• What symptoms do you have if you cannot get drugs?
• Do you ever inject? If so, where do you get the needles and
• Do you ever share needles, syringes or other drug-taking
• Do you see your drug use as a problem?
• Do you want to make changes in your life or change the way you
• Have you been checked for infections spread by drug use?
identified as the index case, around whom the pedigree chart is constructed.
Fig. 5.14 Assessing chest expansion from the front. A Expiration.
Fig. 5.15 Subcutaneous air (surgical emphysema) seen in the neck
and chest wall on chest X-ray (arrows).
are usually absent. These two causes of absent sounds are
readily distinguished by percussion, which will be resonant with
pneumothorax and completely dull over pleural fluid.
Remember to wear the stethoscope with the ear pieces facing
forwards to align them with your auditory canal. Normal breath
sounds are relatively quiet, so the greater area of contact offered
by the diaphragm is usually well adapted to chest auscultation.
The two common exceptions are in patients with:
• A cachectic chest wall with sunken intercostal spaces,
where it may be impossible to achieve flat skin contact
• A hairy chest wall, where movement of chest hairs against
the diaphragm are easily mistaken for lung crackles. In
these situations, use the stethoscope bell instead to listen
As with percussion, the absolute volume and character of breath
sounds in individuals are greatly affected by the thickness,
muscularity and fat content of the chest wall. The symmetry of
sounds is therefore the key feature.
• Auscultate the apices, comparing right with left, and
changing to the bell if you cannot achieve flat skin contact
• Ask the patient to take repeated slow, deep breaths in
and out through their open mouth. Auscultate the anterior
chest wall from top to bottom, always comparing mirror
image positions on right and left before moving down.
• Use the same sequence of sites as for percussion (see
Fig. 5.16B and C). Do not waste time by listening to
repeated breath cycles at each position, unless you
suspect an abnormality and wish to check.
• Note whether the breath sounds are soft and muffled,
absent, or loud and harsh (bronchial, like those heard over
the larynx). Seek and note any asymmetry and added
sounds (see later), deciding which side is abnormal.
• Auscultate the lateral chest wall in the mid-axillary line,
again comparing right with left before changing level.
normal lung is almost all air. Resonance on percussion together
with unilateral absent breath sounds indicates pneumothorax.
To understand chest auscultation it is necessary to understand
the origin of breath sounds. The tracheobronchial tree branches
23 times between the trachea and the alveoli. This results in an
exponential rise in the number of airways and their combined
cross-sectional area moving towards the alveoli. During a maximal
breath in and out, the same vital capacity (about 5 L of air in
healthy adults) passes through each generation of airway. In
the larynx and trachea, this volume must all pass through a
cross-sectional area of only a few square centimetres and therefore
flow rate is fast, causing turbulence with vibration of the airway
wall and generating sound. In the distal airway, the very large
total cross-sectional area of the multitude of bronchioles means
that 5 L can easily pass at slow flow rates, so flow is normally
virtually silent. The harsh ‘bronchial’ sound generated by the
major airways can be appreciated by listening with the diaphragm
of the stethoscope applied to the larynx (try this on yourself).
Most of the sound heard when auscultating the chest wall
originates in the large central airways but is muffled and deadened
by passage through overlying air-filled alveolar tissue; this, together
with a small contribution from medium-sized airways, results in
‘normal’ breath sounds at the chest wall, sometimes termed
‘vesicular’. When healthy, air-filled lung becomes consolidated
by pneumonia or thickened and stiffened by fibrosis, sound
conduction is improved, and the centrally generated ‘bronchial’
breath sounds appear clearly and loudly on the overlying chest
wall. In the same way, with soft speech (‘say one, one, one’),
the laryngeal sounds are muffled by healthy lung but heard
clearly and loudly at the chest wall overlying consolidation and
fibrosis, due to improved conduction of major airway sounds
When there is lobar collapse caused by a proximal bronchial
obstruction, the signs are different from those in simple
consolidation. The usual findings are diminished expansion,
sometimes with chest asymmetry due to loss of volume, dullness
to percussion over the collapsed lobe, and reduced breath sounds
When the lung tissue is physically separated from the chest
wall by intervening air (pneumothorax) or fluid (pleural effusion),
sound conduction is greatly impaired and the breath sounds
Fig. 5.16 Percussion of the chest. A Technique. B Anterior and lateral sites. C Posterior sites.
breath sounds). These signs can be confirmed by asking the
patient to generate laryngeal sounds deliberately (‘Please say “one,
one, one” each time I move my stethoscope on the skin’) and
listening on the chest wall in the same sequence of sites used
for breath sounds. The spoken sound is muffled and deadened
over healthy lung, but the spoken sound is heard loudly and
clearly through the stethoscope over consolidation or fibrotic
lung scarring. Consistent with absent breath sounds, vocal
resonance is absent or greatly diminished over pneumothorax
‘Whispering pectoriloquy’ may be used to confirm the same
changes in sound conduction. Whispered speech is muffled to
silence by normal lung but may be heard over consolidated or
Interpretation of the findings
Review your findings and assemble the positive features you
have uncovered. On completion of the history and examination
you should have a broad idea of the category of respiratory
illness with which you are dealing. As with any system, consider
as you go the likely categories of disease and how these affect
presentation. This approach is summarised in Box 5.6.
Selecting the relevant investigation depends on the clinical problem
revealed on history and examination. Investigations are costly
and many carry risks, so choose tests capable of distinguishing
the likely diagnoses and prioritise the most decisive ones. In
respiratory disease, imaging of the lungs is fundamental, but
respiratory function testing is equally important to distinguish
obstructive disease of the airways from the restrictive pattern
seen in many parenchymal diseases, and to quantify the degree
of abnormality. A summary of the appropriate initial investigations
according to the type of respiratory presentation is included in
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