head-to-toe comprehensive assessment
In order for a clinician to clear a child or adolescent for sports, a thorough head-to-toe comprehensive assessment is required. This assessment should emphasize the neurological, cardiovascular, and musculoskeletal systems, as well as evaluate past medical history, family medical history, allergies, history of injuries, any restrictions on participating in sports in the past, and mental health history. Prior to performing the physical examination, reviewing pre-answered questions and all histories can guide the clinician on which areas to focus and assess in more detail (Preparticipation Sports Screening for Children and Adolescents, 2021).
Jose’s responses to “passing out during exercise in the past” and “becoming ill while exercising in the heat” both trigger a red flag for the clinician because a cardiovascular referral should be considered if one or more questions from “Preparticipation Physical Evaluation Fourth Edition (PPE-4)” (Sports Preparticipation Cardiovascular Screening, 2024) are answered yes.
The clinician should gather more detailed information by asking Jose to describe the circumstances when he passed out during exercise, including the type of exercise, the frequency of these episodes, the most recent occurrence, any precursor signs before passing out (such as dizziness, chest pain, shortness of breath, or feeling of fainting), the duration of unconsciousness, and whether he received medical attention or evaluation following these episodes.
The clinician should also inquire about Jose’s experience of feeling ill during exercise in the heat by asking about the specific circumstances, such as the month, weather conditions, time of day, type of exercise, duration of exercise before feeling ill, hydration status during exercise, frequency of these episodes, the most recent occurrence, and any medical attention or follow-up he received.
It is also important to review Jose’s medical history, including any history of asthma, heart problems, medications he is currently taking, and the health history of his parents, grandparents, and siblings. The clinician should focus on examining Jose’s heart by auscultating for signs of arrhythmia, murmurs, gallops, friction rubs, and any adventitious heart sounds. A 12-lead EKG is also a great baseline to perform in the office (Sports Preparticipation Cardiovascular Screening, 2024).
The clinician should also investigate any history of head concussion or head injury by asking about the occurrence, severity, duration of unconsciousness, and any medical attention or follow-up received. A full neurological exam is essential due to this history (Preparticipation Sports Screening for Children and Adolescents, 2021).
Jose’s nutritional assessment should also be carefully examined, as adolescent athletes require higher energy and dietary protein (Sports Nutrition, 2023). Fainting and feeling ill during exercise could be associated with a lack of nutritional needs.
Given Jose’s history of passing out during exercise, feeling ill during exercise in the heat, and history of head concussion or injury, it is important to educate Jose and his mother about safety precautions. These include maintaining a high-protein diet, recognizing signs and symptoms of dehydration, heat stroke, and concussion. Jose should be referred to a cardiologist for further evaluation to determine his fitness for sports. A note can be provided to the school or coach regarding the findings from the office visit so that the coach is aware of the signs to watch for and the appropriate steps to take.
For this sport physical, the ICD-10 codes used would be: “Z02.5 for examination of participation in sport or a sports physical, S06.0XAS for history of concussion, T67.1XXS for history of heat syncope, and R55 for history of syncope and collapse” (2024 ICD-10 CM Codes, n.d.).
References
Preparticipation sports screening for children and adolescents. (2021, July 3). Dynamed. https://www.dynamed.com/condition/preparticipation-sports-screening-for-children-and-adolescents#GUID-88341D13-972B-482F-A89C-E43CDEAE62D7
Sports nutrition. (2023, August 28). Dynamed. https://www.dynamed.com/management/sports-nutrition#TOPIC_KHM_VQR_2QB
Sports preparticipation cardiovascular screening. (2024, July 29). Dynamed. https://www.dynamed.com/prevention/sports-preparticipation-cardiovascular-screening#GUID-DCC15054-1FA3-4F0A-A8FB-2ED37B47984D
2024 ICDU-10 CM Codes. (n.d.). ICD 10 data. Retrieved August 6, 2024, from https://www.icd10data.com/ICD10CM/Codes
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