An 18-year-old man is evaluated during a preparticipation physical examination for his college soccer team. He is asymptomatic. He describes no limitation in his exercise capacity, palpitations, syncope, presyncope, dyspnea, or chest discomfort. He has exercise-induced bronchospasm. His only medication is a budesonide-formoterol inhaler that he uses before exercise. He does not smoke, drink alcohol, or use any drugs. There is no family history of cardiac disease or sudden death.
Physical examination findings, including vital signs and cardiac auscultation, are normal.
Which of the following is the most appropriate test to perform?
A. Chest radiography
D. No testing is indicated
MKSAP Answer and Critique
The correct answer is D. No testing is indicated. This item is Question 87 in MKSAP 19's General Internal Medicine 2 section. More information about MKSAP is available online.
There is no indication for testing (Option D). Preparticipation physical examination is often required for adolescents and young adults before participation in organized sports. The goal of a preparticipation physical evaluation is to determine an individual's safe participation in sports, although studies have not found that the preparticipation screening examination prevents morbidity and mortality associated with sports. Advocates claim that it may detect conditions that predispose the athlete to injury or illness, which then may guide advice or intervention. The examination should not be a barrier to competitive sports participation, and unnecessary testing should be avoided owing to its attendant costs and unintended consequences, such as downstream testing for incidental findings. Mandatory components include evaluating for exertional symptoms, family history of premature or sudden cardiac death, and presence of a heart murmur. Routine testing beyond the history and physical examination is not necessary unless concerning symptoms and physical findings are uncovered. This patient has exercise-induced bronchospasm but an unlimited exercise capacity and no other concerning symptoms or physical findings. There is no indication for testing.
Chest radiography and spirometry (Options A, C) are not indicated for a preparticipation physical examination in a patient with either well-controlled asthma or exercise-induced bronchospasm, as is the case for this patient. The indications for these tests are the same as those in other patients, specifically a suspicion of pulmonary disease on the basis of symptoms or abnormal findings on pulmonary examination.
Echocardiography (Option B) is not indicated as a component of the preparticipation physical examination unless there is known or suspected cardiac disease. Although hypertrophic cardiomyopathy may very rarely present as sudden death in the young athlete, the prevalence of the disease is so low that routine echocardiography is not an effective screening strategy. Findings that would prompt echocardiography include exertional syncope; family history of sudden death; and physical findings suggestive of cardiac disease, including an unexplained murmur. This patient has none of these findings, and echocardiography is not necessary. An ECG is clearly indicated if the patient has unexplained syncope; palpitations; or a family history of sudden death that is suggestive of a congenital abnormality, such as long QT syndrome. Although some guidelines suggest routine ECG, the American College of Cardiology and American Heart Association do not.
- Routine testing beyond the history and physical examination is not necessary in the preparticipation physical examination unless concerning symptoms and physical findings are uncovered.
- Mandatory components of the preparticipation physical examination include evaluating for exertional symptoms, family history of premature or sudden cardiac death, and presence of a heart murmur.