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