Structures pre-participation physical evaluations with cardiac screening and clearance decisions. Use when performing sports physicals, screening for cardiac conditions, or documenting athletic clearance.
Structures the pre-participation physical evaluation (PPE) for pediatric and adolescent athletes using the AAP/AAFP/AMSSM PPE Monograph 5th Edition framework. Covers targeted cardiovascular screening with the AHA 14-element assessment, musculoskeletal screening, concussion history evaluation, and clearance determination with sport-specific risk stratification.
Why This Skill Exists
Sudden cardiac death (SCD) in young athletes, while rare (estimated 1:50,000-1:80,000 per year), is the leading cause of death during sport participation. The pre-participation physical evaluation is designed to detect conditions that predispose to SCD (hypertrophic cardiomyopathy, anomalous coronary arteries, Long QT syndrome, arrhythmogenic right ventricular cardiomyopathy) as well as musculoskeletal conditions that increase injury risk. A standardized PPE also screens for concussion history, heat illness risk, sickle cell trait, and psychosocial concerns. This skill enforces the 5th Edition PPE Monograph standards.
Checkpoint A — Intake Verification
Required Intake Questions
What sport(s) does the athlete plan to participate in?
Skills relacionados
Has the athlete completed a PPE history form (preferably the standardized form from PPE Monograph 5th Edition)?
Has the athlete ever fainted, passed out, or had chest pain during exercise?
Has the athlete ever had a seizure or been told they have a heart murmur?
Has anyone in the family died suddenly before age 50, or had unexpected heart problems?
Has the athlete had any prior concussions? If so, how many and when was the most recent?
Does the athlete have any chronic conditions (asthma, diabetes, seizures, single organ)?
Is the athlete taking any medications or supplements?
For female athletes: menstrual history (age of menarche, regularity, amenorrhea)?
Does the athlete have sickle cell trait status known?
Required Documents
Completed PPE history form (signed by parent/guardian if < 18)
Prior PPE records (if available)
Specialist clearance letters (if prior cardiac, orthopedic, or neurologic restrictions)
Chest pain/discomfort/tightness/pressure with exertion
Unexplained syncope/near-syncope (especially during or immediately after exercise)
Excessive or unexpected dyspnea or fatigue with exercise
Prior recognition of a heart murmur
Elevated systemic blood pressure
Prior restriction from sports for a cardiac reason
Prior cardiovascular testing ordered by a physician (ECG, echo, stress test)
Family History:
8. Premature death (sudden and unexpected) before age 50 attributed to heart disease in ≥ 1 relative
9. Disability from heart disease in a close relative < 50
10. Specific knowledge of: hypertrophic cardiomyopathy, dilated cardiomyopathy, Long QT syndrome, short QT syndrome, Brugada syndrome, ARVC, Marfan syndrome, or clinically significant arrhythmia
Physical Examination:
11. Heart murmur (auscultation in supine and standing positions; assess with Valsalva)
12. Femoral pulse diminished or delayed (suggesting aortic coarctation)
13. Physical stigmata of Marfan syndrome (tall, arm span > height, pectus excavatum, joint hypermobility, arachnodactyly, lens subluxation)
14. Brachial artery blood pressure (sitting; use appropriate cuff size)
Interpretation
Any positive cardiac history element or abnormal cardiac exam → further evaluation BEFORE clearance
Dynamic murmur (louder with standing or Valsalva) → suspect HCM → echocardiogram before clearance
Fixed murmur (unchanged with position) → likely benign flow murmur; Still's murmur is most common benign murmur in children
Marfan features → echocardiogram to assess aortic root diameter; refer to genetics/cardiology
Family history of SCD → ECG minimum; consider cardiology referral for echo, exercise stress test, or genetic testing
Elevated BP → repeat measurement; confirm per AAP 2017 BP guidelines; stage 2 hypertension requires workup before clearance
ECG Screening (Not Currently Recommended Universally in the US)
AHA/AAP do NOT recommend universal ECG for PPE (cost, false-positive rate, limited evidence for mortality reduction)
European and some international guidelines DO recommend ECG
ECG should be obtained if ANY of the 14 AHA elements are positive
Refer abnormal ECG to pediatric cardiologist before clearing
Step 2 — Musculoskeletal Screening
2-Minute Musculoskeletal Screening Exam
Perform the following systematic screen:
Stand facing examiner: symmetry of trunk, shoulders, and extremities; inspect for scoliosis
Look at ceiling, floor, over both shoulders: cervical spine ROM