Physical Examination – Sports Physicals (APRN)

00:01 Now we're going to move on to the five parts of a physical examination that is focused on sports preparticipation physicals.

00:09 So let's take a look at the physical exam.

00:12 You're going to look at: One, general health screen.

00:15 Two, cardiovascular screen. Three, neurologic screen.

00:19 Fourth orthopedic screen, and five, a general medical screen.

00:24 Okay, so you'll notice that this is focused on just what you need for the preparticipation sports physical.

00:32 So let's start with a general health screen.

00:35 These are things that you're going to do height and weight.

00:37 Complete vital signs - temperature, pulse, respirations, and blood pressure.

00:41 We'll vision testing, pulmonary testing, neurological testing, abdominal testing, skin examination, and like we talked about could also involve appropriate examination of the testicles for male athletes.

00:54 Now, if you're in a setting, where you do not have the privacy to do this exam, the best ideal thing would be to find a setting for that where you do these exams.

01:04 But some practitioners also ask them out athletes to check and make sure that they have two testicles, because this is an important part of the examination due to their risks.

01:17 Now we're going to move into the cardiovascular screen.

01:20 Now there's key assessments and cues for heart murmurs.

01:23 And that's particularly what you're going to be on the lookout for.

01:26 So as a nurse practitioner, you should be skilled and comfortable with auscultation heart sounds with a stethoscope.

01:32 So you want to practice that and feel very confident in that before you're doing sports physicals on your own.

01:38 So the environment where you're doing this has to be quiet, so that you can hear those heart tones.

01:45 If you find any abnormalities here, if you find anything that you suspect should be as a heart murmur, the client student athlete should not be cleared for activity.

01:55 You're gonna need to refer them for a complete cardiac exam, likely a 12 lead ECG and an echocardiogram as indicated.

02:03 So this is critically important that you do this in an area that you can hear, and that you feel comfortable with your skills and auscultation heart sounds with a stethoscope.

02:17 Now, when we're looking for the key assessment cues for heart murmurs, you want to listen to the auscultate the heart in multiple positions.

02:26 Supine, seated, standing, with and without the valsalva maneuver.

02:30 That way, you're doing a thorough auscultation.

02:33 Now, why do we use the valsalva maneuver? Well, the valsalva maneuver, remember that is like asking them to bear down as if they're trying to have a bowel movement.

02:42 This increases the intrathoracic pressure, which decreases the preload.

02:47 Now most of the murmurs that you see will decrease in intensity during Valsalva. But there are two exceptions.

02:53 So, when you're doing an assessment for heart murmurs it's going to be in a quiet environment.

02:58 You want to listen to their heart tones in multiple positions.

03:01 You want to listen to it with and without the valsalva maneuver, and most murmurs will decrease during the Valsalva except these two - the systolic murmur because of hypertrophic cardiomyopathy will become louder, and a systolic murmur of the mitral valve prolapse becomes longer and louder.

03:21 Okay, so the two systolic murmurs, those types of murmurs, hypertrophic cardiomyopathy becomes louder, mitral valve prolapse becomes longer and louder.

03:33 And any variations of those two.

03:35 So keep that in mind. That is why it is critically important.

03:39 You feel solid and proficient in your skills to auscultation heart tones.

03:43 And you're able to do it in a quiet enough environment where that's you're able to accomplish that, and that you recognize the impact of the valsalva maneuver on heart tones.

03:56 Now, we're going to talk about cardiomyopathy.

03:59 This is one thing that you are definitely on the lookout for, because cardiomyopathy is the leading cause of cardiac arrest and death in young athletes.

04:08 This is why we now have defibrillators.

04:11 The units that are in gyms to help save lives in this manner.

04:16 So, this is critically important that you recognize this.

04:20 And it can be really difficult to identify on a clinical evaluation in sports physicals unless you are highly skilled in auscultating heart tones.

04:30 So that should make the many hours.

04:31 I know you're going to spend practicing heart tones worth it, because you could be the one to catch this in a student athlete and avoid cardiac arrest or death.

04:43 Now, let's talk about some specific cues for cardiomyopathy.

04:48 Athletes with cardiomyopathy often develop a systolic murmur.

04:51 And the reason they do that is because they have left ventricular outflow obstruction and therefore mitral valve regurgitation.

04:59 So it's going to sound like this harsh crescendo-decrescendo systolic murmur.

05:03 It begins right kind of after S1, and is best hurt at the apex and left sternal border.

05:10 So you want to make sure that you are on point for recognizing these.

05:14 Remember, cardiomyopathy is a leading cause of death in young athletes.

05:20 And you're going to be able to hear this systolic murmur harsh crescendo-decrescendo, begin slightly after S1, and you're going to hear it more specifically at the apex and left sternal border.

05:34 Now, ask some questions about that might give you a hint that the patient could be at an increased risk for cardiomyopathy, ask them if they've had a history of difficulty breathing, if they've ever lost consciousness, without having hit their head the reason is lost consciousness.

05:49 Or if they have a family history of cardiac abnormalities.

05:52 These are all cues in the patient's history that may, they may not associate with their heart.

05:59 Because in cardiomyopathy of that resulting diastolic dysfunction, and outflow obstruction, and this is what can be the underlying cause of syncope and ventricular arrhythmias with exertion.

06:13 So, you don't have to explain that to the client when you're talking to them.

06:18 But these are the types of cues you want to be engaged in.

06:21 You can also ask them, "Hey, do you notice a difference when you're exerting yourself?" Now, all of us are going to have become short of breath with extreme effort.

06:32 But see if you can phrase your questions in a way as you're developing a rapport and a therapeutic relationship with your patient, to ask them if they have ever experienced passing out at a practice or if they've had a really had a difficult time breathing, feeling overloaded, that seem to be significantly different than their peers.

06:53 Remember, you're on the lookout for cardiomyopathy.

06:57 And these are the cues that you should listen for when you auscultate and the questions that you should ask.

07:05 Now, as this is the leading cause of cardiac arrest and death in young athletes, you want to make sure that you have any concern that the client athlete could be suffering from cardiomyopathy.

07:17 You should not clear them for activity.

07:19 They should be restricted from playing sports, if you find murmurs, and you want to make sure that they're referred to a qualified cardiologist, and they'll likely end up getting an echocardiogram before they can be cleared.

07:31 So this is both a responsibility and a liability to you to make sure that you identify these risk factors and that you ask these questions. And I would always document that.

07:45 Going back to the previous thought thinking about I would document asked athlete regarding episodes of syncope, extreme shortness of breath. Athlete denied.

07:57 So, I would make sure that when you're charting and you're documenting this, so everyone knows that you did try to assess this and you were very thorough in your examination.

08:07 Now, the next one is kind of unusual.

08:09 Marfan's syndrome, which you have an image in your mind, probably of what Marfan Syndrome look like.

08:15 But it's a genetic condition.

08:16 And because it affects your connective tissue that support your organs, this can be really problematic.

08:21 It also damages the blood vessels. Your heart, the bones.

08:25 I mean it is ravaging the patient's body.

08:29 Now, the median age of diagnosis for Marfan's is usually in the later teens.

08:34 So odds are that you see an athlete with this you may be the beginning of that diagnosis, depending on what type of healthcare they've had before or outside of their sports physicals.

08:46 Now, unfortunately, because Marfan syndrome is so difficult on the blood vessels predominant causes of death are aortic dissection, aortic rupture, or heart failure because that mitral valve and aortic valve regurgitating.

09:01 So, take a look at your client just back up a little bit and see what they look like to you? Do they appear different than the average student their age.

09:11 Now, key risk factors and assessment cues, you're looking for Marfan's, is family history, a long narrow face, they have a smaller lower jaw.

09:20 Their palate is really narrow and highly arch.

09:23 So may look like their teeth are kind of crowded into their mouth.

09:26 They could have extreme nearsightedness.

09:29 Their breastbone may not appear the same to you as you do with other students.

09:34 It could protrude outward or dip inward.

09:36 Now these students are usually long and lean, right? They are tall and lean.

09:41 And they have arms and legs that are disproportionately long.

09:45 So kind of what I would call gangly.

09:48 They also may have flat feet and an abnormally curved spine.

09:52 So these are Hallmark characteristics.

09:54 Your client may have a different variation of these or maybe not every one of these, but these are the types of cues you should be looking for that would make you suspicious of a possibility of Marfan Syndrome.

10:09 Now we're going to move on to the neurological screen.

10:12 So history questions you're going to ask.

10:15 Ask about a history of concussions no matter what the sport is, ask the athlete if they've ever had a concussion.

10:23 Ask them if they've ever had a seizure disorder if they've had a spinal cord injury, or if they've ever been told they have cervical spinal stenosis.

10:31 Now I'm sure you're ready depending on the age of the athlete.

10:35 You may have to phrase those questions a little differently using words other than cervical spinal stenosis.

10:41 So you'll need to think that through on how you want to ask the student or maybe the parent would also be with them.

10:47 But even if the parent is with them there is not a guarantee that they will understand some of our medical language.

10:54 So make sure that you do thorough sensory testing, motor control testing and reflex examination.

11:01 You're trying to keep them safe on the field or the court or wherever they are playing their sport.

11:08 Now, if you have any idea that this student might have some cervical issues, they might complain that their extremities get numb and I have like these "stingers" at pains and cervical pain, don't clear them, they're going to need a referral, they're going to be followed up by a qualified physician or nurse practitioner.

11:30 So we've done the neurologic. Now let's talk about the orthopedic.

11:34 And this is the one that gets kind of difficult, especially if you're dealing with kids that are pretty competitive athletes, and they just want to be out there and play, play, play, play, play.

11:45 So try to do a careful review of their history of injuries.

11:48 What injuries they have experienced as an athlete? This may kind of tell you there's an ongoing problem, you know, of all the injuries involve a right shoulder, or a left knee, or an ankle.

12:00 That's what you kind of want to be listening for a patterns.

12:02 You can put these things together.

12:04 Make sure that you ask the athlete to tell you when the injury occurred, and how it happened? So get information just like we would on any type of accident victim.

12:15 Was it a traumatic? What was involved? What happened to cause the injury is going to help you understand how much trauma was involved in that injury.

12:26 So ask them about recurrent pain. Does their knee hurt all the time? Does our shoulder who is there other joint pain? Is there a muscle strain that they feel all the time? Those are the types of things that you want to ask about to determine if there's a pattern in injury.

12:42 The problem comes and it's a very touchy topic with parents of competitive athletes how often athletes are encouraged to walk it off, not pay attention to the pain, just get back out there.

12:54 I've seen student athletes that are pitchers.

12:57 You know that arm has just been...

12:59 they end up with shoulder injuries and recurrent injuries there because they have overthrown their arm from an early age on.

13:06 So just be aware of that and recognize from a psychosocial perspective.

13:10 This can be a very touchy tuff subject with your parent of the athlete and with the athlete themselves because they are competitive and they really just want to play.

13:21 And they may be trying to maneuver through you and not mention the types of pain and injuries they have because they don't want to tell you anything that might keep them away from playing.

13:33 So make sure you do appropriate examinations that are specific to prior or current or injuries.

13:38 So, if a athlete tells you that they've had recurrent knee pain, make sure you are site specific and extra focused on that knee.

13:48 Strength, range of motion, look for any deformities, instabilities, asymmetries.

13:52 So you're looking for all of that really focus on site specific, but also you want to look at that overall.

13:59 But just make sure you zero in on the areas where the athlete has told you they've had recurrent injuries.

14:04 Remember, it's all about safety.

14:07 So you are the gatekeeper of trying to keep our students as safe as possible while they're enjoying their sport, and to hopefully prevent a lifetime of pain and injuries.

14:21 Now, the general medical screen.

14:23 You are still a healthcare practitioner.

14:27 You are a nurse practitioner, and the families are looking to you for your opinion.

14:33 I know we talked about that's kind of a two edged sword.

14:36 But honestly, you may be the only health care provider or the most frequent healthcare provider that the athlete sees.

14:44 So make sure if you're looking at their medical history, and you're concerned of the potential chronic disease development, you may need to draw some additional lab tests.

14:53 So it could be anything from hypertension, diabetes, anemia, you know, those are asthma, something else.

15:01 You want to make sure that if you see something that could lead to a chronic problem, that you order additional tests, additional lab work, or make a referral.