Borchers Andrea Ann (ed.) Handbook of Signs & Symptoms 2015
.pdf
exceeds 180/110 mm Hg, the patient may be experiencing hypertensive crisis and may require prompt treatment. Maintain a patent airway in case the patient vomits, and institute seizure precautions. Prepare to administer an I.V. antihypertensive and diuretic. You’ll also need to insert an indwelling urinary catheter to accurately monitor urine output.
If blood pressure is less severely elevated, continue to rule out other life-threatening causes. If the patient is pregnant, suspect preeclampsia or eclampsia. Place her on bed rest, and insert an I.V. line. Administer magnesium sulfate (to decrease neuromuscular irritability) and an antihypertensive. Monitor her vital signs closely for the next 24 hours. If diastolic blood pressure continues to exceed 100 mm Hg despite drug therapy, you may need to prepare the patient for induced labor and delivery or for cesarean birth. Offer emotional support if she must face delivery of a premature neonate.
If the patient isn’t pregnant, quickly observe for equally obvious clues. Assess the patient for exophthalmos and an enlarged thyroid gland. If these signs are present, ask about a history of hyperthyroidism. Then, look for other associated signs and symptoms, including tachycardia, widened pulse pressure, palpitations, severe weakness, diarrhea, fever exceeding 100°F (37.8°C), and nervousness. Prepare to administer an antithyroid drug orally or by nasogastric tube, if necessary. Also, evaluate fluid status; look for signs of dehydration such as poor skin turgor. Prepare the patient for I.V. fluid replacement and temperature control using a cooling blanket, if necessary.
If the patient shows signs of increased intracranial pressure (such as a decreased level of consciousness and fixed or dilated pupils), ask him or a family member if he has recently experienced head trauma. Then, check for an increased respiratory rate and bradycardia. You’ll need to maintain a patent airway in case the patient vomits. In addition, institute seizure precautions, and prepare to give an I.V. diuretic. Insert an indwelling urinary catheter, and monitor intake and output. Check his vital signs every 15 minutes until he’s stable.
If the patient has absent or weak peripheral pulses, ask about chest pressure or pain, which suggests a dissecting aortic aneurysm. Enforce bed rest until a diagnosis has been established. As appropriate, give the patient an I.V. antihypertensive or prepare him for surgery.
Note headache, palpitations, blurred vision, and sweating. Ask about wine-colored urine and decreased urine output; these signs suggest glomerulonephritis, which can cause elevated blood pressure.
Obtain a drug history, including past and present prescriptions, herbal preparations, and over-the- counter drugs (especially decongestants). If the patient is already taking an antihypertensive, determine how well he complies with the regimen. Ask about his perception of elevated blood pressure. How serious does he believe it is? Does he expect drug therapy to help? Explore psychosocial or environmental factors that may impact blood pressure control.
Follow up the history with a thorough physical examination. Using a funduscope, check for intraocular hemorrhage, exudate, and papilledema, which characterize severe hypertension. Perform a thorough cardiovascular assessment. Check for carotid bruits and jugular vein distention. Assess skin color, temperature, and turgor. Palpate peripheral pulses. Auscultate for abnormal heart sounds (gallops, louder second sound, murmurs), rate (bradycardia, tachycardia), or rhythm. Then, auscultate for abnormal breath sounds (crackles, wheezing), rate (bradypnea, tachypnea), or rhythm.
Palpate the abdomen for tenderness, masses, or liver enlargement. Auscultate for abdominal
bruits. Renal artery stenosis produces bruits over the upper abdomen or in the costovertebral angles. Easily palpable, enlarged kidneys and a large, tender liver suggest polycystic kidney disease. Obtain a urine sample to check for microscopic hematuria.
Medical Causes
Anemia. Accompanying elevated systolic pressure in anemia are pulsations in the capillary beds, bounding pulse, tachycardia, systolic ejection murmur, pale mucous membranes and, in patients with sickle cell anemia, ventricular gallop and crackles.
Aortic aneurysm (dissecting). Initially, this life-threatening disorder causes a sudden rise in systolic pressure (which may be the precipitating event), but no change in diastolic pressure. However, this increase is brief. The body’s ability to compensate fails, resulting in hypotension. Other signs and symptoms vary, depending on the type of aortic aneurysm. An abdominal aneurysm may cause persistent abdominal and back pain, weakness, sweating, tachycardia, dyspnea, a pulsating abdominal mass, restlessness, confusion, and cool, clammy skin. A thoracic aneurysm may cause a ripping or tearing sensation in the chest, which may radiate to the neck, shoulders, lower back, or abdomen; pallor; syncope; blindness; loss of consciousness; sweating; dyspnea; tachycardia; cyanosis; leg weakness; murmur; and absent radial and femoral pulses.
Atherosclerosis. With atherosclerosis, systolic pressure rises while diastolic pressure commonly remains normal or slightly elevated. The patient may show no other signs, or he may have a weak pulse, flushed skin, tachycardia, angina, and claudication.
Cushing’s syndrome. Twice as common in females as in males, Cushing’s syndrome causes elevated blood pressure and widened pulse pressure as well as truncal obesity, moon face, and other cushingoid signs. It’s usually caused by corticosteroid use.
Hypertension. Essential hypertension develops insidiously and is characterized by a gradual increase in blood pressure from decade to decade. Except for this high blood pressure, the patient may be asymptomatic or (rarely) may complain of suboccipital headache, lightheadedness, tinnitus, and fatigue.
With malignant hypertension, diastolic pressure abruptly rises above 120 mm Hg, and systolic pressure may exceed 200 mm Hg. Typically, the patient has pulmonary edema marked by jugular vein distention, dyspnea, tachypnea, tachycardia, and coughing of pink, frothy sputum. Other characteristic signs and symptoms include severe headache, confusion, blurred vision, tinnitus, epistaxis, muscle twitching, chest pain, nausea, and vomiting.
Increased intracranial pressure (ICP). Increased ICP causes an increased respiratory rate initially, followed by increased systolic pressure and widened pulse pressure. Increased ICP affects the heart rate last, causing bradycardia (Cushing’s reflex). Associated signs and symptoms include headache, projectile vomiting, a decreased level of consciousness, and fixed or dilated pupils.
Metabolic syndrome. According to the American Heart Association (AHA), a blood pressure equal to or greater than 135/85 mm Hg is symptomatic of metabolic syndrome. Metabolic syndrome refers to a group of conditions: increased blood pressure, elevated glucose and insulin levels, excess body fat around the waist, or abnormal cholesterol levels that put the patient at a higher risk for developing heart disease, stroke, peripheral vascular disease, and type 2 diabetes. Having any combination of these puts the patient at an even higher risk. It’s estimated that more than 50 million Americans have metabolic syndrome. Adapting a healthier lifestyle,
incorporating better eating habits, losing weight, and increasing physical activity are ways to decrease or delay the risks associated with metabolic syndrome.
Myocardial infarction (MI). MI is a life-threatening disorder that may cause high or low blood pressure. Common findings include crushing chest pain that may radiate to the jaw, shoulder, arm, or epigastrium. Other findings include dyspnea, anxiety, nausea, vomiting, weakness, diaphoresis, atrial gallop, and murmurs.
Pheochromocytoma. Paroxysmal or sustained elevated blood pressure characterizes pheochromocytoma and may be accompanied by orthostatic hypotension. Associated signs and symptoms include anxiety, diaphoresis, palpitations, tremors, pallor, nausea, weight loss, and headache.
Polycystic kidney disease. Elevated blood pressure is typically preceded by flank pain. Other signs and symptoms include enlarged kidneys; an enlarged, tender liver; and intermittent gross hematuria.
Preeclampsia and eclampsia. Potentially life threatening to the mother and fetus, preeclampsia and eclampsia characteristically increase blood pressure. They’re defined as a reading of 140/90 mm Hg or more in the first trimester, a reading of 130/80 mm Hg or more in the second or third trimester, an increase of 30 mm Hg above the patient’s baseline systolic pressure, or an increase of 15 mm Hg above the patient’s baseline diastolic pressure. Accompanying elevated blood pressure are generalized edema, sudden weight gain of 3 lb (1.4 kg) or more per week during the second or third trimester, severe frontal headache, blurred or double vision, decreased urine output, proteinuria, midabdominal pain, neuromuscular irritability, nausea, and possibly seizures (eclampsia).
Renovascular stenosis. Renovascular stenosis produces abruptly elevated systolic and diastolic pressures. Other characteristic signs and symptoms include bruits over the upper abdomen or in the costovertebral angles, hematuria, and acute flank pain.
Thyrotoxicosis. Accompanying the elevated systolic pressure associated with thyrotoxicosis, a potentially life-threatening disorder, are widened pulse pressure, tachycardia, bounding pulse, pulsations in the capillary nail beds, palpitations, weight loss, exophthalmos, an enlarged thyroid gland, weakness, diarrhea, a fever over 100°F (37.8°C), and warm, moist skin. The patient may appear nervous and emotionally unstable, displaying occasional outbursts or even psychotic behavior. Heat intolerance, exertional dyspnea and, in females, decreased or absent menses may also occur.
Other Causes
Drugs. Central nervous system stimulants (such as amphetamines), sympathomimetics, corticosteroids, nonsteroidal anti-inflammatory drugs, hormonal contraceptives, monoamine oxidase inhibitors, and over-the-counter cold remedies can increase blood pressure, as can cocaine abuse.
HERB ALERT
Ginseng and licorice may cause high blood pressure or an irregular heartbeat. St. John’s wort can also raise blood pressure, especially when taken with substances that antagonize
hypericin, such as amphetamines, cold and hay fever medications, nasal decongestants, pickled foods, beer, coffee, wine, and chocolate.
Treatments. Kidney dialysis and transplantation cause transient elevated blood pressure.
Special Considerations
If routine screening detects elevated blood pressure, stress to the patient the need for follow-up diagnostic tests. Then, prepare him for routine blood tests and urinalysis. Depending on the suspected cause of the increased blood pressure, radiographic studies, especially of the kidneys, may be necessary.
If the patient has essential hypertension, explain the importance of long-term control of elevated blood pressure and the purpose, dosage, schedule, route, and adverse effects of prescribed antihypertensives. Reassure him that there are other drugs he can take if the one he’s taking isn’t effective or causes intolerable adverse reactions. Instruct him not to discontinue medications without contacting the physician. Encourage him to report adverse reactions; the drug dosage or schedule may simply need adjustment.
Be aware that the patient may experience elevated blood pressure only when in the physician’s office (known as white coat hypertension). In such cases, 24-hour blood pressure monitoring is indicated to confirm elevated readings in other settings. In addition, other risk factors for coronary artery disease, such as smoking and elevated cholesterol levels, need to be addressed.
Patient Counseling
Emphasize the importance of weight loss and exercise. Explain the need for sodium restriction. Discuss stress management and ways to reduce other risk factors for coronary artery disease. Discuss the importance of regular blood pressure monitoring, and explain how to take prescribed antihypertensives correctly. Explain what adverse drug reactions the patient should report, and emphasize the importance of long-term follow-up care.
Pediatric Pointers
Normally, blood pressure in children is lower than it is in adults, an essential point to recognize when assessing a patient for elevated blood pressure. (See Normal Pediatric Blood Pressure, page 99.)
Elevated blood pressure in children may result from lead or mercury poisoning, essential hypertension, renovascular stenosis, chronic pyelonephritis, coarctation of the aorta, patent ductus arteriosus, glomerulonephritis, adrenogenital syndrome, or neuroblastoma. Treatment typically begins with drug therapy. Surgery may then follow in patients with patent ductus arteriosus, coarctation of the aorta, neuroblastoma, and some cases of renovascular stenosis. Diuretics and antibiotics are used to treat glomerulonephritis and chronic pyelonephritis; hormonal therapy is used to treat adrenogenital syndrome.
Geriatric Pointers
Atherosclerosis commonly produces isolated systolic hypertension in elderly patients. Treatment is warranted to prevent long-term complications.
REFERENCES
Myers, M. G., Godwin, M., Dawes, M., Kiss, A., Tobe, S. W. , Grant, F. C., Kaczorowski, J. (2011) . Conventional versus automated measurement of blood pressure in primary care patients with systolic hypertension: Randomised parallel design controlled trial.
British Medical Journal, 342, d286.
Bowel Sounds, Absent[Silent abdomen]
Absent bowel sounds refers to an inability to hear any bowel sounds with a stethoscope in any quadrant after listening for at least 5 minutes. Bowel sounds cease when mechanical or vascular obstruction or neurogenic inhibition halts peristalsis. When peristalsis stops, gas from bowel contents and fluid secreted from the intestinal walls accumulate and distend the lumen, leading to lifethreatening complications (such as perforation, peritonitis, and sepsis) or hypovolemic shock.
Simple mechanical obstruction, resulting from adhesions, hernia, or tumor, causes loss of fluids and electrolytes and induces dehydration. Vascular obstruction cuts off circulation to the intestinal walls, leading to ischemia, necrosis, and shock. Neurogenic inhibition, affecting innervation of the intestinal wall, may result from infection, bowel distention, or trauma. It may also follow mechanical or vascular obstruction or metabolic derangement such as hypokalemia.
Abrupt cessation of bowel sounds, when accompanied by abdominal pain, rigidity, and distention, signals a life-threatening crisis requiring immediate intervention. Absent bowel sounds following a period of hyperactive sounds are equally ominous and may indicate strangulation of a mechanically obstructed bowel.
EMERGENCY INTERVENTIONS
If you fail to detect bowel sounds and the patient reports sudden, severe abdominal pain and cramping or exhibits severe abdominal distention, prepare to insert a nasogastric (NG) or intestinal tube to suction lumen contents and decompress the bowel. (See Are Bowel Sounds Really Absent?) Administer I.V. fluids and electrolytes to offset dehydration and imbalances caused by the dysfunctioning bowel.
Because the patient may require surgery to relieve an obstruction, withhold oral intake. Take the patient’s vital signs, and be alert for signs of shock, such as hypotension, tachycardia, and cool, clammy skin. Measure abdominal girth as a baseline for gauging subsequent changes.
History and Physical Examination
If the patient’s condition permits, proceed with a brief history. Start with abdominal pain: When did it begin? Has it gotten worse? Where does he feel it? Ask about a sensation of bloating and about flatulence. Find out if the patient has had diarrhea or has passed pencil-thin stools — possible signs of a developing luminal obstruction. The patient may have had no bowel movements at all — a possible sign of complete obstruction or paralytic ileus.
EXAMINATION TIP Are Bowel Sounds Really Absent?
Before concluding that the patient has absent bowel sounds, ask yourself these three questions:
Did you use the diaphragm of your stethoscope to auscultate for the bowel sounds?
The diaphragm detects high-frequency sounds, such as bowel sounds, whereas the bell detects low-frequency sounds, such as a vascular bruit or venous hum.
Did you listen in the same spot for at least 5 minutes for the presence of bowel sounds?
Normally, bowel sounds occur every 5 to 15 seconds, but the duration of a single sound may be less than 1 second.
Did you listen for bowel sounds in all quadrants?
Bowel sounds may be absent in one quadrant but present in another.
Ask about conditions that commonly lead to mechanical obstruction, such as abdominal tumors, hernias, and adhesions from past surgery. Determine if the patient was involved in an accident — even a seemingly minor one, such as falling off a stepladder — that may have caused vascular clots. Check for a history of acute pancreatitis, diverticulitis, or gynecologic infection, which may have led to intra-abdominal infection and bowel dysfunction. Be sure to ask about previous toxic conditions, such as uremia, and about spinal cord injury, which can lead to paralytic ileus.
If the patient’s pain isn’t severe or accompanied by other life-threatening signs or symptoms, obtain a detailed medical and surgical history and perform a complete physical examination followed by an abdominal assessment and pelvic examination.
Start your assessment by inspecting the abdominal contour. Stoop at the recumbent patient’s side and then at the foot of his bed to detect localized or generalized distention. Percuss and palpate the abdomen gently. Listen for dullness over fluid-filled areas and tympany over pockets of gas. Palpate for abdominal rigidity and guarding, which suggest peritoneal irritation that can lead to paralytic ileus.
Medical Causes
Complete mechanical intestinal obstruction. Absent bowel sounds follow a period of hyperactive bowel sounds in this potentially life-threatening disorder. This silence accompanies acute, colicky abdominal pain that arises in the quadrant of obstruction and may radiate to the flank or lumbar regions. Associated signs and symptoms include abdominal distention, bloating, constipation, and nausea and vomiting (the higher the blockage, the earlier and more severe the vomiting). In late stages, signs of shock may occur with fever, rebound tenderness, and abdominal rigidity.
Mesenteric artery occlusion. With mesenteric artery occlusion, a life-threatening disorder, bowel sounds disappear after a brief period of hyperactive sounds. Sudden, severe midepigastric or periumbilical pain occurs next, followed by abdominal distention, bruits, vomiting, constipation, and signs of shock. Fever is common. Abdominal rigidity may appear later.
Paralytic (adynamic) ileus. The cardinal sign is absent bowel sounds. In addition to abdominal distention, associated signs and symptoms of paralytic ileus include generalized discomfort and
constipation or the passage of small liquid stools. If paralytic ileus follows acute abdominal infection, the patient may also experience fever and abdominal pain.
Other Causes
Abdominal surgery. Bowel sounds are normally absent after abdominal surgery — the result of anesthetic use and surgical manipulation.
Special Considerations
After you’ve inserted an NG or intestinal tube, elevate the head of the patient’s bed at least 30 degrees, and turn the patient to facilitate passage of the tube through the GI tract. (Remember not to tape an intestinal tube to the patient’s face.) Ensure tube patency by checking for drainage and properly functioning suction devices, and irrigate accordingly.
Continue to administer I.V. fluids and electrolytes, and make sure that you send a serum specimen to the laboratory for electrolyte analysis at least once per day. The patient may need X-ray studies and further blood work to determine the cause of absent bowel sounds.
After mechanical obstruction and intra-abdominal sepsis have been ruled out as the cause of absent bowel sounds, give the patient drugs to control pain and stimulate peristalsis. Remember that opioids may slow peristalsis.
Patient Counseling
Explain the need for diagnostic tests and therapeutic procedures, including postoperative ambulation. Also, explain which foods and fluids the patient should avoid.
Pediatric Pointers
Absent bowel sounds in children may result from Hirschsprung’s disease or intussusception, both of which can lead to life-threatening obstruction.
Geriatric Pointers
Older patients with a bowel obstruction that doesn’t respond to decompression should be considered for early surgical intervention to avoid the risk of bowel infarct.
REFERENCES
Hyun-Dong, C. (2011). Perforation of Meckel’s diverticulum by a chicken bone: Preoperatively presenting as bowel perforation. Journal of Korean Surgical Society, 80, 234–237.
Kong, V., Parkinson, F., Barasa, J., & Ranjan, P. (2012) . Strangulated paraumbilical hernia—An unusual complication of a Meckel’s diverticulum. International Journal of Surgery Case Reports, 3, 197–198.
Bowel Sounds, Hyperactive
Sometimes audible without a stethoscope, hyperactive bowel sounds reflect increased intestinal motility (peristalsis). They’re commonly characterized as rapid, rushing, gurgling waves of sounds. (See Characteristics of Bowel Sounds.) They may stem from life-threatening bowel obstruction or GI
hemorrhage or from GI infection, inflammatory bowel disease (which usually follows a chronic course), food allergies, or stress.
EMERGENCY INTERVENTIONS
After detecting hyperactive bowel sounds, quickly check the patient’s vital signs and ask him about associated symptoms, such as abdominal pain, vomiting, and diarrhea. If he reports cramping abdominal pain or vomiting, continue to auscultate for bowel sounds. If bowel sounds stop abruptly, suspect complete bowel obstruction. Prepare to assist with GI suction and decompression, to give I.V. fluids and electrolytes, and prepare the patient for surgery.
If he has diarrhea, record its frequency, amount, color, and consistency. If you detect excessive watery diarrhea or bleeding, prepare to administer an antidiarrheal, I.V. fluids and electrolytes, and, possibly, blood transfusions.
Characteristics of Bowel Sounds
The sounds of swallowed air and fluid moving through the GI tract are known as bowel sounds. These sounds usually occur every 5 to 15 seconds, but their frequency may be irregular. For example, bowel sounds are normally more active just before and after a meal. Bowel sounds may last less than 1 second or up to several seconds.
Normal bowel sounds can be characterized as murmuring, gurgling, or tinkling. Hyperactive bowel sounds can be characterized as loud, gurgling, splashing, and rushing; they’re higher pitched and occur more frequently than normal sounds. Hypoactive bowel sounds can be characterized as softer or lower in tone and less frequent than normal sounds.
GENDER CUE
Homosexual males who report acute diarrhea and who have negative fecal ova and parasite cultures may be infected with chlamydial proctitis not associated with lymphogranuloma venereum. Because rectal cultures will probably be negative, treatment with tetracycline is appropriate.
History and Physical Examination
If you’ve ruled out life-threatening conditions, obtain a detailed medical and surgical history. Ask the patient if he has had a hernia or abdominal surgery because these may cause mechanical intestinal obstruction. Does he have a history of inflammatory bowel disease? Also, ask about recent eruptions of gastroenteritis among family members, friends, or coworkers. If the patient has traveled recently, even within the United States, was he aware of any endemic illnesses?
In addition, determine whether stress may have contributed to the patient’s problem. Ask about food allergies and recent ingestion of unusual foods or fluids. Check for fever, which suggests infection. Having already auscultated, now gently inspect, percuss, and palpate the abdomen.
Medical Causes
Crohn’s disease. Hyperactive bowel sounds usually arise insidiously. Associated signs and symptoms include diarrhea, cramping abdominal pain that may be relieved by defecation, anorexia, a low-grade fever, abdominal distention and tenderness, and, in many cases, a fixed mass in the right lower quadrant. Perianal and vaginal lesions are common. Muscle wasting, weight loss, and signs of dehydration may occur as Crohn’s disease progresses.
Food hypersensitivity. Malabsorption — typically lactose intolerance — may cause hyperactive bowel sounds. Associated signs and symptoms include diarrhea and, possibly, nausea and vomiting, angioedema, and urticaria.
Gastroenteritis. Hyperactive bowel sounds follow sudden nausea and vomiting and accompany “explosive” diarrhea. Abdominal cramping or pain is common, usually after a peristaltic wave. Fever may occur, depending on the causative organism.
GI hemorrhage. Hyperactive bowel sounds provide the most immediate indication of persistent upper GI bleeding. Other findings include hematemesis, coffee-ground vomitus, abdominal distention, bloody diarrhea, rectal passage of bright-red clots and jelly-like material or melena, and pain during bleeding. Decreased urine output, tachycardia, and hypotension accompany blood loss.
Mechanical intestinal obstruction. Hyperactive bowel sounds occur simultaneously with cramping abdominal pain every few minutes in patients with mechanical intestinal obstruction, a potentially life-threatening disorder; bowel sounds may later become hypoactive and then disappear. With small-bowel obstruction, nausea and vomiting occur earlier and with greater severity than in large-bowel obstruction. With complete bowel obstruction, hyperactive sounds are also accompanied by abdominal distention and constipation, although the part of the bowel distal to the obstruction may continue to empty for up to 3 days.
Ulcerative colitis (acute). Hyperactive bowel sounds arise abruptly in patients with ulcerative colitis and are accompanied by bloody diarrhea, anorexia, abdominal pain, nausea and vomiting, fever, and tenesmus. Weight loss, arthralgias, and arthritis may occur.
Special Considerations
Prepare the patient for diagnostic tests. These may include endoscopy to view a suspected lesion, barium X-rays, or stool analysis. An increased white blood cell count may indicate an infection.
Patient Counseling
Explain which dietary changes are necessary or beneficial and which physical activities the patient should avoid. Discuss stress reduction techniques.
Pediatric Pointers
Hyperactive bowel sounds in children usually result from gastroenteritis, erratic eating habits, excessive ingestion of certain foods (such as unripened fruit), or food allergy.
REFERENCES
Irani, S. R., & Vincent, A . (2011) . Autoimmune encephalitis—New awareness, challenging questions. Discovery Medicine, 11,
449–458.
Rizos, D. V., Peritogiannis, V., & Gkogkos, C. (2011). Catatonia in the intensive care unit. General Hospital Psychiatry, 33, e1–e2.
Bowel Sounds, Hypoactive
(See Also Bowel Sounds, Absent)
Hypoactive bowel sounds, detected by auscultation, are diminished in regularity, tone, and loudness from normal bowel sounds. In themselves, hypoactive bowel sounds don’t herald an emergency; in fact, they’re considered normal during sleep. However, they may portend absent bowel sounds, which can indicate a life-threatening disorder.
Hypoactive bowel sounds result from decreased peristalsis, which, in turn, can result from a developing bowel obstruction. The obstruction may be mechanical (as from a hernia, tumor, or twisting), vascular (as from an embolism or thrombosis), or neurogenic (as from mechanical, ischemic, or toxic impairment of bowel innervation). Hypoactive bowel sounds can also result from the use of certain drugs, abdominal surgery, and radiation therapy.
History and Physical Examination
After detecting hypoactive bowel sounds, look for related symptoms. Ask the patient about the location, onset, duration, frequency, and severity of any pain. Cramping or colicky abdominal pain usually indicates a mechanical bowel obstruction, whereas diffuse abdominal pain usually indicates intestinal distention related to paralytic ileus.
Ask the patient about any recent vomiting. When did it begin? How often does it occur? Does the vomitus look bloody? Also, ask about changes in bowel habits. Does he have a history of constipation? When was the last time he had a bowel movement or expelled gas?
Obtain a detailed medical and surgical history of conditions that may cause mechanical bowel obstruction, such as an abdominal tumor or hernia. Does the patient have a history of severe pain; trauma; conditions that can cause paralytic ileus, such as pancreatitis; bowel inflammation or gynecologic infection, which may produce peritonitis; or toxic conditions such as uremia? Has he recently had radiation therapy or abdominal surgery or ingested a drug, such as an opiate, which can decrease peristalsis and cause hypoactive bowel sounds?
After the history is complete, perform a careful physical examination. Inspect the abdomen for distention, noting surgical incisions and obvious masses. Gently percuss and palpate the abdomen for masses, gas, fluid, tenderness, and rigidity. Measure abdominal girth to detect any subsequent increase in distention. Also, check for poor skin turgor, hypotension, narrowed pulse pressure, and other signs of dehydration and electrolyte imbalance, which may result from paralytic ileus.
Medical Causes
Mechanical intestinal obstruction. Bowel sounds may become hypoactive after a period of hyperactivity. The patient may also have acute colicky abdominal pain in the quadrant of obstruction, possibly radiating to the flank or lumbar region; nausea and vomiting (the higher the obstruction, the earlier and more severe the vomiting); constipation; and abdominal distention and bloating. If the obstruction becomes complete, signs of shock may occur.