Principles of Examination

Core Concepts in Athletic Training and TherapySusan Kay Hillman

Explain the difference between the primary survey and the secondary survey in the evaluation of an injured person.

List the main steps in performing a complete on-site examina tion.

List the main steps in performing a complete acute injury examination.

Explain the term “SINS” as used in acute and clinical examinations.

Explain the difference between the subjective and the objective segments of the examination.

List the elements one should include in the objective component of the clinical examination.

Explain the importance of documenting an examination.

Objectives

Examination Components Before making a diagnosis must thoroughly

examine the injury Sequentially performing tasks involved in specific

examination components Dictated by location and timing of examination Three different environments

On field (onsite On sideline (acute) Athletic training facility (clinical)

Each demands different examination, but all should begin with evaluation to eliminate any critical or life threatening concerns

Introduction

Primary Survey Determine status of life threatening or limb threatening conditions Life threatening conditions (ABC’s or CAB’s)

Other vital signs and severe bleeding Treat emergency conditions or move on to secondary survey

depending on your findings

Secondary Survey Occurs when primary survey is concluded or deemed unnecessary

No life threatening conditions, patient is breathing and any bleeding is under control

Examination to determine presence of other injuries Rapid examination to determine seriousness of injury and if and how

patient should be moved Determine nature of injury or illness and identify positive findings for

referral to medical professional

Examination Components

SIDEBAR: When to Refer for Further Evaluation (Emergency Room or Physician)

Patient fails to regain consciousness within few minutes

Cannot determine cause of unconsciousness, even if consciousness is regained

Observe abnormal vital signs

Note any signs of serious or limb threatening or life threatening injury or illness

Examination Components

Goals and Purposes

Rule out life threatening and serious injuries Determine severity of injury Determine most appropriate method of transporting

patient Perform a quick accurate examination and treat injury

to minimize effects Initial decisions among most critical

Incorrect decision can have dire or even deadly consequences

On-Site Examination

Determine conscious vs. unconscious Unconscious serious situation

Trauma or general medical condition

Rapid decision making Stay calm Take your time Be focused and efficient Good examination skills, knowledge and experience are

essential Err on the side of caution Stay within the scope of your practice and training Make all decisions with persons safety in mind

Goals and Purposes

Determine mechanism, location and severity of injury On site history: investigate chief complaint and problems that

are readily apparent and in need of attention Always watch to observe for mechanism but also ask patient

what happened Also ask bystanders if patient unconscious or mechanism is unclear

Ask questions regarding exact location of pain and severity of pain and other symptoms

Pain scale 1 to 10

More detailed history can be obtained during acute and clinical examination

Obtain a History

Observe patient movement ability and patterns Check for abnormal positioning of head, neck or

extremities Observe discoloration, deformity, swelling,

patients reaction, movement If suspect spinal injury, stabilize patients head

and neck and examine peripheral nerves for sensory and motor function

Head injury: Alert and Oriented x 4

Observe and screen

Observe for bony injury Deformity Palpation (feel) for fracture or dislocation

Observe for muscular and or ligament injury Palpation for defect ROM test Strength test Stress Test Special Test

Observe and screen

Patients with severe pain, first time injury of any severity, or poor tolerance for any injury observe for signs and symptoms of shock Pale, cool, clammy skin Rapid, shallow breathing Weak, rapid pulse Nausea, falling blood pressure

Treat immediately and transport to emergency medical facility

Monitor for Shock

If determine life threatening or serious injury refer patient for further examination and treatment Follow your emergency operating plan (EOP)

If immediate transport not necessary determine transport method off playing surface More detailed examination can occur on sideline or in

AT Room Rehearse and practice methods of transport and

implementation of emergency operating plan

Implement Immediate Action Plan

Communicate findings with staff, coaches, officials and other healthcare professionals

Provide detailed information to allow for appropriate care for athlete

Communicate in Site Examination Results

Follows the on-site examination

SINS: severity, irritability, nature, and stage of an injury

Determine more precisely the nature and severity so you can administer appropriate treatment, provide referral, or return athlete to participation

Acute Examination

History Observation Palpation Special Test

ROM Test Strength Test Stress Test Neurological and circulatory tests Functional tests Other Special Tests

Acute Examination

Subjective Segment How does the patient feel

Patients opportunity to describe injury or illness More detailed history from on site examination

Questions should not be leading Athlete may be able to recall information they could

not during on site eval. Athlete has calmed down and is less agitated

All pertinent medical information Past and present injuries

Acute Examination

Objective Segment What you can see or evaluate Swelling, discoloration, deformity Be careful not to perform test that may cause

more injury or pain Use common sense and information gathered

during subjective testing Best time to evaluate is immediately after injury

A.T. get the most accurate testing in first 10 minutes after injury before pain and swelling have developed

Acute Examination

General Principles of the Clinical Examination If injury not witnessed or is chronic,

examination may be broader and more detailed

Continuation of on site or acute exam or first encounter with athlete

Subjective Segment

Clinical Examination

Objective Segment Comparable sign

Negative response if tissue is not injured Positive response if tissue is injured

Reproduction of patients symptoms is called comparable sign

Bilateral Comparison Always perform all test bilaterally Understand purpose of the test and what is normal for

the patient

Clinical Examination

Observation Posture, movement patterns, Contour, alignment, discoloration and symmetry

Palpation Feel anatomical structures for pain, swelling, deformity, spasm, tissue

thickening, crepitus Superficial to deeper structures Bony to Soft tissue

Range of Motion AROM, PROM, RROM Quality and quantity of physiological and accessory movement End feels: abnormal end feels may be indicative of injury

Strength Isometric or Break test Strength test through ROM Grading scale of 0 to 5

Clinical Examination

Stress Tests

Special Tests

Neurological Tests Rule out brain, spinal, or peripheral nerve pathology Performed if you suspect nerve injury or if patient

symptoms include sensory deficits (radiating pain, tingling, burning, numbness, etc.,)

Sensory, motor and reflex responses Unilateral changes=nerve root or peripheral nerve

lesion Bilateral changes-central cord or brain pathology

Clinical Examination

Vascular Tests Examine integrity of vascular system Palpate pulses Check capillary refill distal to injury

If absent, weakness or disappears=medical emergency

Functional Tests Used only to when patient is ready to return to former

participation levels Determine patients ability to return safely and fully

resume all activities Increase patients confidence and readiness to return

Sidebar Page 198

Clinical Examination

HAVE A GREAT WEEKENDHOMEWORK??!!

Accurate and thorough documentation of your findings Legal standpoint Continuity of care Re-examining of injury

Follow HIPAA (Health Insurance Portability and Accountability Act) guidelines

Documenting the Examination