Preparticipation Physical Exam

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Preparticipation Physical Exam

• Qiuyang Li, PGY3

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First year team physicians dilemma

• This is your 1st yr as team physician for the
  local high school. All the talk in the community
  is about the schools football team, which is
  expected to win the state championship this
  season. The coach of the football team doesnt
  like to lose and was known to put pressure on
  the previous team physician to give medical
  clearance to player before games.

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Q1

• Which of the following is the most common cause
  of sudden death in an athlete younger than age 35
  years?
• CAD
• Premature CAD
• Myocarditis
• HCM
• Rupture of the aorta

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Q2

• Which of the following is a contraindication to
  participation in contact sports?
• Sickle cell trait
• HIV
• Solitary testicle
• Fever of 102F
• Convulsive disorder, well controlled

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Q3

• Which of the following tests is recommended for
  routine screening of athletes during the
  preparticipatation evaluation (PPE)?
• Echo
• ECG
• Exercise stress test
• Vision screen
• UA

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s

• During PPE, you note that the 17yo boy has a BP
  of 148/95mmHg. His past medical history is
  negative, and he has never been told that he had
  HTN. He is 6 ft2in tall and wt 175 lb. As the
  team physician, you tell him
• Cant play any contact sports
• Cant play until BP is under control
• He is cleared to play, but must have his BP
  measured twice during next month
• If he begins BP med immediately, then he is
  cleared
• He must lose 10lb before he will be cleared

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Q5

• The schools wrestling team has had an unusually
  high amount of injuries this season. Which of the
  following conditions is reason to disqualify a
  wrestler from competition?
• Herpes simplex
• Hep C
• Inguinal hernia
• Diabetes mellitus

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Q6

• Which of the following statement concerning PPE
  is true?
• About 10 of athletes are denied clearance during
  PPE
• The PPE ideally should be performed 6 month prior
  to present practice
• A primary objective of the PPE is to detect
  conditions that may predispose an athlete to
  injury
• A complete hx will identify about 95 of problems
  affecting athletes.

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Introduction

• Each yr , between 17 and 25 million adolescents
  engage in some type of sports activity.
• gt6 million high school athletes at about 20,000
  high schools.
• gt2 million injuries occur each yr requiring
  500,000 doctor visit and 30,000 hospitalization.
• Since 8/08, at least 12 high school football, 2
  youth
• league football and 2 soccer players have
  died during or as a result of athletic
  participation.

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N M A A S P O R T S M E D I C I N E A D V I
S O R Y C O M M I T T E E 2009

• Goal 1 Safe Participation
• Goal 2 Meeting Legal Requirements
• Goal 3 Preventative Healthcare

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To detect underlying CV abnormality that may
predispose an athletes to sudden death
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To disclosure defects that may limit participation
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N M A A S P O R T S M E D I C I N E A D V
I S O R Y C O M M I T T E E 2009Facts

• A thorough medical history can reveal up to 75
  of conditions that would limit or alter sports
  participation.
• In conjunction with basic musculoskeletal
• testing highlights the fact that the majority
  of athletes are healthy.
• Only 3 to 13 percent require further evaluation

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CV causes of sudden death in young athletes

• HCM
• Coronary artery anomalies
• Commontio cordis (i.e, blunt trauma to the chest
  causing VF)
• LVH
• Myocarditis
• Marfan syndrome
• Arrythmogenic Right ventricular cardiomyopathy
• Tunneled coronary artery
• Dilated CM
• AS
• Myxomatous MV degeneration
• MVP
• Drug abuse
• Long QT syndrome
• Cardiac sarcoidosis
• Brugada syndrome (genetic disorder of myocardial
  sodium ion channels)
• AAFP, The athletic PPE cardiovascular assessment

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(No Transcript)
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Quiz

• The most common abnormalities leading to
  disqualification are _____________
• The most common cause of sudden death in age
  older than 35?

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Major Questions to ask in Medical History
Screening?

• ?

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Critical screening questions

• Exertional CP or discomfort, or SOB?
• Exertional syncope or near-syncope, or unexpected
  fatigue?
• Hx of cardiac murmur or systemic HTN?
• FH of HCM, long QT syndrome, Marfan syndrome,
  significant dysrhythmias?
• FH of premature death or known CAD in a first- or
  second-order relative younger than 50 years?
  (More concern if younger than 40 years.)

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Physical Finding of Marfan Syndrome

• ?

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Physical Findings of Marfan Syndrome

• Aortic insufficiency murmur
• Arachnodactyly
• Arm span that is greater than body height
• High arched palate
• Kyphosis
• Lenticular dislocation
• MVP
• Pectus excavatum
• Myopia
• Thumb sign
• Wrist sign

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Physical Finding of HCM

• ?

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Physical Finding in HCM

• Systolic murmur
• Louder with standing, decreases with squatting
• 2nd RT ICS or Lt sternal border
• Lateral displacement of apical impulse
• Holosystolic murmur of mitral regurgitation at
  apex with radiation to axilla

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Discussion
EKG from a 33-year-old man with HCM. These are
voltage criteria for left ventricular
hypertrophy. Note the ST-segment elevation (short
arrow) in the lateral leads and biphasic T-waves
(long arrow) in V1 to V3. AAFP The
pre-participation Athletic evaluation 2000
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Discussion

• 19 y.o. football player come for PPE, he was
  found to have II/VI systolic murmur at LLSB. He
  was referred for an Echo. Echo showed mild LVH,
  EF 60, mild TR. Can he play football?

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Athletic Heart SyndromeThe Merck Manual online
library

• A constellation of structural and functional
  changes that occur in the heart of athlete.
• ?Asymptomatic
• ?Signs include bradycardia, a systolic murmur,
  and extra heart sounds.
• ?ECG abnormalities are common.
• ?Diagnosis is clinical or by echocardiography.
• ?No treatment is necessary.
• ?It must be distinguished from serious cardiac
  disorders.
• http//www.merck.com/mmpe/sec07/ch082/ch082c.html

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The Merck Manual online library
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Athletic Heart Syndrome Prognosis and Treatment

• Although gross structural changes resemble those
  in some cardiac disorders, no adverse effects are
  apparent. In most cases, structural changes and
  bradycardia regress with detraining, although up
  to 20 of elite athletes have residual chamber
  enlargement, raising questions, in the absence of
  long-term data, about whether the athletic heart
  syndrome is truly benign.
• No treatment is required, although 3 mo of
  deconditioning may be needed to monitor LV
  regression as a way of distinguishing this
  syndrome from cardiomyopathy. Such deconditioning
  can greatly interfere with an athlete's life and
  may meet with resistance.

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Female Athletic Triad

• Anorexia nervosa
• Osteoporosis
• Amenorrhea

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Preparticipatation Physical Exam

• VS
• GA Marfan syndrome (Arachnodactyly, arm spangtht,
  Pectus excavatum)
• EYE vision defect. Lens subluxation, severe
  myopia, retinal detachment, strabismus.
• CV PMI, murmur
• RESP wheezing
• ABD liver or spleen
• GU hernia, varicoceles, testicular mass
• MS spine and extremity
• SKIN molluscum contagiosum, HSV, impetigo, tinea
  corporis, scabies

International Pediatric Hypertension Association
(2006) www.pediatrichypertension.org
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AAFP The pre-participation Athletic evaluation
2000
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(No Transcript)
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AAFP The pre-participation Athletic evaluation
2000
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Benign Murmur

• Absence of associated symptoms
• Absence of family history
• Associated with normal, physiologic splitting of
  S2 absence of other abnormal heart sounds (e.g.,
  clicks, gallops)
• Early to midsystolic
• Crescendo-decrescendo murmur
• Musical, vibratory, or buzzing quality
• Normal blood pressure, pulse contour,
  electrocardiography, or precordial examination
• Often heard best over pulmonic area or mid-left
  sternal border
• Soft murmur (grade 1 or 2)

AAFP The pre-participation Athletic evaluation
2000
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Pathologic Murmur

• Associated arrhythmia
• Associated left ventricular apical or right
  ventricular parasternal heave
• Associated with abnormal jugular venous pulse
  wide pulse pressure or brisk, rapidly rising
  pulse or weak, slowly rising pulse
• Change in intensity with physiologic maneuvers
  (especially if murmur becomes louder with
  valsalva or squat-to-stand maneuvers)
• Diastolic murmur
• Family history of sudden death or cardiac disease
• Long duration (mid- or late-peak or holosystolic
  murmur)
• Loud murmur (grade 3 or more)
• Other abnormal heart sounds (e.g., loud S1, fixed
  or paradoxically split S2, midsystolic click)
• Presence of associated symptoms (e.g., chest
  pain, dyspnea on exertion, syncope)
• Radiation to axilla or carotids

AAFP The pre-participation Athletic evaluation
2000
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Contraindications for Sports

• Active myocarditis or pericarditis
• HCM
• Severe HTN until controlled by therapy
• Suspected coronary artery disease until fully
  evaluated (patients with impaired resting left
  ventricular systolic function lt50, or
  exercise-induced ventricular dysrhythmias, or
  exercise-induced ischemia on exercise stress
  testing are at greatest risk of sudden death)
• Long QT interval syndrome
• History of recent concussion and symptoms of post
  concussion syndrome (no contact or collision
  sports)
• Poorly controlled convulsive disorder
• Recurrent episodes of burning upper-extremity
  pain or weakness, or episodes of transient
  quadriplegia until stability of cervical spine
  can be assured (no contact or collision sports)
• Sickle cell disease
• Eating disorder
• Acute enlargement of spleen or liver
• Information from Smith DM. Preparticipatation
  physical evaluation. 2d ed. Minneapolis
  Physician and Sports medicine, 1997.

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Common Questions on PPE

• Eye
• Fever
• Heart murmur
• Diabetes mellitus
• Diarrhea
• Eating disorders
• HIV infection
• HTN
• Convulsive disorder
• Asthma
• Sickle cell disease

• Sickle cell trait
• Enlarged spleen
• Testicle
• MVP
• Enlarge liver
• Absence of one kidney
• Molluscum contagiosum
• HSV
• Impetigo
• Tinea corporis
• Scabies

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Required stations on PPE

• Sign in, ht, wt, vital signs, vision
• History review
• PE (medical and orthopedic)
• Medical clearance

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Conclusion

• The pre-participation physical exam is the single
  most effective method of addressing the health
  concerns of the adolescent student-athlete.
• ? Promotes safe participation
• ? Identifies areas of concern
• ? Helps satisfies legal requirements
• ? Addresses risk management issues
• ? Increasing the chance that the student athlete
  will have the best possible outcome

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References

• Primary care reports The practical journal for
  primary care and family physician. Nov. 13, 2000
• The athletic preparticipation evaluation
  cardiovascular assessment AFP April 1, 2007.
• The preparticipation athletic evaluation AFP
  May 1, 2000
• NMAA sports medicine advisory committee 2009
• The Merck Manual online library