A Guide to the Sports Preparticipation Examination
Authors: Steven Stahle, MD, Assistant Medical Director, U.S. Center for Sports Medicine, St. Louis, and Susan Stahle, MS, PNP
Peer Reviewers: Stephen T. House, MD, Associate Clinical Professor, Wright State University School of Medicine, Department of Family Medicine; Brent S.E. Rich, MD, ATC, Team Physician, Arizona State University, Arizona Diamondbacks, Mountain Pointe High School, University Sports Medicine, Arizona Orthopaedic and Sports Medicine Specialists; Andrew Tucker, MD, Director, Primary Care Sports Medicine, University Sports Medicine, Team Physician, Baltimore Ravens, Assistant Professor, Family Medicine, University of Maryland Medical Center, Baltimore.
Editor’s NoteSports participation is an exciting means of enhancing self esteem, increasing coordination, and boosting physical fitness. Athletics can also provide a positive experience in competition for young athletes. Amateur athletes in competition sports require a pre-participation physical exam (PPE). The screening exam performed today is much more sophisticated than the "general health" exam offered years ago. The family physicians who frequently work with young athletes should be knowledgeable about today’s required elements in the pre-participation exam. This article specifically provides the goals and objectives of the PPE, routine testing in conjunction with the screening physical, and means of determining clearance in a private or station-based setting. This article does not include the special questioning or testing needed for athletes with disabilities. The authors also provide PPE forms for use during the exam. The ultimate determination in testing and clearance of the young athlete should be guided by each physician’s clinical judgment.
The overall goal of the PPE is to help maintain the health and safety of the athlete in training and competition.1 It provides a practical means for the physician to educate the young athlete on a variety of health topics. Health education is an important aspect of the PPE with young athletes because this may be the only health maintenance exam they seek out all year. Athletes may also use this time to discuss overall health goals as they specifically relate to their own athletic performance. A strengthening or rehabilitation program may then be developed by coaches and trainers. The purpose of the PPE is not to disqualify athletes from competition, but to promote safety, identify ongoing injuries, and prevent future injuries. Only 0.3-1.3% of athletes are denied clearance during the PPE.2
The specific objectives of the PPE may vary slightly from physician to physician, but should always include: 1) detection of conditions that limit participation or may predispose to injury; 2) detection of conditions that may be life threatening or disabling; and 3) meeting legal requirements as set forth by the state or sponsoring school or club.3 Other common objectives include determining the general health of the athlete, evaluating the athlete’s fitness level, and optionally assessing the level of maturity.4,5
Healthcare professionals who wish to perform PPEs must be qualified based on specialty, training, and clinical expertise. Each state certifies healthcare practitioners qualified to perform PPEs at the secondary school level. College, professional, and international competitors are governed by their own athletic boards as to specifically who may perform their PPE. The primary care physician is a well qualified candidate for performing the PPE due to his or her training in a broad range of problems. The primary care physician is also knowledgeable in consulting with specialty physicians when detected problems require further clinical expertise.
Timing. The PPE should be scheduled six weeks prior to the pre-season.6 This allows adequate time for correction and rehabilitation of any problems detected. Timing for a collegiate athlete is often based on availability. Some athletes may return to school just days before pre-season begins. Physicians in this case may prefer to perform outgoing physicals at the end of the season with a follow-up review of the medical history just prior to the season. This would allow the physician to detect any conditions and the athlete to rehabilitate any injuries during his or her off season. Many schools will require one PPE for Fall/Winter sports and another for Spring/Summer sports. However, in general, an annual PPE is all that is required in high school athletes. Athletes who are minors are required to provide written permission from their legal guardian for the examination.
Settings. The two most common settings for performing PPEs are in a station-based environment or in the physician’s office. Each setting has its own advantages and disadvantages in providing the best overall health screening to the athlete.
Advantages. Station-based evaluations offer the athlete a group of clinical experts that can provide an extremely time-efficient and cost-effective examination Hundreds of PPEs can be performed in one day with a well-trained staff. Effective station-based setups will include the expertise of nurses, physical therapists, exercise physiologists, athletic trainers, and possibly dentists and nutritionists. Other assistants can be guided by physicians to efficiently administer sign in, vision checks, and weights and measurements. An athlete who receives care from a "team" setting may improve his communication with the medical personnel. Additionally, all members of the medical team and coaches will become more knowledgeable regarding each individual athlete.
Disadvantages. The disadvantages of a station-based format can be assessed simply by its requirementsprecise training and coordination of staff members and a large physical space to set up the stations.7 The setting itself can become confusing and noisy.
A lack of privacy may inhibit the athletes from discussing personal health matters. A feeling of being rushed may also decrease the health education and counseling offered by the physician. In addition, if a disqualifying condition is detected, an athlete and his or her parents may not fully understand the need for further evaluation or disqualification from play due to the lack of time and privacy.
Finally, the continuity of care may be compromised with a station-based evaluation.8,9 Coordinating personnel and schedules can become difficult for the physician who is previously unknown to the athlete.
The station-based PPE can be divided into required and optional stations. Personnel best suited for each of the stations should be assigned by the physician. If more then one physician is present, the author suggests dividing the physical exam into two parts, medical and musculoskeletal. Female and male examining sites should be separated into two distinct areas. A suggested format of the stations is given in Table 1.
Advantages. An office-based PPE performed by the athlete’s own primary care physician offers the major advantage of familiarity. If the physician has treated the athlete throughout childhood, a complete medical history including previous physical examinations and medical records will provide a thorough review in comparison with the PPE screening evaluation form. The previously established working relationship may make it easier for the physician to educate and counsel the athlete on sensitive health issues such as drugs, alcohol, birth control, and sexually transmitted diseases. The continuity of care provided by the athlete’s own physician can be crucial in detecting, evaluating, and treating any conditions discovered during the PPE.
Disadvantages. A physician’s busy office schedule often only allows for a short general health screen. This is not an adequate amount of time to detect conditions that may predispose the athlete to injury or illness. Furthermore, many primary care physicians lack the interest or knowledge regarding sports-related medical problems. The physician may not be comfortable or qualified in determining clearance for an athlete.
We should not assume all athletes have an established primary care physician. In general, athletes represent a healthy population that may not seek medical attention unless required. Additionally, not all athletes can afford the cost of a private office-based PPE.
The office-based PPE follows the same examination procedure as any other primary care examination. The major difference between routine office-based examinations and the PPE is allowance of extra time for the PPE.
"Though issues surrounding routine laboratory screening tests are frequently discussed and often times controversial, the author societies concur that routine laboratory screening tests in asymptomatic athletes should not be required for the PPE."10 Screening tests in the young athlete must be cost-effective. Studies thus far in evaluating the use of such tests as UA, CBC, Chemistry Profile, Lipid Profile Sickle Cell trait, and Ferritin Level in the PPE have not revealed any cost-effectiveness.11-14 Extensive cardiopulmonary testing for routine screening in the PPE is also not recommended.15-17 According to new AHA standards, a complete and careful personal and family history and physical examination designed to identify or raise the suspicion of cardiovascular lesions is the best available and most practical approach.18 Symptomatic individuals and those athletes with significant familial medical history should be re-evaluated and scheduled for specific diagnostic tests. Individual symptoms and overall health should indicate to the physician whether or not clearance should be denied during the waiting period. In general, the athlete is allowed to continue participating.
The most crucial portion of the PPE is the medical history. A complete history will identify approximately 75% problems affecting athletes.19 It is important to remember that frequently a medical history completed by the athlete does not reveal the same results as one completed by the athlete’s parent/guardian. Ideally, the athlete and parent will complete the form together prior to the exam. A sports screening evaluation form used by the U.S. Center for Sports Medicine for use with PPEs is shown in the supplement.
Questions in the medical history are arranged by their significance and emphasize the areas of greatest concern for sports participation. It is important to remember that these questions are screening questions and not all-inclusive.
Questions 1 and 2 are designed to signal the physician to the most common risks of sudden death (hypertrophic cardiomyopathy, anomylous vessels, arrhythmias, etc.) during exercise for young athletes.
Question 3 will assist the physician in assessing for exercise-induced bronchospasm (EIB), which will affect athletic performance.
Question 4 can also help screen for EIB due to an allergic link. The need for knowledge of specific allergies is obvious.
Question 5 identifies the need for possible neurologic evaluation along with recognizing significant risk for additional concussions.
Question 6 identifies the increased risk of heat injury.
Question 7 screens for previous sports-related injuries and significant joint trauma. This is important because prior injury that has not been rehabilitated is the most common reason athletes are not initially cleared for participation.20
Question 8 assesses for acute illness such as mononucleosis, hepatitis A, and febrile illnesses, which may temporarily restrict the athlete’s ability to participate.
Question 9 and Question 10 are self-explanatory.
Question 11 reveals female maturation and identifies amenorrhea (which may be linked to stress fractures) and oligomenorrhea.
Question 12 is an effective screening question to help recognize eating disorders.
Question 13 is self-explanatory and is not necessarily a reason for disqualification.
Question 14 is an opportunity for education.
Question 15 is a variety of conditions that may or may not restrict an athlete’s participation in play.
Item 16 provides an opportunity for the athlete to discuss sensitive issues with a qualified professional.
The standard components of the preparticipation physical examination are shown in Table 2. This screening tool should be used to focus specifically on areas of concern in the particular athletic activity and areas identified as problems in the history. Males and females should be dressed in shorts, tank tops and athletic shoes.
Height and Weight. Height and weight should be recorded and reviewed yearly. Athletes who are extremely thin or obese should be questioned regarding sudden weight change, eating habits, and body image. Body composition determination is an optional station.
HEENT. Visual acuity should be 20/40 or better in each eye. Protective eyewear should be recommended for use with corrective eyewear, history of serious trauma, or absence of an eye. Protective eyewear should always be checked prior to play. Pupils should be checked for anisocoria. If found, this baseline information should be clearly recorded in the medical record and communicated to members of the athlete’s medical team. This is a significant point of reference in assessing for head trauma. The general health of the remaining components of this exam should be assessed. Assessment of the ears should specifically check for scarring of the auditory canal, which may indicate the need for a hearing evaluation, and perforated tympanic membranes in athletes competing in water sports, which indicate the need for earplugs.21 The oral cavity should be checked for ulcers and decreased enamel seen with bulimia; braces, which may indicate the need for a mouthguard; and a high-arched palate seen in those with Marfans.22 Nasal polyps, deviated septum, and repeated trauma to the nose should be assessed for referral. Finally, any adenopathy should be assessed for infection or malignancy.
Cardiovascular. The American Heart Association (AHA) recently issued a new medical/scientific statement from the Sudden Death Committee and the Congenital Cardiac Defects Committee in which they believe that the standard pre-participation screening process for athletes appeared to be limited in their ability to identify cardiovascular lesions responsible for sudden death in young athletes.23 As a consequence of this belief, the AHA statement recommends the development of a national standard for PPEs and strongly recommends that athletic screening be performed by health care workers who possess the requisite training, skill, and background to reliably obtain a detailed cardiovascular history, perform a related physical examination, and recognize heart disease.24 The specific recommendation for a brachial artery blood pressure measurement was included in the statement. The new AHA statement should be reviewed for further recommendations by all sports medicine providers in order to insure their professional liability. Blood pressure that is initially high should be repeated a few minutes after the initial check. If the condition continues, the athlete should be questioned about stimulants such as caffeine, ephedrine, or nicotine.25 A radial and femoral pulse should be palpated for rate and rhythm. Auscultation of the heart should be performed with the athlete in supine and standing positions.26 A murmur of hypertrophic cardiomyopathy is best heard when the athlete is standing. Murmurs and the timing of murmurs should be assessed. Any detected murmur should be further clarified by instructing the athlete to perform deep inspiration, squat-to-stand, and Valsalva’s maneuver. In detecting aortic stenosis, the systolic murmur will decrease with Valsalva and increase with squatting. Conversely, with hypertrophic cardiomyopathy, squatting will decrease the intensity of the murmur, and Valsalva’s will increase the intensity. Benign systolic murmurs are common in young athletes. Innocent murmurs will also increase with squatting and decrease with Valsalva but can be differentiated from aortic stenosis by volume, location, radiation, and duration.27 Arrhythmias may require electrocardiographic evaluation. Any further cardiac evaluation should be referred to a cardiologist.
Lungs. Clear breath sounds should be revealed during the pulmonary exam.
Abdomen. The athlete should be supine during the assessment for masses, tenderness, and hepatosplenomegaly.
GU. The male should be assessed for singular or undescended testicles, testicular masses, and herniation. The female’s GU exam should be deferred to a private primary care physician.
Musculoskeletal. The musculoskeletal system can be assessed by three different types of screening exams. The type and extent of musculoskeletal examination appropriate for the PPE is a widely debated topic. Asymptomatic athletes with no history of injury rarely reveal a musculoskeletal injury. In fact, history alone has been shown to be 92% sensitive in detection of significant musculoskeletal injuries.28 This author supports the notion that a general screening examination is appropriate for asymptomatic athletes with no history of injury. If an athlete is currently symptomatic of an injury, or has a history of previous injury, weakness, or instability, the physician should perform a relevant joint-specific examination. If time is allowed, a joint-specific exam should be performed instead of a general screening; a sport-specific exam may be performed if time does not allow for a joint-specific exam.
General Screening Examination. A general screen will quickly assess range of motion, gross muscle strength, and muscle asymmetry along with identifying significant injuries.29 The general screen will not allow for specific diagnosis or severity of injury.
Joint-Specific Testing. Joint-specific testing assesses individual joints by inspection, palpation, and maneuvers. It is much more thorough than the general screen but also significantly more time-consuming. A description of each joint-specific test is beyond the scope of this article but can be found in it’s entirety in Physical Examination of the Spine and Extremities.30
Sports-Specific Testing. Sports-specific examinations include endurance, strength, and flexibility testing in addition to an orthopedic examination. The focus is indicated by the particular sport and the area of greatest stress. For instance, runners would be assessed for knee and ankle stability, strength, and flexibility by use of specific orthopedic maneuvers. The sports-specific exam is time-consuming and requires greater knowledge of particular sports than does the joint-specific testing. The author generally saves sports-specific examinations for highly competitive and professional athletes.
Neurologic. In general, a normal musculoskeletal examination denotes normal neurologic function. However, for athletes who have suffered severe or multiple concussions, an exam of cranial nerves along with cerebellar and cognitive function tests may be indicated. An athlete who has experienced recurrent nerve root or brachial plexus injuries ("stingers") should be assessed for deep tendon reflexes and upper extremity strength. Referral may be appropriate for any impairments noted.
The culmination of the detailed medical history and lengthy physical examination in the PPE is the determination of clearance. Clearance can be divided into three categories: 1) unrestricted clearance for contact, limited contact, or noncontact play; 2) clearance upon further evaluation or rehabilitation; and 3) clearance deferred for a specific or all sports. If a condition is detected, the following questions should guide the physician to determining clearance for an athlete.31
1. Does the problem place the athlete at increased risk of injury?
2. Does the problem place any other participant at increased risk of injury?
3. Can the athlete safely participate with treatment?
4. Can limited participation be allowed while treatment is initiated?
5. If clearance is denied for specific sports, can other athletic activities be substituted?
Medical conditions affecting sports participation should be reviewed for clearance based on guidelines established by the 1994 American Academy of Pediatrics Committee on Sports Medicine and Fitness. (See Table 3.)32 Cardiovascular abnormalities and congenital heart disease are thoroughly covered in the guidelines from the "26th Bethesda Conference: Recommendations for Determining Eligibility for Competition Athletes with Cardiovascular Abnormalities."33 Furthermore, a review of the classification of sports by dynamic and static strenuousness should also assist in determining clearance for athletes with cardiovascular conditions. (See Table 4.) In consideration of potential for injury due to contact or collision, the physician should review the contact categories established by the AAP. (See Table 5.)34 These published guidelines and recommendations in conjunction with the judgment of the physician provide an accurate means of determining clearance.
Two very important medicolegal issues related to the PPE have been debated and should be reviewed. The primary legal issue is the athlete’s right to participate. The right to make a final decision on whether to engage in athletics has been repeatedly recognized by the courts as resting with the athlete or with his or her parents.35,36 A physician who is disqualifying an athlete from play should consult with expert physicians. Both the examining and the consulting physician should clearly review all reasons why the athlete should not participate with the athlete and his or her parents. Should the athlete choose to participate against medical advice, an exculpatory waiver stating the physician(s) has clearly informed the family of all risks accompanying the participation of play should be signed. An exculpatory waiver is a written form stating that the family recognizes and assumes the risk of injury and releases the physician(s) and the school from liability. The validity of these waivers is not nationally recognized, and legal counsel is recommended for the physician on an individual case basis.37
The other major legal issue is professional liability for physicians performing PPEs as volunteers. Until recently, Good Samaritan laws did not cover preparticipation evaluations even if performed without charge. Some states have now instituted protection for examiners for athletic programs under Good Samaritan statutes. The physician should become familiar with his or her own state’s statutes. Physicians providing preparticipation evaluations should be familiar with standards set forth by significant medical committees such as those discussed throughout this article. After all, none of us can be protected from our own lack of knowledge.
The preparticipation physical examination can be successfully used to help our young athletes remain healthy and safe in sports. By encouraging young athletes to remain in athletics we may stimulate a personal commitment to physical fitness. Through continued contact with the athlete, we can also provide health education and physical care that may promote a healthy lifestyle for years to come
References
1. American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American Medical Society for Sports Medicine (AMSSM), American Orthopaedic Medicine (AOASM). Preparticipation Physical Evaluation, 2nd ed. Minneapolis, MN: Phys Sportsmed; 1997:1-2.
2. Sallis R. The Preparticipation Examination. In: Sallis R, Massimino F. (eds): ACSM’s Essentials of Sports Medicine, 1st ed. St. Louis: Mosby; 1997:151-160.
3. American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American Medical Society for Sports Medicine (AMSSM), American Orthopaedic Society for Sports Medicine (AOSSM), and American Osteopathic Academy of Sports dicine (AOASM). Preparticipation Physical Evaluation, 2nd ed. Minneapolis, MN: Phys Sportsmed; 1997:1.
4. Snoddy RO. The Preparticipation Screening Examination. In: Baker CL (ed.): The Hughston Clinic Sports Medicine Book, 1st ed, Media: Williams & Wilkins; 1995:31-34.
5. Lombardo J. Preparticipation Examination. In: Cantu R, Micheli L. (eds): ACSM’s Guidelines for the Team Physician, 1st ed, Malvern, Lea & Febiger; 1991:71-94.
6. Ibid.
7. Snoddy RO. The Preparticipation Screening Examination. In: Baker CL. (ed): The Hughston Clinic Sports Medicine Book, 1st ed, Media: Williams & Wilkins; 1995:31-34.
8. American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American Medical Society for Sports Medicine (AMSSM), American Orthopaedic Society for Sports Medicine (AOSSM), and American Osteopathic Academy of Sports Medicine (AOASM). Preparticipation Physical Evaluation, 2nd ed. Minneapolis: Physd Sportsmed; 1997:5.
9. Sallis R. The Preparticipation Examination. In: Sallis R, Massimino F. (eds): ACSM’s Essentials of Sports Medicine, 1st ed. St. Louis: Mosby; 1997:151-160.
10. American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American Medical Society for Sports Medicine (AMSSM), American Orthopaedic Society for Sports Medicine (AOSSM), and American Osteopathic Academy of Sports Medicine (AOASM). Preparticipation Physical Evaluation, 2nd ed. Minneapolis: Phys Sportsmed; 1997:7.
11. Lombardo JA, Robinson JB, Smith DM, et al: Preparticipation Physical Evaluation, ed.1. Kansas City, American Academy of Family Practice, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Association for Sports Medicine,and American Osteopathic Association for Sports Medicine; 1992.
12. Committee on Sports Medicine. Sports Medicine: Health Care for Young Athletes. Evanston, IL, American Academy of Pediatrics; 1983.
13. American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American Medical Society for Sports Medicine (AMSSM), American Orthopaedic Society for Sports Medicine (AOSSM), and American Osteopathic Academy of Sports Medicine (AOASM). Preparticipation Physical Evaluation, 2nd ed. Minneapolis: Phys Sportsmed; 1997:7
14. Taylor WC III, Lombardo JA. Preparticipation screening of college athletes: Value of the complete blood cell count. Phys Sportsmed 1990;18:106-118.
15. Maron BJ, Isner JM, McKenna WJ: Task Force 3: Hypertrophic cardiomyopathy, myocarditis and other myopericardial diseases and mitral valve prolapse, in 26th Bethesda Conference: Recommendations for Determining Eligibility for Competition in Athletes with Cardiovascular Abnormalities. Med Sci Sports Exerc 1994;26 (10 suppl):S261-S267.
16. Ades PA. Preventing sudden death: Cardiovascular screening of young athletes. Phys Sportsmed 1992;20:75-89.
17. Feinstein RA, Colvin E, Oh MK. Echocardiographic screening as part of a preparticipation examination. Clin J Sports Med 1993;3:149-152.
18. Herbert D. Pre-Participation screening: Competitive athletes and sudden death. Sports Med Pri Care 1996;2:90.
19. Johnson RJ. The sports qualifying screening evaluation.
20. Ibid.
21. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Preparticipation Physical Evaluation, 2nd ed. Minneapolis: Phys Sportsmed; 1997:18.
22. Ibid.
23. Herbert D. Pre-participation screening: Competitive athletes and sudden death. Sports Med in Pri Care 1996;2:90.
24. Ibid
25. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Preparticipation Physical Evaluation, 2nd ed. Minneapolis: Phys Sportsmed; 1997:18.
26. American Heart Association. Cardiovascular preparticipation screening of competititve athletes. Circulation 1996;94:850-856.
27. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Preparticipation Physical Evaluation, 2nd ed. Minneapolis: Phys Sportsmed; 1997:19.
28. Gomez JE, Landry GL, Bernhardt DT. Critical evaluation of the 2-minute orthopedic screening examintion. Am J Dis Child 1993;147:1109-1113.
29. Ibid
30. Hoppenfeld S. Physical Examination of the Spine and Extremities. Appleton-Centruty-Crofts; 1976.
31. American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American Medical Society for Sports Medicine (AMSSM), American Orthopaedic Society for Sports Medicine (AOSSM), and American Osteopathic Academy of Sports Medicine (AOASM). Preparticipation Physical Evaluation, 2nd ed. Minneapolis: Phys Sportsmed; 1997;29.
32. Lombardo JE. Preparticipation Examination. In: Cantu R, Micheli L (eds). ACSM’s Guidelines for the Team Physician, 1st ed. Malvern, Lea & Febiger; 1991:71-94.
33. 26th Bethesda Conference: Recommendations for determining eligibility for competition in athletes with cardiovascular abnormalitites. January 6-7, 1994. Med Sci Sports Exerc 1994;26 (10 Suppl):S223-S283 [published erratum appears in Med Sci Sports Exerc 1994;26(12): following table of contents]; also in J Am Coll Cardiol 1994;24:845-899.
34. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Preparticipation Physical Evaluation, 2nd ed. Minneapolis: Phys Sportsmed; 1997:32-33.
35. Gallup EM. Law and the Team Physician. Champaign, IL: Human Kinetic Books; 1995:80-81.
36. Feinstein RA, Soileau EJ, Daniel WA, Jr. A national survey of preparticipation physical examination requirements. Phys Sportsmed 1988;16:51.
37. Gallup EM. Law and the Team Physician. Champaign, IL: Human Kinetic Books; 1995:76-77.
Physician CMEQuestions
27. Common objectives of the pre-participation exam can include:
a. injury detection.
b. evaluating fitness level.
c. meeting legal requirements set by the state.
d. evaluating general health questions.
e. all of the above.
28. Advantages of station-based PPEs include:
a. secluded office exams.
b. decreased noise in between stations.
c. cost-effective exams
d. ease with coordinating personnel to perform ancillary duties during exams.
e. continuity of care.
29. The PPE should ideally take place:
a. during the season.
b. one week prior to conditioning.
c. three weeks prior to the season.
d. six weeks prior to the season.
e. two weeks after the season.
30. The murmur of hypertrophic cardiomyopathy is best heard when an athlete is:
a. squatting.
b. standing.
c. lying prone.
d. exercising.
e. coughing.
31. Routine screening tests in asymptomatic athletes should include:
a. echocardiograms.
b. urinalysis.
c. EKG.
d. CBC.
e. blood pressure.
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