The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore...
-
Upload
terence-eric-lee -
Category
Documents
-
view
218 -
download
1
Transcript of The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore...
![Page 1: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/1.jpg)
The Preparticipation Physical
Jeffrey Rosenberg MD
Residency Program in Social Medicine
Montefiore Hospital
![Page 2: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/2.jpg)
The Preparticipation Physical
Goal– To prepare for
future preparticipation sports physicals
![Page 3: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/3.jpg)
The Preparticipation Physical
Objectives– Understand the controversies of performing
preparticipation physicals– Review the common causes of Sudden Cardiac
Death – Learn what elements of the history or physical
exam are most important– Review the quick one minute orthopedic exam
![Page 4: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/4.jpg)
Goal of Preparticipation Exam
Maintain the health and safety of athletes and promote safe participation
Not meant to exclude, but rather include safely
![Page 5: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/5.jpg)
Purpose
– Detect conditions that may be life threatening or disabling---HCM, AS, ARVD
– Detect conditions that may predispose to injury--- chronic injury, laxity, subluxation,
– Address legal or insurance requirements
![Page 6: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/6.jpg)
Secondary objectives
Provide primary care?????
Determine general health
Assess fitness level
Counsel on health-related issues
![Page 7: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/7.jpg)
What are the CONS??
Time consumingCostly: J Sch Health 1985 Sep;55(7):270-3 – Study of 763 students; 2.1% needed further eval,
only 2 disqualified; costs $4500 per child
1 in 300,000 athletes/year have SCDRemember: they are screening examinations-most athletes that eventually die while on the field had one
![Page 8: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/8.jpg)
Italian StudyN Engl J Med 1998 Aug 6;339(6):364-9
Prospective study of >30,000 Italians <35 yo, comparing athletes vs. nonathletes for >20 yr
269 deaths < 35yo; 49 in athletes-22% arrhythmogenic right ventricle dysplasia, 18% CAD, 12% anomalous coronary artery, 2% HCM– Non Athletes-7% HCM– HCM detected in 22 athletes-prevented
participation None Died
![Page 9: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/9.jpg)
Evidence Base Review
Clinical Journal of Sports Medicine; May 2004– 639 papers about preparticipation screening and
sudden cardiac death– 25 original research-all type II population based
clinical studies, rest are type III case based opinion studies/position papers
– 5 studies assessed effectiveness of PPE• No randomized control trials exist
![Page 10: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/10.jpg)
Screening Tests ECG
AHA does not recommend ECG Italy requires ECG, Echo, Stress Tests
Human physiologic cardiac adaptation vs pathologic changes-Athletic Heart Vs HCMItalian ECG study vs Echo: 51% sens, 61% specificity, PPV 7%HS Athletes: Sens 65%, Spec 97.4%; ECG picked up 23/33 problems; 2.6% further tested
![Page 11: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/11.jpg)
Sudden Death
Very Rare: 1 per 300,000-500,00 HS athletes/yr1983-1993: Non Traumatic sports related death 126 high school; 34 college. 100 of these are cardiac in originMale 5x > FemaleCongenital Cardiac Anomalies which lead to sudden and fatal arrhythmia
![Page 12: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/12.jpg)
![Page 13: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/13.jpg)
Hypertrophic Cardiomyopathy
Most common cause of sudden cardiac death in young athletes in USA
Mutations in cardiac sarcomere
21% of eventual deaths have prior symptoms: exert CP, Dyspnea, Light headed, Syncope
Italy: 2% of sudden death: stringent screening
![Page 14: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/14.jpg)
Hypertrophic Cardiomyopathy
Asymmetric LV hypertrophyDehydration/decreased preload cause increase outflow obstruction-presyncopal sx.Large muscle mass doesn’t get enough blood->ischemia->arrhythmia
![Page 15: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/15.jpg)
Hypertrophic Cardiomyopathy
Harsh, systolic ejection murmur. Decreases with squatting (increased VR and preload); increases when standing up (decrease VR and preload)
Diagnosis confirmed by ECHO
Idiopathic LVH (10% of deaths):concentric
![Page 16: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/16.jpg)
Congenital Coronary Anomaly
18-20% of sudden cardiac death
Origin from right sinus
31% have previous sx
Stress echo or Cardiac Cath
![Page 17: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/17.jpg)
Marfan’s syndrome
Autosomal Dominant, connective tissue dis. 1:5000; Defect in gene for fibrillin protein
Complicated Diagnosis: Cardiac, Optho, Muskuloskeletal, Skin Involvement. Genetic Testing
Echo: dilated aortic root or MVP w/MR
Contact/Strenuous Sports Contraindicated
![Page 18: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/18.jpg)
Other Causes of Sudden Death
Myocarditis-Absolute Contraindication to physical activity. Viral; >50% coxsachie B– Need 6 months post illness before exertion
Wolff Parkinson White-contraindication until ablated
Long QT syndrome-risk of Torsades de Pointe; familial or from meds
![Page 19: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/19.jpg)
ARVD
Arthymogenic Right Ventricular Dysplasia
Autosomal dominant with variable penetrance
Replacement of cardiac cells with fat or fibrosis predominately in Right Ventricle
Sudden arrhythmia and death
MRI can be useful; Treatment is AICD
![Page 20: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/20.jpg)
![Page 21: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/21.jpg)
History
Most important aspect of PPE to is screen for cardiac symptoms, asthma, review family hx.
Board of Education form doesn’t list all important symptoms
Family History of sudden death <50 yo in 1st degree relative: HCM, Long QT, Congenital coronary anomaly, Arrhythmia
![Page 22: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/22.jpg)
Cardiac Screening Questions:
Dizzy or Syncope during/after exercise
Chest Pain during/after exercise
Tired more quickly than others
Racing of heart or skipped beats
High Blood Pressure/High Cholesterol
Heart Murmur
![Page 23: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/23.jpg)
Cardiac Screening Questions
Family member died before age 50
Recent Mononucleosis/Myocarditis
Has a physician ever limited your participation in sports
Any relatives with cardiomyopathy, Marfan’s syndrome, heart arrhythmia
![Page 24: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/24.jpg)
RED FLAG SYMPTOMS:
Wheezing with exertion: EIB (85% of asthmatics have EIB)
History of Concussion: MTBI causes neuropsychiatric symtoms-headaches, fatigue, memory loss
![Page 25: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/25.jpg)
History
Menstrual History: Primary amenorrhea, or secondary (>3 months): Female Triad
Meds: Albuterol, Theophylline, TCA, Pseudophedrine, stimulants
Anabolic Steroid Usage: 9% HS, 3% JHS
![Page 26: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/26.jpg)
Hypertension
Age Appropriate values most important
Mild to Moderate HTN, no evidence of End-organ damage OK to compete; evidence of End organ damage NOT allowed until treated
Severe HTN NOT allowed until treated
![Page 27: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/27.jpg)
Hypertensive ValuesPediatrics 99:637-678
Age Mild Moderate Severe Very Severe
13-15 135-39
85-89
140-149
90-94
150-159
95-99
>160
>100
16-18 140-149
90-95
150-159
95-99
160-169
100-109
>170
>110
![Page 28: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/28.jpg)
Orthopedic Issues
Previous sports injuries: attention to ankles, knees, shouldersAnkle sprain need full rehabilitation to regain proprioceptionShoulder dislocation may need surgical repair to decrease another incident; rehab for Rotator Cuff SymptomsKnee instability: r/o ACL, Meniscus tear
![Page 29: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/29.jpg)
Physical Findings
Gen:– Obesity, Phenotypic Variation (Marfan's)
Skin: – Impetigo, Molluscum, Herpes, Scabies
Visual Acuity > 20/40
![Page 30: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/30.jpg)
Physical Findings
Pulmonary:– Wheezing
Abdomen:– Organomegaly
GU:– Testicle Exam, teach STE– Single Testicle: Needs Protection
![Page 31: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/31.jpg)
Cardiac Findings
Palpate PMI; S3, S4, midsystolic clickAusculate with pt supine; again standing or Valsalva: – HCM: Murmur incr. with decreased end
diastolic volume: when squatting ->standing; release of Valsalva
– AS: Increases with squatting, decreases with Valsalva
Femoral Pulses
![Page 32: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/32.jpg)
One Minute Orthopedic Exam
Screen for normal range of motion and strength
![Page 33: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/33.jpg)
Orthopedic Issues
Neck:– Previous C-Spine Injury– Stingers: OK as long as symptoms resolve
Back:– Kyphosis, Scoliosis– Range of motion: pain with extension occurs
with stress fractures, spondylolithesis
![Page 34: The Preparticipation Physical Jeffrey Rosenberg MD Residency Program in Social Medicine Montefiore Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062407/56649f425503460f94c6226a/html5/thumbnails/34.jpg)
Orthopedic Issues
Shoulder:– ROM, Instability, RTC strength
Knee:– Lachmans, Valgus/Varus Stress, Q angle
Ankle:– Anterior drawer test