16965906. Single prospective cohort, n=278 inpatients admitted with respiratory symptoms (rural India); two physicians blinded to history, chest radiograph, and each other; chest-radiograph reference standard; pleural-effusion prevalence 21%. Table 3, reduced vocal (tactile) fremitus: sens 0.82 (0.70-0.91), spec 0.86 (0.80-0.90), LR+ 5.67 (4.04-8.01), LR- 0.21 (0.12-0.35); inter-observer kappa for vocal fremitus 0.84-0.89 (excellent). This single primary cohort is the source of the decreased-tactile-fremitus estimate incorporated into Wong CL, Holroyd-Leduc J, Straus SE. Does this patient have a pleural effusion? JAMA 2009;301(3):309-317 (PMID 19155458), the JAMA Rational Clinical Examination that highlights tactile fremitus LR- 0.21 (0.12-0.37) as the top rule-out sign for pleural effusion. · Simel DL, Wong CL, Holroyd-Leduc J, Straus SE. Pleural Effusion. In: Simel DL, Rennie D, eds. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. McGraw-Hill Education; 2009.
McGee S. Evidence-Based Physical Diagnosis. 6th ed. Philadelphia, PA: Elsevier; 2025.