What questions and evaluations should be included in a sports physical for a 19-year-old with a history of possible asthma, diabetes, or heart problems, and current medications, to assess their readiness to participate in athletic activities?

Sports Physical for a 19-Year-Old: Essential Questions and Evaluations

For a 19-year-old athlete, you must conduct a structured cardiovascular and musculoskeletal screening focused on detecting life-threatening conditions, particularly occult cardiac disease, while addressing specific risk factors related to asthma, diabetes, and cardiac history. 1, 2

Personal History: Critical Questions to Ask

Cardiovascular Symptoms

• Ask specifically about exertional chest pain, pressure, tightness, or discomfort during physical activity 2, 3
• Inquire about any episodes of unexplained syncope or near-syncope, particularly during or immediately after exercise 2, 4
• Evaluate for excessive dyspnea, unusual fatigue, or palpitations that seem disproportionate to the level of exertion 2
• Determine if there has been any prior recognition of a heart murmur or elevated blood pressure 2

Prior Medical Restrictions and Testing

• Ask whether the athlete has ever been restricted from sports participation or told they have a heart problem 2
• Document any previous cardiac testing (ECG, echocardiogram, stress test) ordered by any physician 2
• Inquire about history of concussions or neurologic symptoms 5

Medication and Substance Use

• Document all current medications, particularly those for asthma (bronchodilators, inhaled corticosteroids), diabetes (insulin, oral hypoglycemics), or any cardiac conditions 6
• Screen for use of nonsteroidal anti-inflammatory agents, which are common among athletes 6
• Ask about use of stimulants, including prescription medications for ADHD, as these can affect cardiovascular function 6
• Inquire about any performance-enhancing substances or supplements 6

Asthma-Specific Questions

• Determine frequency and severity of asthma symptoms, particularly exercise-induced bronchospasm 6
• Ask about recent exacerbations, emergency department visits, or hospitalizations
• Assess adequacy of current asthma control and medication compliance 6

Diabetes-Specific Questions

• Document type of diabetes (Type 1 vs Type 2), duration, and current management 6
• Ask about history of hypoglycemic episodes, particularly during or after exercise
• Inquire about presence of any diabetic complications (retinopathy, neuropathy, nephropathy) 6

Family History: Essential Screening

A thorough family history is critical and often reveals more than the physical examination alone. 2, 4

• Ask about premature sudden death (before age 50) in any family members, particularly if unexplained or attributed to heart disease 2
• Inquire about disability from heart disease in close relatives under age 50 2
• Screen for family history of specific conditions: hypertrophic cardiomyopathy, dilated cardiomyopathy, long QT syndrome, other channelopathies, Marfan syndrome, or clinically significant arrhythmias 2
• Ask about family history of hypertension, premature cardiovascular disease, or diabetes mellitus 6

Physical Examination: Focused Assessment

Cardiovascular Examination

• Perform cardiac auscultation in BOTH supine/sitting AND standing positions to identify dynamic left ventricular outflow tract obstruction characteristic of hypertrophic cardiomyopathy 1, 2
• Assess bilateral femoral pulses to exclude aortic coarctation 1, 2
• Measure blood pressure in the sitting position, preferably in both arms 2
• Look for physical stigmata of Marfan syndrome (arm span exceeding height, pectus deformity, arachnodactyly, lens dislocation) 1, 2

Musculoskeletal Examination

• Evaluate spine for scoliosis or other abnormalities 5
• Assess joint stability, range of motion, and strength in all major joints 5
• Screen for previous injuries that may predispose to re-injury 3

Additional Systems

• Perform visual acuity testing 7
• Assess for signs of poorly controlled diabetes (acanthosis nigricans, signs of neuropathy) 6
• Evaluate respiratory function and listen for wheezing if asthma history present 6

Laboratory and Diagnostic Testing

Routine Screening (Not Recommended)

Routine ECG, echocardiography, blood work, and urinalysis are NOT recommended for asymptomatic athletes with normal history and physical examination. 3, 4 This represents a key difference from some international guidelines but reflects the U.S. consensus approach.

Indicated Testing Based on Risk Factors

For Hypertension (if BP elevated on screening)

• Obtain fasting lipid profile (total cholesterol, HDL, triglycerides) 6
• Check fasting glucose, electrolytes, and hemoglobin 6
• Perform urinary protein estimation by dipstick 6
• Consider 12-lead ECG if stage 2 hypertension (systolic >160 or diastolic >100 mmHg) to assess for left ventricular hypertrophy 6
• Echocardiography is advisable for stage 2 hypertension or suspected target-organ damage to distinguish physiological athletic heart from pathological hypertrophy 6

For Diabetes

• Check hemoglobin A1c to assess glycemic control 6
• Assess for diabetic complications if long-standing disease 6

For Cardiac Concerns (abnormal history or exam)

• Refer for cardiology evaluation with ECG, echocardiography, and potentially exercise testing if ANY abnormal findings on history or physical examination 1
• Exercise testing should be considered to evaluate cardiovascular response to exertion and screen for exercise-induced arrhythmias or ischemia 6

For Asthma

• Consider spirometry if asthma control is questionable 6
• Exercise challenge testing may be warranted if exercise-induced bronchospasm is suspected but not confirmed 6

Mental Health Screening

Screen for depression, anxiety disorders, and attention-deficit/hyperactivity disorder, as these are common in young athletes and can affect performance and safety. 5

Clearance Decision Algorithm

Full Clearance

• Unremarkable personal and family history 1
• Normal cardiovascular and musculoskeletal examination 1
• Well-controlled asthma with no recent exacerbations
• Well-controlled diabetes without complications
• No concerning cardiac findings

Conditional or Restricted Clearance

• Mild hypertension: may participate in low- to moderate-intensity sports pending further evaluation 6
• Exercise-induced asthma: clearance with appropriate pre-exercise bronchodilator use 6
• Well-controlled diabetes: clearance with education about hypoglycemia prevention and monitoring

Requires Further Evaluation Before Clearance

• Any positive cardiac symptoms (chest pain, syncope, palpitations) 1, 2
• Abnormal cardiac examination (pathologic murmur, absent femoral pulses) 1
• Family history of sudden cardiac death or inherited cardiac conditions 2
• Stage 2 hypertension 6
• Poorly controlled asthma or diabetes
• Physical stigmata of Marfan syndrome 1

Critical Pitfalls to Avoid

• Do not rely solely on physical examination, as hypertrophic cardiomyopathy often has no audible murmur at rest 2
• Do not fail to auscultate in both supine and standing positions, as this can unmask dynamic outflow obstruction 2
• Do not overlook the importance of detailed family history, which may be more revealing than the physical examination 2, 4
• Do not assume asymptomatic status confers complete safety; counsel athletes to report any new symptoms immediately 1
• Do not order routine screening tests (ECG, echocardiogram, blood work) in truly asymptomatic athletes with normal history and examination, as this is not cost-effective and may lead to false positives 3, 4

Patient Education and Documentation

• Educate the athlete about warning symptoms (chest pain, syncope, unusual dyspnea) and instruct them to stop activity and seek immediate evaluation if these occur 1
• Provide guidance on asthma management during exercise, including pre-exercise bronchodilator use if indicated 6
• Counsel on diabetes management during sports, including blood glucose monitoring, carbohydrate intake, and recognition of hypoglycemia
• Document all screening findings, clearance decision, and education provided 1