Medical Evaluation of Athletes: Medical History and Physical Examination

Abstract

Medical history and physical examination still represent the basis of medical evaluation of athletes. Although the accuracy of detecting relevant underlying cardiovascular disease is only moderate, “red flag symptoms” as syncope, exertional chest pain, shortness of breath or palpitations should raise suspicion and prompt further assessment to complete the overall clinical image. Positive family history is a strong marker for genetically determined increased risk and further supports clinical suspicion. An accurate physical examination may efficiently reduce the number of unnecessary further examinations (e.g. by cardio-pulmonary auscultation) or enables to prompt specific and tailored further assessment of an athlete. Apart from current, highly sophisticated technical opportunities for the detection and diagnosis of cardiovascular disease, still the personal and in-depth clinical assessment of an athlete, performed by an experienced and dedicated sports physician, represents the basis of optimal medical care. This initial approach allows an intuitive interpretation based on the accurate assessment of the athlete’s personal, systemic and family history, as well as a focused physical examination. Nevertheless, as recent data impressively suggests: In the setting of primary screening to prevent sudden cardiac death in young athletes medical history and physical examination have a low yield of less than 50% yield to detect underlying disease in this population, and an ECG should be added.

Review

1.1 Questions

• 1. A 26-year old male leisure endurance athlete reports recurrent lightheadedness after brisk changing from a sitting to a standing position (i.e. after a meal). Two days ago, he experienced a syncope during his regular training (jogging of moderate intensity). The syncope appeared unheralded and the patient does not remember any warning symptoms and denied amnesia. However, due to his syncope he suffered from bruises on the knees, elbows and the forehead. What is your suspicion after knowledge of the patient’s history?

• 2. You see a 19-year old asymptomatic male basketball player for routine pre-competition examination. During physical examination some clinical findings are suspicious. The skin on his back shows multiple slightly blue “scar-like” striae and during auscultation you can detect a mid-systolic click with a moderately loud tele-systolic murmur. What is your suspicion and what tests would you add?

• 3. A 54-year old marathon runner asks for consultation due to massive headaches, particularly during exercise, slowly decreasing vision and with a recent laboratory test which exhibited moderate renal failure. The patient’s personal history is normal, and his family history only highlights systemic hypertension of his father. Physical examination shows normal findings with unsuspicious auscultation and normal blood pressure measurement (135/85 mmHg on both arms in supine position). In an additional exercise test the athlete performed well without abnormal ECG changes during exercise but headache and pronounced increase of blood pressure (up to 240/110 mmHg until exhaustion). What are your thoughts and what examination should be added to confirm your suspicion?

1.2 Answers

• 1. The patient’s history of the syncopal event is highly suspicious for cardiac/arrhythmic etiology. This is due to four classical points: The syncope occurred during exercise and without any prodromal symptoms. Amnesia has been denied but he suffered from (minor) injury (bruises) due to the syncope.

• 2. Skin striae are highly suspicious for connective tissue disease and are part of the so-called “Ghent Criteria” characterizing Marfan Syndrome. Thus, the next clinical step would be to complete these clinical criteria. The auscultatory findings are classical for mitral valve prolapse which is also part of the Ghent criteria and frequently seen in patients with connective tissue disease. To confirm this suspicion transthoracic echocardiography should be performed. It is also crucial, particularly in contact sports, to assess the diameter of the ascending aorta as aortic aneurysm (and possible dissection) may occur as another clinical finding in these patients.

• 3. The patient’s history and physical examination raises suspicion for “masked hypertension”. Systemic hypertension is genetically linked (positive family history) and may clinically appear with headaches. Ocular and renal damage can also be explained by longstanding hypertension. Although “office” blood pressure measurements were normal “masked hypertension” is most likely as up to 40% of athletes with exercise hypertension show underlying (often undetected and masked) hypertension. Thus, in a next diagnostic step ambulatory blood pressure monitoring (24-h automatic device or self-measurement at home) should urgently be recommended.