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J Athl Train. 2001 Apr-Jun; 36(2): 190–196.
PMCID: PMC155535

Auscultation of the Chest and Abdomen by Athletic Trainers

Abstract

Objective:

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.

Background:

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.

Description:

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.

Clinical Advantages:

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.

Keywords: murmurs, vesicular breath sounds, rhonchi, rales, borborygmi, bruits

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.

THE AUSCULTATION EXAMINATION

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

Auscultation of the Heart

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.

  1. Evidence of cyanosis of the skin and mucous membranes accompanied by clubbing of the nails could indicate congenital heart disease, which would reveal cardiac murmurs upon auscultation.5 An ATC who finds such cyanosis should immediately refer the athlete to a physician. In addition, cyanosis can be caused by severe chronic obstructive pulmonary disease in older adult athletes, which also requires immediate referral. Cyanosis, no matter what the cause, may be the result of an acute life-threatening condition warranting the immediate administration of emergency medical techniques and activation of the emergency medical system.
  2. Any signs of Marfan syndrome, such as very tall stature, spider fingers, a high and arched palate, excessive arm length, chest-wall deformity, or a family history of sudden cardiovascular death at a young age.6,7
  3. Palpitations, a history of syncope, or dizzy spells (discussed subsequently).
  4. A very rapid pulse (tachycardia) over 100 beats per minute at rest or a very slow pulse (bradycardia) of less than 40 beats per minute.
  5. Unusual and severe dyspnea after routine exercise.
  6. Sustained arterial hypertension.
  7. Any symptoms of hypertrophic cardiomyopathy (HCM), which can cause sudden death in athletes after severe exertion. The average age of presentation for this condition is 26 years, and such athletes usually have a family history of sudden death. They commonly present with dyspnea (due to an elevation in pulmonary venous pressure secondary to elevated left-ventricular diastolic pressure) and may also present with angina, syncope, fatigue, and palpitations. Unfortunately, many patients are asymptomatic until the sudden death event.8,9 A harsh systolic murmur on auscultation is evidence for HCM, and the athlete should be referred to a physician immediately.
  8. Complaints of effort-related retrosternal pain relieved by rest (ie, angina pectoris). Angina heralds the probable occurrence of an acute heart attack and is a manifestation of coronary heart disease. Recent studies, including autopsy studies, have shown that coronary heart disease is a cause of sudden death in athletes, including marathon runners.10
  9. Traumatic chest injuries. Blunt, nonpenetrating chest trauma can cause cardiac concussion, “commotio cordis,” or myocardial contusion, which can result in cardiac arrest. Such trauma can occur in young athletes from a blow to the chest (including blows from projectiles such as baseballs and even hockey pucks) and can cause sudden death. The survival rate is very low; Maron et al11 reported 25 fatal cases. Specifically, the traumatic precordial blow is delivered at an electrically vulnerable period of ventricular excitability, thus inducing cardiac arrest. Almost all victims are under 20 years of age.1113 Experimental models are now being developed to study this serious problem.14

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.

Figure 1
Points of cardiac auscultation. Reprinted with permission from Crawford M. Heart Sounds: A Practical Guide. Point Pleasant, PA: Merck, Sharp & Dohme; 1989:10.

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:

  1. Cardiac rhythm. Note if the rhythm is regular and constant or irregular and skipping beats.
  2. Heart sounds (Sl and S2). These sounds are commonly referred to as the lub-dub sounds. The Sl sound, or lub, is caused by the closure of the mitral and tricuspid valves, whereas the S2 sound, or dub, is due to closure of the aortic and pulmonic valves.3 These sounds should be clear and distinct. They are depicted in Figure Figure2.2. In young athletes with high cardiac outputs, a third, normal heart sound (S3) may be heard. The S3 sound occurs during the rapid-filling phase of the left ventricle with some recoil of the left ventricle; it sounds like lub–dub-dub and is called ventricular gallop. Although this third heart sound is often of no concern, when it is detected by an ATC, referral or physician consultation is warranted.
    Figure 2
    The physiologic heart sounds of a 21-year-old athlete. Reprinted with permission from Crawford M. Heart Sounds: A Practical Guide. Point Pleasant, PA: Merck, Sharp & Dohme; 1989:16.
  3. Murmurs. These sounds are produced by turbulent blood flow through partially obstructed or incompetent cardiac valves or septal defects within the heart.20 The resultant vibrations range from 50 to 500 Hz and vary greatly. An example of a murmur caused by obstruction of valves is the systolic murmur of partial aortic or pulmonic valve stenosis. Murmurs due to valvular incompetence include the systolic murmur of mitral valve regurgitation and the diastolic murmur of aortic valve incompetence, which sounds like a whispered, prolonged letter R.16 Systolic murmurs are heard as abnormal sounds between Sl and S2, whereas diastolic murmurs are heard after S2 and before S1. These murmurs not only vary in timing (systolic and diastolic) but also in length, pitch, and intensity of loudness. They may present as sounds that are rough, blowing, musical, cooing, or honking or sound like a whispered, prolonged R sound (the latter in individuals with aortic valve incompetence).16 Recall that as one listens with the stethoscope, the fingers are to remain on an arterial pulse to assess the timing of these murmurs. High-pitched murmurs, as well as Sl and S2 sounds, are best heard with the diaphragm of the stethoscope, whereas those with low pitch are better heard with the bell head.4 In certain hyperkinetic states, a cardiac murmur may be physiologic in origin and benign. However, a note of caution is called for here. Wood,21 in a landmark cardiology text, stated that to dismiss a murmur as “functional” is inappropriate and that functional murmurs are not insignificant and are not meaningless.21 It is beyond the scope of an ATC to determine whether or not a murmur is pathologic. All athletes presenting with previously undiagnosed murmurs must be referred to a physician.
  4. Extracardiac sounds. These sounds are harsh, rough, to-and-fro, and rubbing sounds due to pericarditis and are sometimes heard during auscultation. They must be heard in both systole and diastole in order to be attributed to pericarditis. Unless the friction rub sounds are heard in all phases of the cardiac cycle, the sounds may be arising from structures other than the pericardium. An example is pleuropericardial rubs. Pleural rubs disappear when the patient holds his or her breath, whereas pericardial rubs do not.22 Extracardiac sounds due to pericarditis are heard more clearly and are termed “close to the ear.” Pericarditis is frequently due to viral infections or may be present during acute myocardial infarction. Athletes presenting with extracardiac sounds should be referred.22

Auscultation of the Lungs

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.

  1. Dyspnea, or shortness of breath, which is present at rest or disproportionate to the subject's exercise activity.23 Dyspnea can indicate conditions such as (but not limited to) pneumonia, pneumothorax, asthma, or heart failure.
  2. Cough, with or without hemoptysis, which can indicate pneumonitis, bronchitis, fibrotic lung disease, or even bronchial carcinoma.
  3. Pleuritic pain, which can be due to acute inflammation of the parietal pleural surface, herpes zoster involving intercostal nerves, or rib fracture.
  4. A resting respiration rate of 22 per minute or more. The athlete's lungs should be auscultated to rule out underlying lung disease.
  5. Cyanosis or finger clubbing, which can indicate a number of pulmonary diseases, including chronic suppurative disease or pulmonary carcinoma.24,25

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.

Figure 3
Points of breath sound auscultation on the patient's posterior chest.

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:

Figure 4
Graphic representation of the breath sounds found in the ill patient and the well patient.
  1. Crackles, or rales, are short, discontinuous sounds heard at the end of inspiration and are of 2 types. Dry or fine rales sound like rubbing dry strands of hair together between the thumb and finger close to the ear and are usually heard in individuals with pneumonia. The other type of rales are termed moist or coarse rales. These rales mimic the sound of a hook-and-loop fastener opening and are frequently heard in heart failure.26 Pathologic rales are associated with serious pulmonary disease and do not disappear after a sharp cough. Benign rales, which are not associated with pulmonary disease, ordinarily disappear after coughing.
  2. Wheezes, also called sibilant wheezes, are high-pitched musical sounds heard during inspiration and expiration. These sounds are caused by the passage of high-velocity air through bronchi narrowed by bronchospasm, tenacious mucus, or foreign bodies. They are heard frequently in individuals with asthma and chronic bronchitis.27
  3. Rhonchi, also called sonorous wheezes, are deeper-sounding, more rumbling breath sounds. They are usually caused by the passage of air through bronchi obstructed by thick mucus. Lower-pitched rhonchi arise from the larger bronchi (for example, those affected by tracheobronchitis) and usually disappear after coughing.27
  4. Bronchial breath sounds are loud, relatively high-pitched sounds with a short pause between inspiration and the longer expiratory component. These sounds may be heard in areas of lung consolidation (solidification), which may occur in cases of consolidated pneumonia or some cases of atelectasis (a shrunken and airless lung). These bronchial breath sounds are transmitted to the examiner through a solid medium, the consolidated lung. This phenomenon produces the same sounds as those heard when auscultating over a bronchus. When sounds are transmitted through air-filled lungs, the sounds are less intense.
  5. A pleural friction rub may be auscultated in the presence of inflammation of the pleural surfaces. A grating, low-pitched sound is heard during inspiration and is caused by friction between the 2 inflamed pleural surfaces. It is heard in cases of pleurisy in which the patient most often complains of chest pain on inspiration.
  6. Absence of breath sounds may be due to pleural effusion, pneumothorax, hemothorax, or blockage of a major bronchus.

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.

Auscultation of the Abdomen

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).

Figure 5
Points of abdominal auscultation.

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.

CONCLUSIONS

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.

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SUGGESTED READINGS

Andreoli TE, Bennett JC, Carpenter CJ, Plum F, editors. Cecil Essentials of Medicine. 4th ed. Philadelphia, PA: WB Saunders; 1997.
Cheitlin MD, Sokolow M. Clinical Cardiology. Los Altos, CA: Lange Publishing; 1997.
Moore K. Essentials of Clinical Anatomy. Baltimore, MD: Williams & Wilkins; 1995.

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