6: 16-year-old male pre-participation evaluation

Question 1

Vasovagal Reflex

Answer 1

• Vasovagal syncope (fainting) is caused by self-limited systemic hypotension due to altered neurocardiogenic reflexes leading to bradycardia and/or peripheral vasodilation.
• Children frequently describe prodromal symptoms that include dizziness, lightheadedness, sweating, nausea, weakness, and visual changes.
• Many times children experience the prodromal symptoms without syncope

Question 2

Osgood-Schlatter Disease

Answer 2

• caused by irritation of the growth plate at the tibial tuberosity (front of the tibia bone). It is usually a self-limited growing pain that resolves with rest and with finishing the growth spurt.
• Ice and NSAIDS can help with the discomfort.
• It resolves after the bones stop growing and usually causes no lasting health issues.

Question 3

Distinguishing Types of Chest Pain: Precordial catch syndrome

Answer 3

• m/c c/o CP in adolescents and is of unknown etiology.
• benign condition characterized by sudden, sporadic onset of sharp pain, usually along the left sternal border, which is often exacerbated with deep inspiration. These pains are brief, lasting seconds to a few minutes, and resolve spontaneously.
• The pain can often be “broken” with a forced deep inspiration.
• It is often not associated with exercise.

Question 4

Distinguishing Types of Chest Pain: Costochondritis

Answer 4

also a benign cause of chest pain but less common. The pain of costochondritis is due to inflammation and typically will last for hours or days.

Question 5

Distinguishing Types of Chest Pain: Gastrointestinal causes

Answer 5

• gastroesophageal reflux, gastritis, and esophagitis

- described as: Retrosternal, Burning, Non-radiating Associated with meals

Question 6

Distinguishing Types of Chest Pain: Asthma or exercise-induced bronchospasm (EIB)

Answer 6

usually in association with cough, wheezing, or respiratory distress.

Question 7

Symptoms and Signs of Cardiac Chest Pain

Answer 7

• Onset: Pain triggered by exertion or stress
• Quality: Pressure or crushing sensation
• Duration: 10-15 minutes
• Associated symptoms: Syncope, palpitations
• Exam findings: Murmur, thrill, hyperdynamic precordium

Question 8

Strategies for Talking With Adolescents About Performance-Enhancing Drugs

Answer 8

• Use may cause undesired physical changes and side effects
• Drug testing
• examples of consequences
• Discussing long term consequences of use
• “just say no” strategy has been recommended for pre-adolescents

Question 9

Phallus development 1

Answer 9

Childlike phallus, testicular volume < 1.5 ml

Question 10

Phallus development 2

Answer 10

Childlike phallus, testicular volume 1.6-6 ml, reddened thinner and larger scrotum

Question 11

Phallus development 3

Answer 11

Increased phallus length, testicular volume 6-12 ml, greater scrotal enlargement

Question 12

Phallus development 4

Answer 12

Increased phallus length and circumference, testicular volume 12-20 ml, further scrotal enlargement and darkening

Question 13

Phallus development 5

Answer 13

Adult scrotum and phallus, testicular volume > 20 ml

Question 14

Hair Growth 1

Answer 14

no pubic hair

Question 15

Hair Growth 2

Answer 15

Small amount of fine hair along the base of scrotum and phallus

Question 16

Hair Growth 3

Answer 16

Moderate amount of more curly, pigmented, coarser hair extending laterally

Question 17

Hair Growth 4

Answer 17

Coarse curly adult like hair that doesn’t yet extend to the medial surface of thighs

Question 18

Hair Growth 5

Answer 18

Adult-type hair extending to medial surface of thighs

Question 19

Tdap (Tetanus, Diptheria, Acellular Pertussis)

Answer 19

• First dose given at the pre- adolescent visit, at 11-12 years of age
• The difference between the DTaP and Tdap vaccines is the amount of diphtheria toxoid contained in each dose.
• Pediatric DTaP (big D) contains 3-5 times more diphtheria toxoid than the adult Tdap (little d) and is only given to children 6 years old and younger.
• Tdap is used for adults and children 7 years of age and older who need booster doses of diphtheria, tetanus toxoid, and acellular pertussis.

Question 20

MCV4 and MenB (Meningococcal conjugate vaccine)

Answer 20

• MCV4: First dose routinely given at age 11 years, with a booster dose at age 16 years
• MenB: One dose given at 16 years
• Complete meningococcal immunization consists of 2 separate vaccines:
• –MCV4 includes serotypes A,C,W and Y
• –MenB includes serotype B
• For high risk populations, MCV4 is indicated as early as 2 months

Question 21

Human papillomavirus

Answer 21

• The 1st dose is routinely administered at 11 yo.
• The series consists of 3 immunizations over 6 mo-.
• Recommended for both males and females.
• Can be administered as early as 9yo

Question 22

Pre-participation Evaluation: CV Screening

Answer 22

• Paramount is an assurance of cardiovascular health.
• While not common, undiagnosed cardiac illnesses such as hypertrophic cardiomyopathy may place the student athlete at significant risk of sudden cardiac death.
• A screening cardiovascular evaluation includes asking specific questions to assess risk and then performing a careful physical examination.

Question 23

Pre-participation Evaluation: Other Issues

Answer 23

• A history of loss of consciousness or concussion (which may predispose the individual to neurologic injury)
• Recovery from significant musculoskeletal injuries
• Assessing general health
• Counseling on health-related issues, and
• Assessing fitness level for specific sports.

Question 24

H (Home)

Answer 24

• “Have there have been any changes in your home life over the last year?”
• Who lives with you?
• Where do you live?
• Do you have your own room?
• What are relationships like at home?
• To whom are you closest at home?
• To whom can you talk at home?
• Is there anyone new at home?
• Has someone left recently?
• Have you moved recently?
• Have you ever had to live away from home?

Question 25

E (Education/employment)

Answer 25

• “How are things going for you at school this year?”
• What are your favorite subjects at school
• Your least favorite subjects?
• How are your grades?
• Any recent changes?
• Any dramatic changes in the past?
• Have you changed schools in the past few years?
• What are your future education/employment plans/goals?
• Are you working? Where? How much?

Question 26

E (Eating disorders screening)

Answer 26

• What do you like and not like about your body?
• Have there been any recent changes in your weight?
• Have you dieted in the last year?
• Have you done anything else to try to manage your weight?
• How much exercise do you get in an average day? Week?
• What do you think would be a healthy diet?
• How does that compare to your current eating patterns?

Question 27

A (Activities)

Answer 27

• What do you and your friends do for fun?
• What do you and your family do for fun?
• Do you participate in any sports or other activities?
• Do you regularly attend a church group, club, or other organized activity?

Question 28

D (Drug use)

Answer 28

• Screening using the CRAFFT begins by asking the adolescent to “Please answer these next questions honestly”; telling him/her “Your answers will be kept confidential”; and then asking three opening questions.
• During the Past 12 months, did you:
  1. Drink any alcohol (more than a few sips)? 2. Smoke any marijuana or hashish?
  3. Use anything else to get high?
• If the adolescent answers “No” to all three opening questions, the provider only needs to ask the adolescent the first question - the CAR question below. If the adolescent answers “Yes” to any one or more of the three opening questions, the provider asks all six CRAFFT questions.

Question 29

CRAFFT

Answer 29

C
Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
R
Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
A
Do you ever use alcohol/drugs while you are by yourself, ALONE?
F
Do you ever FORGET things you did while using alcohol or drugs?
F
Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
T
Have you gotten into TROUBLE while you were using alcohol or drugs?

Question 30

S (Sex)

Answer 30

• Using general and gender-neutral terms is a great strategy to allow teens to express the range of adolescent sexuality.
• Have you ever been in a romantic relationship?
• Tell me about the people that you’ve dated.
• Have any of your relationships ever been sexual relationships? Are your sexual activities enjoyable?
• What does the term “safe sex” mean to you?

Question 31

S (Suicidality, depression, and other mental health issues)

Answer 31

• -Important questions to ask with regard to depression and suicidality: Are you happy with your life?
• -Do you ever feel sad or depressed?
  1. Have you ever thought about hurting yourself?

Question 32

S - Safety (including “savagery” to discuss violence)

Answer 32

• Have you ever been seriously injured? (How?) How about anyone else you know?
• Do you always wear a seatbelt in the car?
• Do you use safety equipment for sports and or other physical activities (for example, helmets for biking or skateboarding)?
• Is there any violence in your home? Does the violence ever get physical?
• Is there a lot of violence at your school? In your neighborhood? Among your friends?
• Have you ever been physically or sexually abused?
• Have you ever been raped, on a date or at any other time?

Question 33

Cardiovascular Exam

Answer 33

• Begin by measuring the blood pressure, using an appropriately sized cuff.
• Palpate the brachial and femoral pulses to assess for a possible coarctation of the aorta.
• Perform auscultation supine and standing.
• -Note: *Murmurs are common in healthy adolescents, but if any of the following characteristics are noted, the murmur deserves further evaluation:
• —Louder than grade III/VI
• —Any diastolic murmur
• —Any murmur that increases with standing or Valsalva

Question 34

The Genitourinary Exam in Males: General

Answer 34

part of the preparticipation physical exam for males, but not for females.

Question 35

The Genitourinary Exam in Males: Inguinal hernia

Answer 35

Checking the male athlete for inguinal hernia is particularly important in sports that involve sprinting and weight lifting.

Question 36

The Genitourinary Exam in Males: Undescended testicle

Answer 36

• It is the responsibility of the examiner to check for undescended testicle and recommend the protective cup for contact sports before clearing the athlete for full participation.
• GU exam gives the clinician an opportunity to educate and demonstrate to the patient the technique of testicular self-exam for early detection of testicular cancer.

Question 37

Musculoskeletal Exam

Answer 37

• The musculoskeletal examination is an essential part of the pre-participation physical exam because it typically accounts for 50% of the abnormal physical findings identified.
• In general, it consists of various maneuvers looking for symmetry in: strength, muscle bulk, range of motion

Question 38

two-minute orthopedic exam

Answer 38

-screening exam that allows the clinician to identify musculoskeletal problems in asymptomatic individuals.

Question 39

Syncope Evaluation

Answer 39

• Syncope is defined as the abrupt loss of consciousness and postural tone.
• In any patient with syncope, an ECG should be obtained-rule out some of the important arrhythmic causes of syncope, such as Wolf-Parkinson-White syndrome and long QT syndrome.
• In addition, hypertrophic cardiomyopathy, the m/c c/o sudden death in young athletes, can first present with syncope; the ECG is abnormal in more that 90% of pts w/ hypertrophic cardiomyopathy and is thus an essential screening test.

Question 40

A 17-year-old boy presents for a sports pre-participation physical. He reports that he occasionally gets short of breath and feels light-headed with exercise, and sometimes he experiences chest pain as well. He lost consciousness once last season during a playoff basketball game, but attributed it to feeling sick at the time. His grandfather died suddenly at age 35 of unknown etiology. Which of the following is the most likely diagnosis?

Answer 40

Prolonged QT syndrome can cause syncopal episodes in late childhood or adolescence. QT intervals are elongated on ECG and lead to arrhythmias, like ventricular fibrillation. This condition is often associated with other abnormalities, including severe congenital sensorineural deafness.

Question 41

A 16-year-old male presents to your office requesting clearance to play football. You begin by taking his medical history. He says that he feels very well, but admits that he recently experienced one episode of syncope that occurred when he trained really hard for football tryouts with his friends. He denies any shortness of breath, or chest pain currently. Family history is significant for an uncle who died of heat stroke at the age of 30 while playing basketball. Physical examination reveals no abnormalities. What is the next best step in management?

Answer 41

Referral to cardiology is the absolute next best step! The combination of syncope with exertion and a family history of a young death is concerning for something like hypertrophic cardiomyopathy. Don’t be fooled about heat stroke. That is a positive family history for sudden death in a young person. This patient must be evaluated by cardiology, even if you don’t hear a cardiac murmur!

Question 42

Claire is a 16-year-old female who presents for birth control management. Her review of symptoms is unremarkable except for chest pain. When you ask her more questions, she reveals the pains are intermittent, on and off for the past couple months. It is not associated with exertion, sharp, and well localized at the left sternal border. It is very brief, lasting only a few seconds, during which she says she sometimes notices it gets worse when she breathes in. She denies recent URI or viral illness. The family history is negative for early cardiac disease. Her vital signs and physical exam are normal. Which is the next best step in management?

Answer 42

Based on the history, and assuming your physical exam is unremarkable, this sounds most suggestive of precordial catch syndrome, the most common cause of chest pain in an adolescent. No further workup is needed.