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John A. McChesney, MD, FACP, and John W. McChesney, ATC, PhD, contributed to conception and design and drafting, critical revision, and final approval of the article.
To present a practical overview of the methods and techniques of auscultation of the chest and abdomen for use during the physical examination of athletes. Our intent is to provide information on this clinical technique to assist athletic trainers in recognizing and referring athletes presenting with potentially serious internal organ conditions.
Use of the stethoscope is a clinical skill increasingly necessary for athletic trainers. Given the expanding breadth of both the assessment techniques used by athletic trainers and the populations they care for and the fact that clinical instruction guidelines have changed in the newly adopted National Athletic Trainers' Association Educational Competencies, our goal is to provide a framework upon which future instruction can be based.
This review covers the use of a stethoscope for auscultation of the chest and abdomen. Auscultation of the heart is covered first, followed by techniques for auscultating the breath sounds. Lastly, auscultation of the abdomen describes techniques for listening for bowel sounds and arterial bruits.
During the assessment of injuries to and illnesses of athletes, knowledge of auscultatory techniques is valuable and of increasing importance to athletic trainers. Athletic trainers who do not know how to perform auscultation may fail to recognize, and therefore fail to refer for further evaluation, athletes with potentially serious pathologic conditions.
The athletic training profession continues to grow and diversify. Clinical athletic training education has recently undergone a significant change as described in the newly adopted National Athletic Trainers' Association Educational Competencies.1 In addition to the populations that certified athletic trainers (ATCs) work with in the typical scholastic, intercollegiate, and clinical settings, ATCs now are being placed in novel work settings (eg, industrial, secondary school, and performing arts settings) to work with nontraditional and varied populations. Furthermore, these populations (which number in the millions and include children, older adults, and individuals with disabilities) are participating in various forms of exercise training.2 Certified athletic trainers are now serving all age groups of the physically active. As allied health professionals, ATCs are in a position to recognize potentially threatening conditions requiring referral, and, therefore, they need to possess the clinical skills necessary to perform this task.
The use of a stethoscope for auscultation of the chest and abdomen is a clinical skill that must be taught to all entry-level athletic trainers. Within the psychomotor domain, candidates for national certification will likely have to evaluate athletes who exhibit signs and symptoms associated with cardiopulmonary and gastrointestinal conditions and will have to use a stethoscope correctly for auscultation of the heart, lungs, and bowel. To identify abnormal sounds on auscultation, ATCs should be familiar with normal chest and bowel sounds. The auscultatory examination may provide information that can assist the ATC in making a medical referral that may point the way to necessary therapy.
The organs of the chest and abdomen to be auscultated are of importance individually, but they are anatomically and physiologically linked to other organs and must be viewed in a comprehensive fashion.3 During auscultation, the examining ATC will recognize that sounds vary according to the underlying normal or pathologic anatomy or disease state of the organ. Sounds that are heard originate from movements of the organs or parts thereof, the flow of air, or movement of fluids through the organs; these sounds may vary greatly in normal as compared with abnormal or diseased organs. The purpose of this clinical techniques paper is to present a practical overview of the methods and techniques of auscultation of the chest (ie, the heart and lungs) and abdomen for use during the examination of athletes. The findings from such an examination may warrant referral. This paper is not intended to provide ATCs with the knowledge to diagnose any condition present in the heart, lungs, or abdomen but rather to detect abnormalities and report these abnormalities to a physician for confirmation. Our intent is to provide information on this important clinical technique to help ATCs recognize and refer athletes with potentially serious internal organ conditions.
To become proficient at auscultation, ATCs must examine many athletes under the guidance of an experienced instructor or physician to learn the skills needed to identify the physical abnormalities associated with various conditions. The use of audiotapes presenting recorded auscultatory sounds will aid in this learning process but will not substitute for live examination. Also, the use of a cardiology teaching device, such as the Harvey Cardiology Patient Simulator (Center for Research in Medical Education, University of Miami School of Medicine, Miami, FL), facilitates learning by demonstrating numerous pathologic heart sounds.
Before auscultation of the chest and abdomen, the ATC should obtain a thorough subjective history from the athlete, targeting his or her personal and family health history. The personal health history should address (but is not limited to) issues such as past injuries and illnesses, allergies, childhood illnesses, current medications, diagnostic tests, diet, exercise level, general health (including any current symptoms), immunization status, surgeries and hospitalizations, sleeping habits, and substance abuse. The family history should address (but is not limited to) the age, health, and cause of death of family members. The family history should also address the presence of allergies, anemia, arthritis, asthma, cancer, diabetes, epilepsy, heart disease, hypercholesterolemia, hypertension, psychiatric illness, renal disease, stroke, substance abuse, and tuberculosis.
After taking the history, the examining ATC should measure the 4 basic vital signs to provide a foundation for the assessment: core temperature, arterial pulse rate, respiratory rate, and sitting blood pressure. Only by measuring these basic vital signs can the correct assessment and interpretation of the auscultatory findings be made. Additionally, the examining ATC should observe the athlete for pallor, cyanosis, jaundice, cough, and dyspnea and should note the athlete's general demeanor in an attempt to gather information on his or her specific medical condition.4
Auscultation simply requires the use of a good acoustic stethoscope. The stethoscope head should be equipped with a rigid diaphragm for effective transmission of high-frequency sounds and a bell for effective transmission of low-frequency sounds. The tubing that transmits sounds to the earpieces should be of heavy gauge, to better transmit all sounds, and from 31 to 40 cm in length.4
The indications for an ATC to perform cardiac auscultation are numerous and include, among others, the following 9 items. Any athlete presenting with any of these signs or symptoms should be referred for examination by a physician.
For optimal auscultatory examination of the heart, an athlete should be approached from the right side. A right-sided approach facilitates effective observation, percussion, and auscultation of the precordial areas as well as assessment of cardiac size.4 The athlete should be at rest and recumbent with the head and chest elevated to 45°. This optimum position is preferred over the upright seated position. We recommend this position because it facilitates the observance of chest movements associated with cardiac function as well as correct placement of the stethoscope head during auscultation. When auscultation is performed in the athletic training quarters, the examination room should be warm, very quiet, and well lighted. Patient modesty is to be maintained, and a same-sex chaperone should be present when necessary. Obviously, in cases of trauma, the ATC may need to modify the examination position or improvise, according to the severity of the situation.
The examiner should begin by determining the approximate size of the heart. Except in very obese patients, heart size can be determined by noting the point of maximum impulse (PMI), otherwise known as the apical impulse. The PMI is produced by an early, brief, left-ventricular pulsation as the heart moves anteriorly during systole and comes in contact with the chest wall. The PMI should also be assessed by palpation. The PMI is the most inferior and lateral position at which the apical impulse can be clearly viewed and palpated, and its location reflects heart size.4 Its position normally corresponds to a point in the midclavicular line near the level of the left fifth intercostal space at the apex (Figure (Figure1).1). If the heart is enlarged, the PMI may be found lower, near the sixth intercostal space and at the anterior axillary line. A cardiac pulsation detected to the right of the sternum is always abnormal and may indicate aneurysmal dilatation of the ascending aorta, situs inversus, or right-ventricular enlargement. Heart enlargement should alert the examining ATC that the athlete may have congenital heart disease, cardiac dilatation due to longstanding hypertension, pericardial effusion, or some serious valvular heart disease.15 All of these conditions also present with abnormal heart sounds.
Examples of some of these abnormal sounds include the diastolic murmur of aortic valve insufficiency, which sounds like a decrescendo whispered letter R. The systolic murmur of mitral valve regurgitation has a blowing sound.16 Systolic murmurs vary in character: some sound like cooing, whereas others sound like honking. Another systolic murmur frequently heard in young people is caused by mitral valve prolapse and is usually accompanied by a clicking sound.17 In contrast, in individuals with a pericardial effusion, the heart sounds are distant, and any murmur may be difficult or impossible to hear due to the intervening pericardial fluid. Please refer to the later section on murmurs for a more complete discussion of these sounds.
The examiner then begins auscultation by putting the fingers of one hand on an arterial pulse of the athlete, usually the radial or carotid pulse, while listening to the heart.3,18 Palpation of the carotid artery is preferred because it provides the most accurate representation of the central aortic pulse.19 Palpation of the pulse can be very valuable for determining the timing (systolic or diastolic) of the murmur being simultaneously auscultated (discussed subsequently). Palpation of the pulse is also fundamental in determining the pulse rate as well as the pulse rhythm. A regular rhythm is a sinus rhythm, whereas irregular rhythms can occur in a variety of cardiac conditions such as atrial fibrillation.
The examiner should lightly and evenly press the diaphragm end of the stethoscope to the exposed precordium to auscultate the chest. The hand holding the diaphragm should be positioned such that the heel of this hand rests on the chest and the fingers are free to hold the stethoscope head stable. The auscultation then proceeds with application of the stethoscope to the 4 main valve areas (Figure (Figure1).1). The examiner must also listen at the valvular area where the cardiac sounds are best heard: the aortic, pulmonic, tricuspid, and mitral valve listening zones. Simultaneous arterial palpation during auscultation allows the ATC to determine the timing of any cardiac murmurs. The importance of the timing cannot be overemphasized. If the murmur is heard simultaneously with the arterial pulse, then the murmur is systolic. If the murmur is heard after the pulse, then the murmur is diastolic, a finding of certain pathologic significance. This technique of simultaneous pulse palpation during auscultation is widely used in medical education for determining the timing of murmurs and, therefore, is appropriate for use by ATCs. It is very helpful to any clinician faced with identifying murmurs accompanied by atrial fibrillation, for example.
The 4 valvular areas are auscultated to assess the following 4 heart sound components:
Auscultation of the lungs should be performed on athletes who exhibit 1 or more of the following complaints or signs, which are given only as examples and are not intended to be a complete listing. These signs and symptoms are reasons for referral to a physician for further examination.
During auscultation of the lungs, the athlete should be seated upright on an examination table, with his or her legs over the edge. The athlete's neck should be slightly forward flexed with his or her arms folded. This position allows the scapulae to move laterally, which enlarges the lung examination area of the posterior and lateral thorax. When the examiner completes the examination of the posterior thorax (including the lung apexes) and moves to the anterior areas, the athlete's arms are then returned to the sides.
The athlete is then asked to take slow, deep, long breaths while the ATC looks for symmetric lung expansion. The diaphragm head of the stethoscope is applied lightly over the posterior and lateral aspects of the chest to hear the breath sounds. The lungs are auscultated over the posterior chest wall, beginning at a point midway between the superomedial border of the scapula and the spine and descending to the level of the diaphragm. Then the ATC listens over the posterolateral chest (Figure (Figure3).3). Upon completion, the anterior chest is auscultated.
Areas over major bronchi and the posterior chest midline should be avoided during auscultation because normal bronchial breath sounds are typically heard in these areas. This caution in technique is stressed because bronchial sounds are usually heard over areas of lung consolidation but are also heard over the trachea and major bronchi during examination of the thorax in normal individuals. Normal breath sounds are soft and low pitched and caused by the flow of air through the bronchi and alveoli. These breath sounds are termed vesicular; they are heard through inspiration and fade away during expiration. Types of normal (well) and abnormal (ill) breath sounds are shown in Figure Figure4.4. The ATC should listen for any abnormal breath sounds, including the following sounds:
Auscultating the chest provides the ATC with information concerning the pitch, length, and intensity of an athlete's breath sounds during inspiration and expiration. Normally, clear, vesicular breath sounds are heard when auscultating the athlete's lungs. Abnormal and questionable findings should prompt an ATC to refer the athlete for further examination.
With the high incidence of collision in sports, the number of athletes complaining of abdominal pain, and the relative frequency of abdominal injuries to athletes, this straightforward examination technique for auscultating the abdomen can be very useful to ATCs. After the athlete's history has been obtained, he or she should be placed in a supine position with the hips and knees flexed for abdominal auscultation. After taking a relevant history and observing the athlete with a potential abdominal injury or illness, the examiner should proceed to auscultate over the 4 quadrants of the abdomen. Palpation of the abdomen is performed after auscultation. During abdominal auscultation, the ATC listens for abnormalities of intestinal motility using the diaphragm head of the stethoscope. Normal bowel sounds include sounds that are scattered and low pitched and loud stomach growls (borborygmi) in the abdominal quadrants. These sounds can be heard at times, as we all are aware, in normal individuals both with and without the aid of a stethoscope. Bates28 noted that normal bowel sounds are quite variable in number, ranging from 5 to 35 sounds per minute. Bowel sounds may be increased in individuals with gastroenteritis and diarrhea. Tinkling bowel sounds may be heard in individuals with bowel obstruction. Decreased or absent bowel sounds may occur in individuals with peritonitis, internal organ injury, and paralytic ileus. Before determining that bowel sounds are absent, one should listen in the right lower quadrant for at least 2 minutes.29
Additional sounds that can be heard in the abdomen are arterial bruits, which resemble harsh, rough, murmur-like sounds. These sounds are best heard with the bell head of the stethoscope, which can be pressed more deeply into the wall of the abdomen than can the diaphragm, bringing the bell closer to the stenosed artery emitting the bruit sound. This technique has been used over many years by the primary author and has proven successful and rewarding in confirming diagnoses.
These bruits are not only heard in partially stenosed arteries, but they also arise from abdominal arterial aneurysms; the incidence of such aneurysms is increasing as the general population ages.30 These bruits are heard in older adults and occasionally in younger adults with Leriche syndrome (partial abdominal aortic occlusion).31 Although the incidence of abdominal vascular stenosis pathology is not high in the traditional young athlete population, ATCs' patient populations have expanded to include large numbers of physically active older adults. These older individuals have a much higher incidence of arterial stenosis and aneurysms, which may be detectable by abdominal auscultation. The ATC should be able to recognize and refer these vascular problems that, not infrequently, are life threatening. The renal, iliac, and femoral artery areas of the abdominal quadrants should be auscultated for arterial bruits (Figure (Figure55).
The presence of any bruit is obviously of great importance. Patients with bruits may present with symptoms of intermittent claudication of the lower extremities when the common iliac or more distal arteries are involved in the stenotic process.
Of great importance also are renal bruits auscultated in patients with hypertension caused by partial stenosis of a renal artery, the Goldblatt kidney.32 This bruit is sometimes heard near the abdominal flank. The associated hypertension is termed renovascular hypertension, and in a large study, these bruits were heard in 46% of the patients.33 When renovascular hypertension occurs in young adults (under age 35), it is usually due to fibromuscular dysplasia, which partially obstructs a renal artery, causing a bruit; in contrast, in older adults, the stenosis typically results from atherosclerosis.34,35 For both causes, corrective surgery can reestablish the normal blood pressure. Certified athletic trainers should always be alert to this serious, remediable problem in any hypertensive athlete. The ATC should always refer any athlete presenting with sustained hypertension (with or without an abdominal bruit). Information on renovascular hypertension and the frequency of bruits is being included because of the diversity of the patient populations seen by ATCs. Although renovascular hypertension is a cause of hypertension in athletes of all ages, it is treatable and curable.
Since its invention by Rene Laennec in 1819, the stethoscope for auscultation of the chest and abdomen has proven to be a necessary and indispensable tool for the examination of patients. The technique of auscultation unmasks pathology in the chest and abdomen that would otherwise remain undiagnosed and untreated. Using auscultatory techniques, structural abnormalities that are causing an athlete's complaints and disability can be identified.
The modern ATC should acquire this skill in order to adequately examine physically active individuals. A wide variety of people of all ages, from the pediatric population through the geriatric population, depend on ATCs to provide competent primary examinations and care before they are seen by a physician and to refer them as needed. In response to this need, the National Athletic Trainers' Association now mandates that ATCs be able to auscultate the chest and abdomen and identify the normal heart, lung, and bowel sounds. This worthy clinical proficiency requires training in the recognition of both normal and pathologic states, and it takes much practice. The athletic trainer who learns these techniques must hear both the normal and abnormal sounds, either from an apparatus or from a patient-athlete with the abnormality, in order to know what is normal and what is abnormal. In the same way that an ATC must understand ligamentous injuries in order to competently assess the normal state of capsuloligamentous stability, so must an ATC have knowledge of pathologic heart, lung, and bowel sounds in order to effectively identify the normal sounds of the chest and abdomen upon auscultation.
We hope that this paper will provide a framework upon which future instruction in these clinical techniques can be based and a stimulus for the further study and observation of patient-athletes. This overview is not intended to enable the ATC to render the type of evaluation rendered by physicians but rather to offer knowledge on techniques that will allow the ATC to gather information on possible conditions afflicting athletes. We in no way imply or suggest that the ATC should act as a physician but rather that the ATC should gather information on the clinical medical status of the athletes under his or her care. Pathologic and abnormal physical findings detected during auscultation always necessitate referral to a physician for further examination.