The Physician and Sportsmedicine
ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsm20
Keys to Successful Preparticipation Exams Richard H. Strauss , Mimi D. Johnson, W. Ben Kibler & David Smith To cite this article: Richard H. Strauss , Mimi D. Johnson, W. Ben Kibler & David Smith (1993) Keys to Successful Preparticipation Exams, The Physician and Sportsmedicine, 21:9, 108-123, DOI: 10.1080/00913847.1993.11710419 To link to this article: http://dx.doi.org/10.1080/00913847.1993.11710419
Published online: 12 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipsm20 Download by: [Australian Catholic University]
Date: 20 August 2017, At: 01:12
Downloaded by [Australian Catholic University] at 01:12 20 August 2017
Photo: C 1993. Brian Drake/F-Stock
108
Vol 21 • No. 9 • September 93
e THE PHYSICIAN AND SPORTSMEDICINE
Sportsmedicine Update Moderator: Richard H. Strauss, MD, Editor-ln-Chief
Keys to Successful Preparticipation Exams
Downloaded by [Australian Catholic University] at 01:12 20 August 2017
Mimi D. Johnson, MD; W. Ben Kibler, MD; David Smith, MD
Timing, frequency, and types of screening tests can be hot tapies of debate among plzysicians trying to detennine how best to evaluate patients for atlzletic participation. Recause of the wide range of opinions conceming many elements of preparticipation physical exams, we brought together three medical experts to discuss a few important aspects ofthese screenings. At a mlnlmum, prepartlcipation physical exams (PPEs) should assess rlsk factors and detect disease and injury that might create health problems for the patient durlng physical activity, acconling to McKeag and Hough.• Advising the patient about optimal performance, classifying the athlete acconling to his or ber qualifications, and improving fitness and performance are other objectives of these screenings. What are other goals of thePPE1 DR SM1111: Meeting legal and insurance requirements is another primary objective of PPEs, as outlined in a monograph recently published by five medical organizations (American Academy of Family Physicians, American Academy of Pediatries, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathie Academy of Sports Medicine). Evcry state has its own requirements about medical eligibility of student -athletes. Secondary objectives include determining general health and counseling athletes on health-related issues, such as alcohol and tobacco use, that may not
THB PHYSICIAN AND SPORTSMEDICIN&
e Vol 21 • No. 9 • September 93
specifically be related to the athlete's sport. DR KmLER: 1 think a goal is to get the most information as cfficiently as possible, and to provide it to players and coaches so that they can amend their preseason conditioningprograms ifnecessary.2 The information can fall into two camps: negative and positive. Negative information will delay or prohibit athletic participation. Examples include: diabetes, epilepsy, or other uncontrolled medical conditions; cardiac irregularities; and unstable or inappropriately rehabilitated knee injuries. Positive information identifies areas that require physical modifications by the athlete, such as muscle strengths, weaknesses, or imbalances, and overweight conditions. These conditions do not eliminate athletes from participation, but they do need to be addressed. Are the goals the same for male and
female patients? DR JoHNsoN: The goals are the same. However, sorne risk factors may be gender specifie, such as menstrual dysfunction, which can result in subsequent bane loss (see "Tailoring the Preparticipation Exam to Female Athletes," July 1992, page 60). Other examples would be disordered eating, which may be more prevalent in female athletes, and anabolic steroid use, which may be more prevalent in male athletes. When should the PPEs take place, and how often should they be performedt DR KmLER: 1 do not think that many of the continued 109
sportsmedicine update continued
Downloaded by [Australian Catholic University] at 01:12 20 August 2017
Participants: MIMI D. JOtiNSON, MD, is a pediatrician practicing sports medicine at Washington Sports Medicine in Kirkland, Washington. She is also a clinical assistant professor in the Division of Adolescent Medicine in the Department of Pediatries at the University ofWashington in Seattle and an assistant team physician for the University ofWashington Departmen t of Athletics.
w. BEN KlBLER, MD, is an orthopedie surgeon and medical director of the Lexington Clinic Sports Medicine Center in Lexington, Kentucky. 1fe is also an editorial board memberof TIIF. 1'1 fY51CIAN AND SPORfSMEDICINE. DAVID M. SMITH,
MD, ls assistant director of the Sports Medicine Institute and assistant professor of family practice and surgery at the University of Kansas Medical Center ln Kansas City, Kansas. He is also a contributing editor of Pœparticipation Physiml Evaluation, a monograph recently published by the American Academy of Family Physicians, American Academy of Pediatries, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathie Academy of Sports Medicine.
goals that we have outlined for the PPE can be met by the once-a-year exarn in which every athlete in school shows up on a Saturday morning and runs sorne drills, stands on one leg and then the other, coughs, and takes a deep breath. These types of screenings are not specifie enough to be useful; and often, they take place as many as 9 or 10 months before the athlete actually participates in the sport. In a growing adolescent, many changes occur during that time. So l'rn an advocate of doing sport- or activity-specific exams with smaller groups of individuals two or three or four times a year. We examine players participating in soccer and basketball in August or September; in winter sports, such as wrestling and swimming, in October; in spring sports, such as baseball, track, and tennis, in January or February. And by performing these exarns 6 to 8 weeks before the season starts, we can be a bit more sport specifie and get sorne idea of the athlete's ability to withstand the demands of the sport. This is ideal. In reality, you often get the kids maybe a week before football season starts. In that situation, we apt to do screenings before the preseason training. We do ail our football exams in May or June because most players work on weights before practices start. Da STRAuss: 1 wonder whether there is a disadvantage to doing this. Until recently here at Ohio State University, we did foothall exarns in the spring as you describe. But we switched to doing them in the fall because so much occurs during the summer with the college students, many of whom are off campus. Da KIBLER: I saw a professional football player just the other day who sustained injuries last season and now is in spring camp. He's got a very bad muscle injury that needs about 2 months of rehabilitation, but the time has run out for him to
110
do that kind of stuff. If possible, you need a little leeway before the start of practice so that you can irnplement plans related to the information you've gathered. Da SMI'Ill: I think it's ideal to do sports-specifie exarns several times a year. But practically speaking, most of these athletes will only come in once unless it's required or unless they play multiple sports. You could see multisport athletes three or four times a year. For these reasons, the committee that put together the monograph recommended a complete evaluation annually with limited reevaluation as necessary. So for instance, you could do the exarn for a high school football player at the end of the spring semester, and then do a quick follow-up before the football season just to make sure nothing significant has changed during the summer. DR KIBLER: That's exactly right. Da SMI'Ill: Or if a football player is going to play baseball in the spring, we try to reevaluate him after the football season and before the baseball season. But we do not make it mandatory because that's not practical. Da KIBLER: So basically you and I are not that far apart. That's what we do. We see many multisport players. Sorne changes often occur by the end of football season that require you to evaluate the athletes before you let them play another sport. For exarnple, I tell our basketball coach, "Look, these football players are going ta pull a harnstring and throw bricks against the backboard for the fust 2 weeks ofpractice unless you let us have a little time to train them into basketball." And our basketball coaches are now much more inclined to let us have sorne time to help them condition. Da SMITH: Right, education is the key. Again, we're not trying to keep them out of their sports, but we are trying to get them into their sports safely and perhaps en-
Vol 21 • No. 9 • September 93 e THa PHYSICIAN AND SPORTSMaDICINa
Downloaded by [Australian Catholic University] at 01:12 20 August 2017
hance their performance by screening for old injuries. What are the components of the PPE1 DR SMITH: The history is equally or more important than the physical examination in PPEs. We start with the his tory. We try to be comprehensive and then focus on specifie items that are pertinent to the individual athlete. The history includes general questions about hospitalizations and surgeries, but then goes on to sport-specifie questions, starting with the most important area, the cardiovascular system. In the PPE monograph, we recommend a history intake form that covers a number of items, including exertional syncope, dizziness during and after exercise, chest pain during and after exercise, heart murmurs, high blood pressure, skipped beats, and family history of heart problems. We look for things that are going to preclude athletes' participation. If they've got a cardiovascular condition that's potentially lethal or limiting, we want to know aboutit. We go on to address neurologie questions, such as previous head injuries or seizure disorders. And then we gather information about previous or current joint or musculoskeletal injuries, allergies, and medications. We also put specifie questions on our form for female patients that address such issues as last menstrual periad and age of menarche. DR JoHNSON: We have an additional health history questionnaire for our female athJetes. In addition to age of menarche and last menstrual period, we inquire about length and frequency of menstrual periods, hormonal therapy (eg, birth control pills), heavy bleeding, and dysmenorrhea. DR SMITH: Dr Johnson, do you usually ask about Pap smears or sexual activity, keeping in mind that we could be talking about the adolescent as well as the college-aged athlete?
DR JoHNSON: Sexual activity is not addressed on the health history questionnaire. However, 1 may discuss this with the athlete individually, if warranted. We do inquire about recurrent urinary tract infections, unusual vaginal discharge, the date of her last pelvic exarn, and any abnormal Pap smears. What, if any, screening tests should be done routinely? DR SMITH: We recommend that no routine screening laboratory tests, radiographs, electrocardiograms (ECGs), or echocardiograms be done. You arder diagnostic testing when the history and physical exam indicate them.
Generally, athletes should receive complete preparticipation evaluations annually with limited reevaluations as necessary. If athletes play more than one sport, additional sport-specifie exams may be necessary before they are allowed to play other sports.
----------111---------We took sorne heat for not including urinalysis (UA) in the monograph. Sorne people have pointed out isolated cases in which theywere able to pick up hematuria through routine UA screenings. But 1wonder wh ether the physician in these instances would have ordered a UA anyway based on the history or physical findings. After further evaluating the hematuria, 1 wonder whether it was significant and how often false-positive or insignificant hematuria has been identified through routine dipstick UA. DR JmiNsoN: Goldberg et al' reported that none of the 41 children who had ab normal urine dipsticks (40 with proteinuria and 1
continued
THI PHYSICIAN AND 8PORTSMIDICINI e Vol 21 • No. 9 • September 93
111
sportsmedicine update continued
Downloaded by [Australian Catholic University] at 01:12 20 August 2017
with glycosuria) had positive findings on further evaluation (fust moming void and glucose tolerance test, respectively). Do we need to do any blood testing on female athletes1 DR JoHNSON: As they do with male patients, physicians should use the history and physical exam to determine whether to arder Jab tests for female athletes. For example, if the athlete has a history of anemia or heavy menstrual bleeding, or if she is an endurance athlete complaining of fatigue, the physician might want to arder a hemoglobin or hematocrit.
Should we test at- risk groups for sickle celltrait1 DR SMITH: 1think the jury is still out on that one (sec "Sickle Cell Trait, Heroic Exercise,
No laboratory tests, radiographs, electrocardiograms, or echocardiograms are recommended for routine preparticipation screenings. Physicians should arder diagnostic testing only when the history and physical exam indicate them.
----------01---------and Fatal Collapse," July, page 51). DR KIBLER: Just like it is on a lot of those tests. Initially, we didn't do any lab work in our routine screenings. But sorne doctors in my community felt strongly that UA was necessary. So we started including it. And then Dr Smith's group sent me its monograph to review. 1 took it to these other people and said "See, here's the best evidence 1know of for not doing it." So we no longer do routine UA But sorne physicians still wonder whether we may miss sorne important
problems or conditions. And my question to them is: How effective is doing UA or other tests for everybody? 1his is a screening exam. 1his is not a medical exam. DR SMITH: We were always taught in medical school that you arder a test only if the result will change the course of treatment or diagnosis. The sickle cell issue is controversial because it goes back to the question: Does a positive sickle cell trait increase the risk of sudden death? 1 don't think that this has been documented yet except under extreme conditions, such as exercising at high altitude or in the heat. Durlng the physical examination, what should be included in your ordinary canliovascular screening1 DR SMrrn: Given a negative cardiovascular history, the cardiovascular examination should include auscultation of the heart and palpation of the pulses. 1 generally auscultate the heart with the patient in two different positions-seated and supine-to increase the sensitivity for murmur evaluation. Most physicians listen to the heart with patients supine. In the athlete who has a high incidence of functional murmurs, you're going to hear a lot of th ose wh en he or she is supine. An upright position, such as sitting or standing, is also important because most functional murmurs will decrease in intensity when patients stand or sit. Other maneuvers, such as deep inspiration, Valsalva's, squat-ta-stand, or standta-squat, can help differentiate a murrnur. Furtherrnore, the relationship of the murmur ta the Sr and Sz heart sounds and the character of the murrnur, Sr, and S2 , are important.
If you were to examine patients in only one position, would it be with them sitting1 DR SMml: Yes. DR KmLER: Sitting with the patient leaning
contimted 112
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sportsmedlclne update continued
WARNINGS: As with 0111er inl1aled beta-adrenerglc agonisls. Ventrlln" ~ can pro00ce paradoxJcal brnncho8pasm thal can be lfe-lhreaiBnlng. Wft ~theprepntk>nstwldbe-lm~ll1dllllemallvethlr1!>r
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ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsm20
Keys to Successful Preparticipation Exams Richard H. Strauss , Mimi D. Johnson, W. Ben Kibler & David Smith To cite this article: Richard H. Strauss , Mimi D. Johnson, W. Ben Kibler & David Smith (1993) Keys to Successful Preparticipation Exams, The Physician and Sportsmedicine, 21:9, 108-123, DOI: 10.1080/00913847.1993.11710419 To link to this article: http://dx.doi.org/10.1080/00913847.1993.11710419
Published online: 12 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipsm20 Download by: [Australian Catholic University]
Date: 20 August 2017, At: 01:12
Downloaded by [Australian Catholic University] at 01:12 20 August 2017
Photo: C 1993. Brian Drake/F-Stock
108
Vol 21 • No. 9 • September 93
e THE PHYSICIAN AND SPORTSMEDICINE
Sportsmedicine Update Moderator: Richard H. Strauss, MD, Editor-ln-Chief
Keys to Successful Preparticipation Exams
Downloaded by [Australian Catholic University] at 01:12 20 August 2017
Mimi D. Johnson, MD; W. Ben Kibler, MD; David Smith, MD
Timing, frequency, and types of screening tests can be hot tapies of debate among plzysicians trying to detennine how best to evaluate patients for atlzletic participation. Recause of the wide range of opinions conceming many elements of preparticipation physical exams, we brought together three medical experts to discuss a few important aspects ofthese screenings. At a mlnlmum, prepartlcipation physical exams (PPEs) should assess rlsk factors and detect disease and injury that might create health problems for the patient durlng physical activity, acconling to McKeag and Hough.• Advising the patient about optimal performance, classifying the athlete acconling to his or ber qualifications, and improving fitness and performance are other objectives of these screenings. What are other goals of thePPE1 DR SM1111: Meeting legal and insurance requirements is another primary objective of PPEs, as outlined in a monograph recently published by five medical organizations (American Academy of Family Physicians, American Academy of Pediatries, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathie Academy of Sports Medicine). Evcry state has its own requirements about medical eligibility of student -athletes. Secondary objectives include determining general health and counseling athletes on health-related issues, such as alcohol and tobacco use, that may not
THB PHYSICIAN AND SPORTSMEDICIN&
e Vol 21 • No. 9 • September 93
specifically be related to the athlete's sport. DR KmLER: 1 think a goal is to get the most information as cfficiently as possible, and to provide it to players and coaches so that they can amend their preseason conditioningprograms ifnecessary.2 The information can fall into two camps: negative and positive. Negative information will delay or prohibit athletic participation. Examples include: diabetes, epilepsy, or other uncontrolled medical conditions; cardiac irregularities; and unstable or inappropriately rehabilitated knee injuries. Positive information identifies areas that require physical modifications by the athlete, such as muscle strengths, weaknesses, or imbalances, and overweight conditions. These conditions do not eliminate athletes from participation, but they do need to be addressed. Are the goals the same for male and
female patients? DR JoHNsoN: The goals are the same. However, sorne risk factors may be gender specifie, such as menstrual dysfunction, which can result in subsequent bane loss (see "Tailoring the Preparticipation Exam to Female Athletes," July 1992, page 60). Other examples would be disordered eating, which may be more prevalent in female athletes, and anabolic steroid use, which may be more prevalent in male athletes. When should the PPEs take place, and how often should they be performedt DR KmLER: 1 do not think that many of the continued 109
sportsmedicine update continued
Downloaded by [Australian Catholic University] at 01:12 20 August 2017
Participants: MIMI D. JOtiNSON, MD, is a pediatrician practicing sports medicine at Washington Sports Medicine in Kirkland, Washington. She is also a clinical assistant professor in the Division of Adolescent Medicine in the Department of Pediatries at the University ofWashington in Seattle and an assistant team physician for the University ofWashington Departmen t of Athletics.
w. BEN KlBLER, MD, is an orthopedie surgeon and medical director of the Lexington Clinic Sports Medicine Center in Lexington, Kentucky. 1fe is also an editorial board memberof TIIF. 1'1 fY51CIAN AND SPORfSMEDICINE. DAVID M. SMITH,
MD, ls assistant director of the Sports Medicine Institute and assistant professor of family practice and surgery at the University of Kansas Medical Center ln Kansas City, Kansas. He is also a contributing editor of Pœparticipation Physiml Evaluation, a monograph recently published by the American Academy of Family Physicians, American Academy of Pediatries, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathie Academy of Sports Medicine.
goals that we have outlined for the PPE can be met by the once-a-year exarn in which every athlete in school shows up on a Saturday morning and runs sorne drills, stands on one leg and then the other, coughs, and takes a deep breath. These types of screenings are not specifie enough to be useful; and often, they take place as many as 9 or 10 months before the athlete actually participates in the sport. In a growing adolescent, many changes occur during that time. So l'rn an advocate of doing sport- or activity-specific exams with smaller groups of individuals two or three or four times a year. We examine players participating in soccer and basketball in August or September; in winter sports, such as wrestling and swimming, in October; in spring sports, such as baseball, track, and tennis, in January or February. And by performing these exarns 6 to 8 weeks before the season starts, we can be a bit more sport specifie and get sorne idea of the athlete's ability to withstand the demands of the sport. This is ideal. In reality, you often get the kids maybe a week before football season starts. In that situation, we apt to do screenings before the preseason training. We do ail our football exams in May or June because most players work on weights before practices start. Da STRAuss: 1 wonder whether there is a disadvantage to doing this. Until recently here at Ohio State University, we did foothall exarns in the spring as you describe. But we switched to doing them in the fall because so much occurs during the summer with the college students, many of whom are off campus. Da KIBLER: I saw a professional football player just the other day who sustained injuries last season and now is in spring camp. He's got a very bad muscle injury that needs about 2 months of rehabilitation, but the time has run out for him to
110
do that kind of stuff. If possible, you need a little leeway before the start of practice so that you can irnplement plans related to the information you've gathered. Da SMI'Ill: I think it's ideal to do sports-specifie exarns several times a year. But practically speaking, most of these athletes will only come in once unless it's required or unless they play multiple sports. You could see multisport athletes three or four times a year. For these reasons, the committee that put together the monograph recommended a complete evaluation annually with limited reevaluation as necessary. So for instance, you could do the exarn for a high school football player at the end of the spring semester, and then do a quick follow-up before the football season just to make sure nothing significant has changed during the summer. DR KIBLER: That's exactly right. Da SMI'Ill: Or if a football player is going to play baseball in the spring, we try to reevaluate him after the football season and before the baseball season. But we do not make it mandatory because that's not practical. Da KIBLER: So basically you and I are not that far apart. That's what we do. We see many multisport players. Sorne changes often occur by the end of football season that require you to evaluate the athletes before you let them play another sport. For exarnple, I tell our basketball coach, "Look, these football players are going ta pull a harnstring and throw bricks against the backboard for the fust 2 weeks ofpractice unless you let us have a little time to train them into basketball." And our basketball coaches are now much more inclined to let us have sorne time to help them condition. Da SMITH: Right, education is the key. Again, we're not trying to keep them out of their sports, but we are trying to get them into their sports safely and perhaps en-
Vol 21 • No. 9 • September 93 e THa PHYSICIAN AND SPORTSMaDICINa
Downloaded by [Australian Catholic University] at 01:12 20 August 2017
hance their performance by screening for old injuries. What are the components of the PPE1 DR SMITH: The history is equally or more important than the physical examination in PPEs. We start with the his tory. We try to be comprehensive and then focus on specifie items that are pertinent to the individual athlete. The history includes general questions about hospitalizations and surgeries, but then goes on to sport-specifie questions, starting with the most important area, the cardiovascular system. In the PPE monograph, we recommend a history intake form that covers a number of items, including exertional syncope, dizziness during and after exercise, chest pain during and after exercise, heart murmurs, high blood pressure, skipped beats, and family history of heart problems. We look for things that are going to preclude athletes' participation. If they've got a cardiovascular condition that's potentially lethal or limiting, we want to know aboutit. We go on to address neurologie questions, such as previous head injuries or seizure disorders. And then we gather information about previous or current joint or musculoskeletal injuries, allergies, and medications. We also put specifie questions on our form for female patients that address such issues as last menstrual periad and age of menarche. DR JoHNSON: We have an additional health history questionnaire for our female athJetes. In addition to age of menarche and last menstrual period, we inquire about length and frequency of menstrual periods, hormonal therapy (eg, birth control pills), heavy bleeding, and dysmenorrhea. DR SMITH: Dr Johnson, do you usually ask about Pap smears or sexual activity, keeping in mind that we could be talking about the adolescent as well as the college-aged athlete?
DR JoHNSON: Sexual activity is not addressed on the health history questionnaire. However, 1 may discuss this with the athlete individually, if warranted. We do inquire about recurrent urinary tract infections, unusual vaginal discharge, the date of her last pelvic exarn, and any abnormal Pap smears. What, if any, screening tests should be done routinely? DR SMITH: We recommend that no routine screening laboratory tests, radiographs, electrocardiograms (ECGs), or echocardiograms be done. You arder diagnostic testing when the history and physical exam indicate them.
Generally, athletes should receive complete preparticipation evaluations annually with limited reevaluations as necessary. If athletes play more than one sport, additional sport-specifie exams may be necessary before they are allowed to play other sports.
----------111---------We took sorne heat for not including urinalysis (UA) in the monograph. Sorne people have pointed out isolated cases in which theywere able to pick up hematuria through routine UA screenings. But 1wonder wh ether the physician in these instances would have ordered a UA anyway based on the history or physical findings. After further evaluating the hematuria, 1 wonder whether it was significant and how often false-positive or insignificant hematuria has been identified through routine dipstick UA. DR JmiNsoN: Goldberg et al' reported that none of the 41 children who had ab normal urine dipsticks (40 with proteinuria and 1
continued
THI PHYSICIAN AND 8PORTSMIDICINI e Vol 21 • No. 9 • September 93
111
sportsmedicine update continued
Downloaded by [Australian Catholic University] at 01:12 20 August 2017
with glycosuria) had positive findings on further evaluation (fust moming void and glucose tolerance test, respectively). Do we need to do any blood testing on female athletes1 DR JoHNSON: As they do with male patients, physicians should use the history and physical exam to determine whether to arder Jab tests for female athletes. For example, if the athlete has a history of anemia or heavy menstrual bleeding, or if she is an endurance athlete complaining of fatigue, the physician might want to arder a hemoglobin or hematocrit.
Should we test at- risk groups for sickle celltrait1 DR SMITH: 1think the jury is still out on that one (sec "Sickle Cell Trait, Heroic Exercise,
No laboratory tests, radiographs, electrocardiograms, or echocardiograms are recommended for routine preparticipation screenings. Physicians should arder diagnostic testing only when the history and physical exam indicate them.
----------01---------and Fatal Collapse," July, page 51). DR KIBLER: Just like it is on a lot of those tests. Initially, we didn't do any lab work in our routine screenings. But sorne doctors in my community felt strongly that UA was necessary. So we started including it. And then Dr Smith's group sent me its monograph to review. 1 took it to these other people and said "See, here's the best evidence 1know of for not doing it." So we no longer do routine UA But sorne physicians still wonder whether we may miss sorne important
problems or conditions. And my question to them is: How effective is doing UA or other tests for everybody? 1his is a screening exam. 1his is not a medical exam. DR SMITH: We were always taught in medical school that you arder a test only if the result will change the course of treatment or diagnosis. The sickle cell issue is controversial because it goes back to the question: Does a positive sickle cell trait increase the risk of sudden death? 1 don't think that this has been documented yet except under extreme conditions, such as exercising at high altitude or in the heat. Durlng the physical examination, what should be included in your ordinary canliovascular screening1 DR SMrrn: Given a negative cardiovascular history, the cardiovascular examination should include auscultation of the heart and palpation of the pulses. 1 generally auscultate the heart with the patient in two different positions-seated and supine-to increase the sensitivity for murmur evaluation. Most physicians listen to the heart with patients supine. In the athlete who has a high incidence of functional murmurs, you're going to hear a lot of th ose wh en he or she is supine. An upright position, such as sitting or standing, is also important because most functional murmurs will decrease in intensity when patients stand or sit. Other maneuvers, such as deep inspiration, Valsalva's, squat-ta-stand, or standta-squat, can help differentiate a murrnur. Furtherrnore, the relationship of the murmur ta the Sr and Sz heart sounds and the character of the murrnur, Sr, and S2 , are important.
If you were to examine patients in only one position, would it be with them sitting1 DR SMml: Yes. DR KmLER: Sitting with the patient leaning
contimted 112
-~USI')-..__FarllnllnhllltlanOnly
BRIEFSIIMMARY
The lcllowing is a bl1ef summav only.ilefore proocriblng, 181 comp1e11 preacr1bilg lnforma1lon ln Venllllln"lnllalallon- product labelng. CONTRAINDICATJONS:-In--is-ln pallontswtlhahistoryothypersensltiviiiDanyofttscom~.
sportsmedlclne update continued
WARNINGS: As with 0111er inl1aled beta-adrenerglc agonisls. Ventrlln" ~ can pro00ce paradoxJcal brnncho8pasm thal can be lfe-lhreaiBnlng. Wft ~theprepntk>nstwldbe-lm~ll1dllllemallvethlr1!>r
Fatalltiesha'leboenreporlodlnassoclatlonwithlliC888Iv8LOOofinl1aled-ctuos. The exact cause at doa1hls llllcnown, but ardlac lmSI t1ow1ng the II18JI)eC1Bd deYelopment d a severe acu1e asthma1lc cr1s1s and IUboequont hypolda il SIJIIIl8d8d. ~ hypersensltivll reactlonsmayocaJ aiiBradmi-ofalbulerol
-
--.a-bynncaaead1111caria,~rall, ~.lf'l8lll!ylaxilll1dOI1lphlryngealedema.
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