Principles of Examination

1. Principles of Examination Core Concepts in Athletic Training and Therapy Susan Kay Hillman

2. Objectives • 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 examina­tion. • 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.

3. Introduction • 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

4. Examination Components • 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

5. 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

8. On-Site Examination • 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

9. Goals and Purposes • 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

10. Obtain a History • 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

11. Observe and screen 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

12. 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

13. Monitor for Shock • 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

14. Implement Immediate Action Plan • 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

15. Communicate in Site Examination Results • Communicate findings with staff, coaches, officials and other healthcare professionals • Provide detailed information to allow for appropriate care for athlete

16. Acute Examination • 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

17. Acute Examination • History • Observation • Palpation • Special Test • ROM Test • Strength Test • Stress Test • Neurological and circulatory tests • Functional tests • Other Special Tests

18. 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

19. 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

21. Clinical 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

22. 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

23. 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

24. 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

25. 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

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28. Documenting the Examination • 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