This is the time of year I get inquiries about pre-season medical check-up’s. I’ve written previously on this subject, including how to find a doctor in your area. I’m frequently asked, though, exactly what type of check-up is needed. Here’s my take.
Today, let me focus specifically on adult male recreational athletes. I’ll deal specifically with women in a follow-up post.
First, in terms of screening adult recreational athletes for sports-related heart risks, adult men are the group where we might expect to get the most “bang for our buck.” We know that men account for the vast majority of victims of sports-related sudden cardiac death, not only in large populations involving all types of sports, but also in very specific sports such as long-distance running and triathlon. There’s a very real reason to be looking for hidden heart disease in male athletes.
Second, in contrast to women, “healthy” men in their 20’s, 30’s, 40’s, and even 50’s are unlikely to make periodic visits to the doctor (except for injury) and very often do not have a current primary care provider (PCP). It may have been years—perhaps back to high school or college—that many men last had a complete physical exam in some context other than for a musculoskeletal injury, which typically requires a rather narrow focus. As a result, there’s often been little opportunity for discussion between adult male recreational athletes and a healthcare provider about any heart risks associated with sports participation.
Let me share how I would approach a pre-season check-up for an adult male recreational athlete who does not already have a PCP….
Although I’m a heart specialist, here I would need to put on my generalist hat to make the most of the encounter.
I would have 3 goals:
- Identify any cardiovascular conditions that required further evaluation or treatment as well as any risk factors for future heart disease that could (and should) be modified;
- Make an assessment of the patient’s cardiovascular risks of exercise in order to offer appropriate advice about safe forms of exercise; and
- Identify any non-cardiovascular conditions that required follow-up with another doctor.
Before the Office Visit
One of the most important parts of a check-up is sharing what we call the “medical history,” an accounting of everything medically-related that’s already happened to a patient. This would include:
- Past medical history (childhood illnesses, adult illnesses, surgical or other procedures)
- Medications and supplements
- Family history (illnesses that run in the family)
- Personal and social history (smoking, drinking, sexual activity and habits, substance use/abuse, work history, travel history)
- Review of symptoms (yes/no answers to a long list of questions about current symptoms).
In addition, I would also want to collect information about insurance coverage, the names and contact information for any other current and previous medical providers, and an outline of an athlete’s current exercise habits.
Depending upon the complexity of a patient’s situation, gathering all of this information could be rather time-consuming. So, in order to make the most of our available face-to-face time at the upcoming office visit, I find it helpful to collect as much of this information as possible well ahead of the office visit. I like to use 2 forms:
- A general purpose medical history form such as the Health Care Consumer Questionnaire.
- American Academy of Family Physicians Preparticipation Physical Evaluation forms. These forms are used ordinarily for secondary school-based screening programs, but I am fond of the first page of the History Form, which asks a series of questions (#5 through #16) related specifically to heart risk. I ask patients to complete items #1 through #51 on the first page and to discard the other pages.
When I’ve received these completed forms, I would review them and consider the possible need to gather additional information ahead of the office visit such as:
- records from other physicians or hospitals
- results from any heart-related diagnostic tests that may already have been completed (eg, ECG, chest x-ray, echocardiogram, Holter monitor, stress test, laboratory tests, pulmonary function tests, carotid Doppler studies, coronary calcium scoring CT scan).
Lastly, I would make a determination about any new diagnostic testing that may be helpful on the day of the office visit and schedule those tests, if any, for the morning of the office visit. If I think such testing will be helpful, I would have a telephone call with the patient ahead of the visit to explain the need for these tests.
At the Office Visit
I would plan for an office visit of approximately 45 to 60 minutes.
The first portion of the office visit is devoted to an interview. I generally spend half of the visit time on the interview. We often say that the medical history provides 80%+ of the clues to diagnosis.
First, I ask what motivated the patient for wanting the visit. There are many possible motivations. Next, we would have a chance to review the information that had already been provided about the patient’s medical history. I would take the time to clarify and better understand anything in the history that was specifically related to the heart. We would focus on those history items and on any symptoms related to exercise. I would finish by asking the patient if there were any additional, specific concerns that we should address at this visit.
The second portion of the office visit is devoted to a physical exam. Here, I would offer a complete, head-to-toe physical exam, but with special emphasis on the cardiovascular system. The exam would include:
- Measurement of the height, weight, and vital signs (blood pressure, heart rate, respiratory rate, temperature)
- Screening neurologic exam
- Examination of the head, neck, ears, eyes, nose, and throat
- Respiratory exam
- Cardiovascular exam (heart, carotid arteries, abdominal aorta, arteries of the arms/legs)
- Abdominal exam, including check for hernias
- Genito-urinary exam
- Rectal and prostate exam, in men older than 40 years
- Examination of the skin
The third portion of the exam is devoted to a discussion, or wrap-up. Here, we would discuss my findings from the medical history and the physical exam and my assessment of the patient’s overall and heart health.
For the majority of patients–those who do not have any heart-related symptoms or any abnormal physical exam findings–we would spend some time discussing the utility of screening tests such as ECG, echocardiogram, laboratory testing (eg, fasting glucose, fasting serum lipid levels), or stress testing, along with the advantages, disadvantages, and potential costs. Together, we would decide if any of these tests would be helpful. There is a place for such screening tests, but only with thoughtful discussion first.
For other patients, we might identify some new heart-related condition–or at least the possibility of one. As examples, we might find that the blood pressure is elevated or note the presence of a heart murmur. In this situation, we would talk about what sort of diagnostic tests might be needed to further clarify a problem and perhaps what treatment(s) would be needed for any conditions we discovered. Needless to say, there are many potentially useful tests, depending upon the patient’s circumstances, so we won’t go into detail here. In the case of potential inherited disorders, we might need to consider evaluating other family members as well.
In either situation, if additional testing were needed we would make a plan for getting those tests completed. We would also plan for how I would share those results with the patient (eg, by telephone or during a follow-up visit). I would ordinarily make plans to visit with the patient again to discuss the results of any important testing and to resume with our wrap-up once all of the important information was at hand. If more specialized heart care were needed, I would discuss referral to the appropriate specialist (eg, general cardiologist, electrophysiologist, interventional cardiologist, specialist in congenital heart disease) and, in some cases, I would turn over the patient’s care to that specialist.
Next, we would discuss how the patient’s overall and heart health related to his/her plans for exercise and sports participation. Together, we would settle on a list of activities that would be “safe” and, likewise, settle on a list of any activities that should be avoided. We would talk about potential warning signs of heart troubles and how to be vigilant for these. If the patient required a “doctor’s letter” or some sort of pre-participation form to be completed, we would go over that form together and review its requirements. I often complete such letters or forms and return them to the patient by mail sometime after the visit.
We would then make an inventory of any other medical problems (that were not heart-related) that needed follow-up and work together to settle on an appropriate action plan. Examples of such medical problems could include: colon cancer screening in men older than 50 years, that would require a gastroenterologist visit; eyesight troubles that might best be evaluated by an ophthalmologist; periodic screening for sexually transmitted illnesses, which might best be accomplished by a primary care physician; dental care which would best be provided by a dentist; and depression, that might best be evaluated by a psychiatrist. The list of possibilities is virtually endless; this is why there can be tremendous value in having a PCP.
Before we finish the wrap-up, I would take time to have a discussion about any questions or concerns the patient brought. I usually suggest that patients bring a written set of questions that we can answer these one by one.
Finally, I would make a recommendation about when the patient should next be seen for another check-up. For “healthy” patients–those without chronic medical conditions that require monitoring–I generally suggest a check-up every 3 years for men <40 years old, every 2 years for those 40-50 years old, and every year thereafter.
- Spring Checkup
- How to Find a Doctor (for Athletes)?
- Who Needs a Doctor?
- Five Questions for Your Doctor