Introduction to Medical Conditions

At the completion of this chapter the reader should be able to do the following:

1. Discuss the basic differences between orthopedic and general medical assessment

2. Appreciate the athletic trainer as a health care provider in the recognition, referral, and disposition of medical conditions

3. Use proper communication as a valuable tool in the general medical assessment of the physically active person

4. Apply principles of disease transmission prevention

5. Implement and use the regulations and laws that govern care and privacy of patients

6. Apply CPT and ICD codes to medical conditions

7. Explain the purpose of the preparticipation examination (PPE) for athletes, and identify the medical organizations that provide guidelines

8. Differentiate between the office visit and station-based PPE

Introduction

This textbook is designed for the health care provider who works with a physically active population. The name of that provider is interchanged throughout the text from athletic trainer to health care provider to clinician. By using interchangeable titles, the reader may identify with the role played in identifying and treating the various conditions outlined in this text. Athletic training programs across the country have tended to concentrate on the knowledge and skills used for orthopedic assessment and provide a systematic overview of athletic injuries. Emphasis is on students learning how to follow the history, inspection/observation, palpation, special tests (HIPS/HOPS) plan in taking a history, and determining what decisions to make regarding return to play. In these largely orthopedic situations, an injury is usually obvious because it has been witnessed by the athletic trainer, and a thorough history may shed light on the type of damage sustained.

Unlike the typical athletic injury, medical conditions are not always immediately apparent in an assessment. This book is a comprehensive resource for health care students and providers that includes medical conditions by body system, their mechanism of acquisition, signs, symptoms, referral, differential diagnoses, treatment, and return-to-participation criteria. Its purpose is not only to provide information but also to help the reader develop a framework for decision-making. We assume that the reader is versed in basic human anatomy and physiology and can build on that knowledge. The text also includes associated chapters on diagnostic imaging and tests, pharmacology, psychological and substance abuse disorders, and special populations.

This introductory chapter provides an overview of the basic information necessary for understanding subsequent chapters. It reviews the role of the athletic trainer in the diagnosis and treatment of medical conditions, the importance of effective communication, the prevention of disease transmission, legal concerns, and the administrative aspects of the preparticipation examination (PPE).

The Role of the Athletic Trainer in General Medical Concerns

Although this text is not exclusively for certified athletic trainers, he or she is often the person who has the first opportunity to identify a medical issue for an athlete. A brief understanding of education and training of certified athletic trainers is warranted for the reader to appreciate their role with the physically active patient (Box 1-1). An athlete who is feeling ill commonly turns to the athletic trainer because the athletic trainer is the most accessible health care provider. The athletic trainer working with a team has established a rapport with the athletes and is familiar with their previous medical history and normal performance. This may allow the athletic trainer to detect a condition that otherwise might go unnoticed. The athletic trainer working with college or professional teams is also responsible for the health care of the entire team while on the road. Although many medical problems are orthopedic, the conditions an athletic trainer encounters also can include infections, colds, and other maladies, which need to be identified and properly treated in order for the athlete to continue to participate in sports at optimal levels.

BOX 1-1 CERTIFIED ATHLETIC TRAINERS (ATs)

A certified athletic trainer is an allied health care provider with a minimum of a Bachelor’s degree from an accredited (Commission on Accreditation of Athletic Training Education; CAATE) athletic training education program. ATs work with physicians in a number of settings, most traditionally in high school, college, professional, and Olympic sports. They can also be found in clinics, hospitals, and industry. Accredited programs require a minimum of the following content areas:

• Anatomy, physiology, exercise physiology, biomechanics

• Orthopedic clinical examination and diagnosis

• Pharmacology

• Medical conditions and disability

• Therapeutic modalities

• Risk management

• Health care administration

• Professional development and responsibility

• Acute care of injuries and illnesses

• Psychosocial intervention and referral

• Four semesters of clinical experience with different populations and various levels of risk, including a general medical experience

• At least 75% of the student’s clinical experiences must be with an AT

• ATs must pass a national certification examination (from the Board of Certification [BOC]) on graduation

• Most states require state licensure or registration to practice athletic training in that state

In 1999 the National Athletic Trainers’ Association (NATA) first identified a new series of educational competencies and clinical proficiencies that focused on several areas not previously part of the athletic trainers’ educational process ¹: pathology of injury and illness, pharmacology, and general medical conditions and disabilities. These competencies and proficiencies have become part of athletic training educational curricula throughout the country and have been expanded in subsequent professional requirements.²

The athletic trainer has also taken on a greater role in the general health care of the physically active, thereby requiring greater emphasis on the clinical evaluation and diagnosis of general medical problems. This is a result, in part, of advances in medical science that enable athletes with medical conditions, who would formerly have been excluded from participation, to compete at the highest levels. It also is the result of expanding employment opportunities for athletic trainers. Athletic trainers are now employed in corporations, industries, inpatient hospitals, outpatient clinics, and other nontraditional workplaces as well as the traditional realms of interscholastic, intercollegiate, and professional sports.3,4 Athletic trainers also serve as physician extenders in many states and see a more diverse population, including the pediatric athlete (Figure 1-1), physically active mature and older adults, as well as those with physical impairments.⁵

FIGURE 1-1 Physically active people who are involved in a variety of activities may require the support, knowledge, and skills of an athletic trainer. (Courtesy Tam Stainbrook.)

Learning more about medical conditions and their assessment is therefore a part of the comprehensive educational process of the athletic trainer. A recent study on the continuing educational needs of athletic trainers revealed that staying abreast of the latest techniques and continuing the learning process throughout their careers were some of the most important reasons cited for completing continuing education.⁶ The athletic trainers included in this study expressed a desire to obtain information about general medical conditions more frequently than other orthopedic conditions because those conditions had been well covered previously in the athletic training curricula.⁶

Communication

Because the medical examination is largely concerned with symptoms, the nature of questions asked when acquiring a health or illness history from an athlete is just as critical as the information gained from them. One way to improve this dialogue between the practitioner and the athlete is to ask open-ended questions, such as “Why have you come to see me today?”

The health care provider can also facilitate and encourage communication by slightly leaning toward the patient, maintaining eye contact, having an open posture, repeating key words the athlete uses, and using simple phrases for encouragement, such as “go on” or “mm-hmmm.”⁷ Being empathetic—for example, “that sounds difficult”—and allowing pauses that give the athlete time to add to comments reassure the patient that the clinician is listening carefully (Figure 1-2). Asking about the patient’s feelings associated with symptoms is also appropriate in medical assessment. Last, a good practitioner can summarize and interpret the athlete’s comments by saying, “I hear you say…” rather than empathetically injecting words or opinions into the conversation during the subjective review of symptoms.⁷

FIGURE 1-2 Athletic trainers use an open posture to facilitate discussion when talking with athletes. Note that the athletic trainer is sitting down rather than standing above the athlete and is leaning forward in a posture that encourages discussion and questions.

Along with verbal communication skills, the health care provider must be sensitive to cultural, ethnic, and gender issues when working with a patient. In certain cultures, touching is impermissible because it violates a personal space. Knowing the patients or asking them if they are comfortable is a good beginning. A person will more freely give medical history if the health care provider uses a quiet and private place to communicate.

The athletic trainer must always be aware of the surroundings when communicating with an athlete about a medical issue. When a practitioner assesses a patient of a different gender, a person of the athlete’s gender should be present in the room as well. Using proper draping and maintaining privacy during physical examinations or discussion of private topics are critical.

Communication with Health Professionals

Federal regulations allow health care providers to exchange information in the medical care of a given patient. This discussion can occur after the patient signs permission under the Health Insurance Portability and Accountability Act (HIPAA). Athletic trainers should be familiar with medical terminology so that they can discuss medical conditions on the same level as other health care providers.

KEY POINTS

SIGNS AND SYMPTOMS

Although generally used together when assessing a medical condition, signs and symptoms are not synonymous.

• Sign refers to something that the athletic trainer sees or feels, such as a temperature, respiration, heart beat, and blood pressure.

• Symptom (Sx) refers to something the athlete feels, such as a headache, nausea, dizziness, or pain.

Because some of these communications may be in written notes, athletic trainers need to understand standard abbreviations as well. Appendix A lists many common abbreviations that relate to medical care. Table 1-1 lists terminology used to describe medical conditions and situations that are used throughout this text.

TABLE 1-1

Common Medical Terminology

Term	Definition
Adventitious	Coming from an external source; occurring spontaneously
Afebrile	Without a fever; also apyretic
Biopsy	Removal and examination of tissue
Comorbid	Two or more possibly unrelated medical conditions existing at the same time
Constitutional	Relating to the body as a whole
Erythema	Redness of the skin brought about by capillary dilation
Febrile	Having a fever
Malaise	A general feeling of discomfort or uneasiness; often the first symptom of an illness or infection
Morbidity	Consequences of a given illness
Mortality	Death from a particular illness or disease
Palliative or supportive	Reducing the severity of an illness or treatment of disease without curing it
Prodromal	Preillness symptoms
Purulent	Pus filled
Sequela, sequelae	A condition occurring as a consequence of a given illness or disease
Suppurative	Pus forming

Prevention of Disease Transmission

Everyone who works in the health care field appreciates the need to prevent disease transmission. Protection from infection and maintaining a sanitary environment are two critical elements in caring for patients with illnesses. Another prevention technique is immunization from specific diseases by vaccine. Chapter 15 discusses vaccination as well as established standards for preventing the spread of disease and illnesses.

Occupational Safety and Health Administration

The Occupational Safety and Health Administration (OSHA) is an organization that sets standards to protect health care workers and their patients. OSHA standards apply only to established relationships between employers and employees and do not extend federal protections to students.⁸ However, students who could potentially be exposed to hazardous waste in facilities where they practice or observe should follow the safety standards set forth by OSHA, receive training, and have ready access to precautionary materials, such as barriers and proper disposal containers.

OSHA has a right to inspect any facility under its auspices without prior notification, and it has the power to suspend or shut down a facility, as well as impose hefty fines for noncompliance with standards.9,10 The most familiar OSHA requirement affecting athletic medical care concerns the blood-borne pathogen (BBP) standard. Athletic trainers must be intimately familiar with this standard because many athletes are at risk of open wounds in the course of their activities and subsequently have potential for the transmission of infection.

OSHA Standards for Blood-borne Pathogens

The BBP standard is intended to safeguard health care workers against hazards resulting from exposure to infectious body fluids and covers anyone who could reasonably anticipate having occupational exposure to infectious waste (e.g., blood). Included in this standard is a description of how to formulate an individualized institutional or setting exposure control plan. A written document outlines steps to take and specific people to call in the event of an exposure to infectious waste. An exposure may range from a needle stick to having blood spilled onto intact skin. All health care workers must have an operating knowledge of their employer’s plan, access to personal protective equipment, BBP training, and knowledge about who to contact should an exposure occur.¹¹

The BBP standard uses the phrase “universal precautions” to emphasize that all human waste should be treated as if it were infectious and that health care workers and patients must be protected in every situation in which they might be exposed to body fluid, including contact with mucous membranes in the eyes, mouth, or nose; genital secretions; or blood. Any sharp object that may be contaminated with infectious waste, such as needles, scalpels, or broken glass, is also considered potentially hazardous material.¹¹ Box 1-2 has suggestions for handling infectious waste.

BOX 1-2 HANDLING INFECTIOUS WASTE

• All infectious waste must be placed in a closeable, leakproof, approved container for storage, transporting, or shipping.

• An OSHA-approved plan for proper disposal of infectious waste bags and sharps units must be on hand and followed.

• Gloves must be worn when personnel handle infectious laundry.

• Laundry contaminated with infectious waste must be separated from other materials to be cleaned.

• Personal protective equipment (gowns, masks, gloves) shall be properly disposed of before leaving the treatment room or on contamination.

• While wearing gloves, personnel may clean bloodstains on material (uniforms, towels) with hydrogen peroxide in cold water and immediately rinse.

• Only red hazardous waste bags should be used to dispose of infectious materials.

• In the absence of antibacterial soap and running water, personnel should use antibacterial wipes or gels to sanitize hands often.

• Personnel should avoid putting hands to face (eyes, nose, mouth) when around ill patients or working with infectious waste.

Data from Klossner D, editor: 2009-10 NCAA sports medicine handbook, Indianapolis, 2009-2010, National Collegiate Athletic Association; U.S. Department of Labor Occupational Safety and Health Administration: Bloodborne pathogens—1910.1030. Available at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051. Accessed May 2010; Howe W: Preventing infectious disease in sports, Physician Sports Medicine 31(2):23-29, 2003.

Barriers to Blood-borne Pathogens

Barriers are devices worn to protect both the health care worker and patient against the spread of disease. The traditionally accepted barrier is latex gloves, but OSHA also requires access to face and eye protection, gowns, and mouthpieces for resuscitation.11,12 Health care workers with allergies to latex must be provided with an alternative material suitable as a barrier against transmission of BBPs.

All health care workers must have ready access to barriers that fit properly in order to retard infection from hazardous materials. Ideally, soap and water are the best methods to clean hands before and after glove use (Box 1-3). If soap and water are not readily available, commercial disinfectant gels or single-use wipes can sanitize hands (Figure 1-3).

BOX 1-3 CORRECT GLOVE USE

1. Thoroughly wash all aspects of both hands and fingers, with liberal use of an antibacterial soap and plenty of water.

2. Dry hands with a disposable single-use hand towel.

3. Apply gloves without touching the external surfaces of the gloves.

When the procedure requiring gloves is complete:

4. Use the gloved index finger and thumb of one hand; gently pinch the glove at the wrist and pull toward fingertips.

5. Invert the glove, and remove all but index finger and thumb.

6. Repeat the procedure with the second hand, inverting the glove as it is removed.

7. Fold gloves inside out and dispose of them in a red (OSHA-approved) bag.

8. Thoroughly wash and dry hands as described previously.

Workers should remove and properly dispose of soiled barriers before leaving the treatment area. Brightly labeled red infectious waste bags are the most common means of storing such waste until it can be disposed of per OSHA protocol. These bags must be contained in a sturdy, leakproof container with a lid and located in an easily accessible area for all to use.

Sharps containers are specially built units that have one-way valves (Figure 1-4) and are used to accommodate sharp instruments such as needles and scalpels that may have infectious materials on them. These containers should never be opened or overstuffed. Intercollegiate sports medicine guidelines require that all necessary materials, such as barriers, bleach, waste receptacles, and wound coverings, comply with universal precautions and be available to all health care providers.¹²