Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Conditions that require treatment plan or restriction
Document related concepts
Transcript
Pre-Participation Exam Chronic Medical Conditions John Colston DO, MS Chief Resident Pikeville Medical Center Integrated Family Medicine/Neuromuscular Medicine Adapted from presentation by Jamie Varney, MD Chronic medical conditions • • • • • • Identified through history Identified through physical exam Relevance depends on type of sport Some require more evaluation Some may require medications Some may limit or exclude them from sports Most important slide • Each athlete is an individual • Each condition is unique • Clinical judgment is absolutely necessary Common medical conditions Cardiovascular conditions • • • • • • Pericarditis/myocarditis Valvular anomalies Hypertension Other structural defects/disease Irregular rhythms Vascular disease Adolescent Hypertension 1 • Normal • SBP and/or DBP < 90th percentile • Prehypertension • • SBP and/or DBP > 90th percentile but <95th percentile SBP > 120 or DBP > 80 • Stage 1 Hypertension • SBP and/or DBP > 95th percentile to 5 mmHg above 99th percentile • Stage 2 Hypertension • SBP and/or DBP > 99th percentile + 5 mmHg Hypertension • Should be screened for in all athletes • Ideally BP in both arms at rest with appropriate cuff size • Remember normal values are different for adolescents • Need three separate occasions with elevated BP to diagnose Hypertension • Systolic and/or diastolic ≥ 95th percentile is associated with higher risk for sudden death and complex arrhythmias • Not necessarily proven in younger population Hypertension • Evaluate for Comorbid disease • Evaluate for presence of secondary HTN • Review meds/ OTC/ supplements/ drugs caffeine/ETOH/tobacco that may cause HTN Hypertension Work-Up • • • • • • • • Renal Function Electrolytes CBC Renal US Glucose / Lipids EKG Echo Retinal exam 1 Secondary Hypertension • Suspect if : • • • • • Age < 10 Stage 2 HTN Stage 1 HTN with systemic signs Acute rise in BP over baseline No family History 1 Secondary Hypertension • Some Causes • • • • • • Medication Renal Disease Renal Artery Stenosis Coarctation of Aorta Obstructive Sleep Apnea Endocrine Disease • Thyroid • Cushing’s • Aldosteronism • Pheochromocytoma 1 Hypertension Treatment • Weight Loss/Exercise/ Decreased Sodium • Diuretics and beta-blocker prohibited by some governing bodies • Diuretic may increase fluid and electrolyte abnormalities • Beta Blockers may increase fatigue and decrease exercise tolerance • If treatment needed ACE-Inhibitors /ARB’s and Calcium channel blockers are usually first choice if not contraindicated Hypertension and Exercise 2,3 • Stage 2 HTN should not exercise until controlled • Stage 1 HTN with end organ damage should also be treated prior to exercise • Careful with strength training or any other high static sports • BP > 95th % will likely need a more complete evaluation • BP >90th % requires periodic monitoring Respiratory diseases • Asthma • Cystic fibrosis • Smoking Asthma Airway obstruction Typically reversible Airway inflammation Airway hyper-responsiveness Allergens Chemical irritants Viral infections Cold air Exercise Symptoms Wheezing Chest tightness Shortness of breath Cough Allergic rhinitis and urticaria occur frequently as comorbid conditions Diagnosis Symptoms consistent with diagnosis Spirometry • FEV1 < 80% • FEV1/FVC < 65% • Reversibility with short acting Beta agonist FEV1 improvement > 11% Treatment Education • Patient, family, coaches, teammates Environmental control • Avoid allergens Medication • Stepwise approach Exercise Induced Bronchoconstriction (EIB) 6 Typically occurs after 5-10 minutes of strenuous activity Generally broncodilation during exercise Bronchoconstriction typically last 30-60 minutes Followed by refractory period (up to 4 hours) EIB Prevalence 4 7-20% of general population6 Up to 80% of those with asthma have EIB Up to 40% of those with allergic rhinitis have EIB Diagnosis of EIB May give trial of treatment if mild/moderate If suspected may do exercise test • • • • Rested and avoid medications prior 6-8 minutes on treadmill 85 % predicted heart rate Spirometry before and after exercise 1,3,5,10 and 15 minutes post4 • Positive test FEV1 drops 20% (15% in children)6 FEF25-75 > 35% drop4 Peak flow rate > 10% drop4 May also try other provocation tests Prevention of EIB Warming up • 30-60 minutes prior • May induce symptoms but then get refractory period Cooling down • May decrease episodes Nasal breathing Covering mouth in cold weather Treatment of EIB Assess for underlying asthma and treat appropriately If solely EIB then may try prophylactic short acting Beta agonist 10-15 minutes prior If frequent exercise through day may need long acting Beta agonist Mast cell stabilizers and leukotriene receptor antagonist may also be beneficial as adjuncts Inhaled steroid not as effective unless has underlying asthma/ inflammatory component • If so must have 2-4 weeks treatment before notice difference Treat allergies if indicated Endocrine diseases • Diabetes • Thyroid Diabetes Fasting glucose > 126 on two occasion Random glucose > 200 and symptoms Fatigue, polyuria, polydipsia, polyphagia 2 hr post prandial glucose > 200 with tolerance test Evaluation of Diabetic Athlete • • • • • Duration (? > 10 yrs) Level of Control • • • • • • • • HBA1C Hospitalization (DKA) Hypoglycemic episodes Medication (?Insulin) Sequelae Retinal exam Neurologic exam Skin condition Nephropathy (Serum creatinine, Urine protein) Consideration of risk for Coronary Artery Disease Identification ? Medic Alert bracelet 5 Activity Selection • Should avoid activities in which hypoglycemia could be life threatening • • • Scuba Parachuting Rock climbing • should discuss lower intensity activity • • Consider cycling or water activity Proper shoes and frequent exams/lubrication • Underlying CAD or untreated retinopathy • Avoid foot trauma if have neuropathy • Consider timing of activity as more prone to hypoglycemia in evening Initiation of Activity • Consideration of stress testing • Known CAD or risk factors • Age > 35-40 • Duration of Diabetes > 10-25 years • Gradual introduction of activity to allow for adjustment of meals/insulin • Should keep detailed diet/medication/exercise diary to allow for adjustments Meal Planning • Meal should be eaten 1-3 hours prior to any training/event • Pre-exercise snack high in complex carbs • Prolonged exercise should include 30-40 grams of carbs (15-20 for children) every 30 -60 minutes • Plan to replace carbs within 30-60 minutes of exercise • Increase caloric intake for 12-24 hours post exercise • Exercising in cold may require more calories • Encourage adequate fluid intake Glucose Monitoring • Before, during and after prolonged exercise • Perhaps > 6 times a day • Late night or 3AM glucose may be necessary for prolonged exercise if not routine activity • If glucose > 300 or > 250 with ketones should avoid activity • May lead to ketosis • May also increase risk of dehydration • If glucose <100 should eat snack prior Insulin Pump • Allows more flexibility of training/meal time • May turn off and remove 1 hour before event • May then need monitoring and bolus during prolonged event • Be aware of possibility of dislodgement • Antiperspirant may decrease sweating Hypoglycemia Headache Hunger Dizziness Sweating Tremors Alteration in consciousness Pre event rise in stress hormones can mask or mimic symptoms Hypoglycemia • Mild (50-70) with mild symptoms • • • Fruit juice Oral glucose tablets Supplement with complex carbs and protein • • • • Don’t delay treatment to check glucose Glucagon 1 mg SubQ or IM Oral or IV glucose Nothing orally if compromised ability to protect airway • Severe (<40) with alteration in consciousness Diabetes Summary • • • Exercise has many benefits for patients with diabetes Several high level athletes perform well with diabetes Individual planning/ adjustment by patient and physician is necessary to find right training/meal/medicine regimen Education about disease / control / symptoms are a vital part to any exercise program for diabetics Others should be educated in how to recognize symptoms of hypo/hyperglycemia and how to manage an emergency situation Steps should be made to ensure availability of emergency medicines • • • • • Glucagon Glucose tablets Neurologic conditions • Cerebral palsy • Seizure disorder • Headaches Seizure Disorder and Sports 4 • Individual plan based on • Control • Low risk if no seizures after 1 year on meds or 2 years off meds • Type • Focal lower risk than generalized • Medication effects • Reaction time/sedation • Precipitating factors • Hyperventilation • Risk of activity • Cautious of contact activity Seizure Disorder and Sports • Restrict from • • • Boxing (regardless of control) Scuba Other high risk sports as needed • Close supervision or restriction • • • • • Swimming/diving Archery /riflery Weight or power lifting/ strength training Sports involving heights Gymnastics 4 High Risk Sports with Seizures • • • • • • Boxing Diving Scuba Parachuting Rock climbing Hang Gliding • • • • • • Aviation Downhill skiing Motor racing Ski Jumping Rodeo Cycling Rheumatologic conditions • Juvenile rheumatoid arthritis • Lupus • Raynaud phenomenon Hematologic/ID conditions • • • • • Sickle cell disease HIV Hepatitis Cancer Bleeding disorders Female Athlete Triad • Disordered eating • Altered menstruation • Abnormal bone mineralization Psychiatric conditions • • • • Eating disorders Anxiety Depression ADD/ADHD Acute illness • Fever • GI complaints – Nausea/vomiting – Diarrhea • URI • UTI • Skin infections References 1. 2. 3. 4. 5. 6. Mattoo, T. , UpToDate. Definition and diagnosis of hypertension in children and adolescents. 8-2007. AMERICAN ACADEMY OF PEDIATRICS: Medical Conditions Affecting Sports Participation. PEDIATRICS Vol. 121 No. 4 April 2008, pp. 841-848. 36th Bethesda Conference: Eligibility Recommendations for Competitive Athletes With Cardiovascular Abnormalities. Journal of the American College of Cardiology Vol. 45, No. 8, 2005. Mellion, M. et al. Team Physician's Handbook 3rd edition. Hanley & Belfus Inc. 2002. Safran, M. et al. Manual of Sport’s Medicine. Ch. 5 Endocrinology. Lippincott-Raven. 1998. O’Byrne, P. UpToDate. Exercise-induced Bronchoconstriction. 9-2007.
