Injury / Illness Quiz 1.4

Documenting the Examination :

- A final ingredient of utmost importance in your examination procedures is accurate and thorough documentation of your findings. Injury documentation is essential for a number of reasons. From a legal standpoint, you may need to reproduce records for a legal dispute or for verifying an insurance claim. - From a more practical standpoint, other colleagues may care for your patient when you are not available; and accurate examination, injury, and treatment records ensure continuity of care. Injury documentation also proves useful for reexamining injuries, allowing you to compare your findings from one examination to the next. - It is never wise to rely on your memory, as you may forget critical findings. Your documentation should be thorough but concise. It is likely that you will perform multiple examinations or treatments in a single day, so efficient documentation is essential if you wish to avoid getting bogged down in paperwork. Many computerized systems for tracking injuries are now avail- able. - Whether in written or computerized form, the same information is recorded. Excellent information on documentation, record keeping, storage requirements, and HIPAA (Health Insurance Portability and Accountability Act) regulations is presented by Shultz and colleagues (2010) and Ray and Konin (2011).

Primary Survey :

- A primary survey determines the status of life-threatening or limb-threatening conditions using the "ABCs" of emergency medical care: examination of Airway, Breathing, and Circulation. - Your first goal is to tend to life-threatening conditions by examining the patient's airway, breathing, and circulation for respirations and pulse. Evaluation of other vital signs and checking for severe bleeding should also occur at this time. - Depending on the results of the primary survey, you will either tend to the emergency conditions or move on to the secondary survey

*On-site Examination* Observe and Screen :

- As you approached the patient on the ground and while you were obtaining the patient's history, you should have been observing the patient's movement ability and patterns. Continue to check for abnormal positioning of the head, neck, or extremities. How is he reacting to the injury? Is he able to move the injured part, is he protecting it, or is he not moving it at all? Do his facial expressions show pain, fear, or panic? Does he show no expression? Is his skin pale, flushed, or normal? Is he bleeding from the head or showing other signs of head trauma? - If he suffered a severe blow to the trunk, especially the abdomen and chest, immediately suspect internal injuries and evaluate the patient as indicated. If you suspect a spinal injury, stabilize the patient's head while bilaterally examining peripheral nerves for sensory and motor innervations. For a suspected head injury, proceed with a head injury examination and ask the patient to ascertain his orientation to time, place, and person, which helps you determine the seriousness of the condition. If the injury involves a bony region, palpate for possible fractures or dislocation - With confirmation of either, proceed with proper immobilization and splinting. If the limb exhibits deformity, test for neurovascular compromise. Muscle injuries require a quick palpation for muscular defects and a gross examination of range of motion (ROM) and strength. - For suspected ligament injury, perform immediate stress tests before transporting the patient, as muscle spasm quickly sets in and precludes accurate stress tests, especially once you move the patient and pain increases. You may use other special tests to determine the patient's disposition or whether it is safe to move him off the field.

*Clinical Examinations* Neurological Tests :

- Because neurological compromise can have serious and even life-threatening consequences, it is crucial to determine if the nerve structures are intact and functioning normally following an injury. The goal of the neurological examination is to rule out any brain, spinal, or peripheral nerve pathology. Although clinical neural tests are the same as those used during the acute examination, they serve a dual purpose in the clinical examination. Since you may not have been a witness to the injury, it may be difficult to determine if the injury is musculoskeletal or neural in nature. - Neurological tests examine the integrity of the central and peripheral nervous systems and should be performed if you suspect a nerve injury or if the patient's symptoms include sensory changes (radia- tion of numbness, tingling, shooting pain, deep pain, or burning pain), weakness, or paralysis. Radiating, or referred, symptoms can result from pathology in the spinal cord, nerve roots, or peripheral nerves secondary to disc herniations, fractures, or dislocations; impingement or compression syndromes; nerve tensioning or stretch; or other nerve trauma. - Neurological symptoms vary with the level of injury. Because nerve roots from the cervical and lumbar spine send branches to more than one peripheral nerve, the symptom profile is more diffuse with a nerve root lesion than with a peripheral nerve lesion. - Unilateral symptoms indicate a nerve root or peripheral nerve lesion (lower motor neuron), whereas bilateral symptoms often result from central cord or brain pathology (upper motor neuron). Although there are specific neurological tests for specific body areas and pathologies, the three primary neurological tests involve examination of sensory, motor, and reflex responses. These tests are designed for spinal cord and nerve root exams, but sensory and motor examination results can also produce peripheral nerve conclusions.

Examination components :

- Before clinicians can make a diagnosis, they must thoroughly examine the injury by sequentially performing tasks involved in specific examination components. The necessity of these components is dictated by the location and timing of the examination. - Injury examinations occur in three different environments: on the field (on-site), on the sideline (acute), and in the athletic training facility (clinical). - Each environment demands a different examination, but all examinations should begin with an evaluation to eliminate any critical or life-threatening concerns. This process is called the injury survey. The injury survey is divided into two components, the primary and the secondary surveys.

*Clinical Examinations* Vascular Tests :

- Circulatory tests examine the integrity of the vascular system. You will often palpate pulses to determine the presence of blood flow. If the pulse weakens or disappears following an injury, the situation is a medical emergency, and you must provide for immediate and emergency medical referral to prevent loss of a limb or worse. You will note pallor or lack of capillary refill in areas of decreased blood flow or ischemia. Shock may also cause some of these pathological signs.

*Clinical Examinations* Functional Tests :

- Functional tests are used only when the patient is ready to return to former partici- pation levels. These final tests determine not so much the nature or severity of an injury but rather the patient's ability to safely and fully resume all activities. Most commonly, you will perform these tests after a course of treatment following an injury rather than at the time of injury. - Only in cases of minor injuries—if symptoms have subsided and all previous tests have demonstrated that the patient is able to return to participation—is functional testing a part of the acute exami- nation process. In these cases, you must per- form functional tests before permitting the patient to return to full participation. - Functional testing helps you determine the patient's confidence and physical readiness to return to participation beyond what you can learn from other aspects of the subjec- tive and objective examination segments. Functional testing requires specific tasks and controlled skill movements that mimic the physical demands and joint stresses inherent to the patient's sport or work activity. - By having the patient perform these functional movements, you can also determine the quality of his performance in a more controlled environment and identify any apprehension or compensation with other movements in an effort to protect an area or avoid pain. Specific functional tests are numerous and many are unique to the specific demands of each case or sport. - Therefore, you should have a working understanding of the physical demands and stresses that a patient will experience so you can provide an appropriate functional examination. Generic lower and upper extremity functional tests are included in the sidebar Lower and Upper Extremity Functional Tests.

*Clinical Examination* Subjective Segment :

- History taking during a clinical examina- tion involves a more in-depth and complete line of questioning. You will ask many of the same questions during the clinical examination that you ask at the sideline regarding the mechanism of the injury and any history of prior injury and treatment. However, allotted time in a clinical examination is usually greater, allowing you to ask additional history questions to obtain the most accurate and detailed injury history possible. - With acute injuries, many of the questions asked during the on-site and acute injury examinations are applicable at this time. Additional questions regarding contributing factors or relevant injury and medical history are helpful. With chronic injuries, inquire also about onset, symptoms, pain profile, and treatments. - Use medical questions to rule out general medical problems and internal injuries, some of which could be serious and refer pain to the extremities.

*On-Site Examination* Implement Immediate Action Plan :

- If the previous steps reveal any serious or life-threatening signs or symptoms, refer the patient for further examination and treatment as needed. If you find that her injury does not require immediate medical care, appropriately transport her off the field or out of the work environment and proceed with a more detailed examination in a quieter environment such as the sideline or a treatment facility - Select the method of transport- ing the patient on the basis of the injury, its severity, and the patient's response. Choose the method that aggravates the injury the least and optimizes the outcome with efficient and safe removal of the patient from the field. The staff responsible for transport must be well rehearsed in the various methods so that transportation proceeds efficiently and effectively. - Procedures for immediate treatment to minimize and control the injury, procedures for immediate medical referral when indicated, and appropriate communication systems must be in place in advance so that the patient's care is optimal, efficient, appropriate, and correct. All facilities should have an Emergency Operating Plan (EOP) (Ray and Konin 2011) to ensure clear role delineations and smooth execution when speed is essential.

*On-Site Examination* Communicate On-site Examination Results :

- If you suspect that an injured patient requires stretcher transport off the field, it may take several minutes to prepare the equipment and personnel for the transport. Although most officials understand this, occasionally an official may pressure you to move more quickly. - You should either address the official or ask someone involved in the examination but not in the transportation to explain to him the importance of careful preparation and transport. - The value of ensuring safety before resumption of work or athletic play is often more readily apparent when it is calmly explained.

Clinical Examination :

- In some cases the clinical examination is a continuation of the on-site or acute injury examinations, and previous observations and findings can be reexamined or tested further. In other cases, the clinical examination may be the first encounter with a particular patient or complaint. In these situations, all components of the examination must be conducted during the visit. - Although the procedures for a clinical examination follow a specific routine and include many of the same components as the acute examination, some components are slightly altered and others are added. Both the acute and clinical examinations include subjective and objective segments, but the on-site and acute examinations are typically not as thorough. The clinical examination does include all the components of the sub- jective and objective segments.

*Clinical Examinations* Special Tests :

- Many of the special tests used during the acute examination are also used in the clinic. However, other special tests may be appropriate during the clinical examination depending on the patient's history, your preliminary findings from other objective tests, and the simple fact that you may have more time available. Special tests are unique to specific joints, body segments, or structures. Each body segment requires unique tests for examining the degree of injury to its distinctive soft tissue structures and bones. - By the time you are ready to use special tests in your examination, the history, palpation, ROM, and strength tests have narrowed the range of injury possibilities. Use special tests to elimi- nate or confirm a suspected condition as well as to quantify the integrity of a structure or the extent of an injury. Special tests should stress the structure enough to allow you to either grade an abnormal response or reproduce the patient's symptoms. The stress must be great enough to elicit an accurate response but not so great that it aggravates the injury. In the beginning, finding this balance can be difficult. Special tests do not provide a complete profile of the injury. - Throughout the examination process, you progressively focus the picture and narrow the possibilities of what the injury is. You must be careful not to rush the investigative process by making assumptions or focusing too quickly on one or two special tests. Remember to keep an open mind until your understanding of the injury, or the injury presentation, becomes certain. - As noted earlier, deciding on the degree of stress or on which special test to use requires good judgment. It is sometimes neither nec- essary nor appropriate to use a special test to stress an injury, for example in the case of an elbow dislocation. A patient may simply be in too much pain to undergo a stress test; in this case, it is better to defer the special test. Special tests confirm the severity and nature of the injury. - The special tests presented throughout this text are those that clinicians most commonly use because of their accuracy and demonstrated reliability. You must remember, however, that some special tests do not have demonstrated reliability or may not be appropriate for some clinicians because of individual circumstances. You will need to determine the most suitable tests for your examination based on the specific injury situation and your knowledge and skills. - You should perform special tests only after you have explained to the patient what will occur. The special tests are performed on the uninvolved extremity first for two reasons: (1) to familiarize the patient with the proce- dure so she is less apprehensive, encouraging relaxation that will achieve better test results, and (2) to learn what response to the test is normal for that patient. Since many special tests produce different results from one patient to another, you must establish a baseline for each person to determine whether a test is positive or negative. - Depending on the test, the result is considered positive if it produces abnormal results compared to the uninvolved side in terms of laxity or stiffness, stability or instability, presence or absence of sounds, restriction or ease of movement, strength or weakness, normal or abnormal function, and presence or absence of pain. - Always remember that negative or positive results of a single special test do not neces- sarily indicate the absence or presence of a specific injury. This is why all the factors in your examination are used in combination to provide a full and consistent profile of the injury. Sometimes a result is false positive and complicates your examination results so that other tests are necessary for providing accurate results. - Your skills and ability to perform the tests reliably can make a big difference in the test results, and thus experience plays an important role in the accuracy of special tests. Another factor to consider is the accuracy of the specific special tests themselves, as some are more sensitive than others. However, though for some injuries there are several tests, it is not necessary to use all that are available. - Remember, a special test is intended to reproduce the patient's symptoms or create a comparable sign; so unless you require additional con- firmation, one or two tests per structure are usually adequate and are better tolerated by the patient.

*Clinical Examination* Range of Motion :

- Normal ROM is influenced by strength and active and passive tissue integrity. The goal of examining ROM is to objectively quantify the amount of active and passive motion available at and around the injury site. - Range of motion examinations assist in confirming or eliminating your suspicions of the structures involved in the injury; help demonstrate the extent of the injury; and determine the integrity of active and passive elements that produce, support, and restrict joint movement. As you test ROM, you should identify the injury's SINS (severity, irritability, nature, and stage) throughout your examination to assist in forming a diagnosis. - Active range of motion (AROM) testing, which is performed first, examines the integrity of the active or contractile tissue of the musculotendinous unit. Active range of motion is produced solely by the patient and is contingent upon adequate strength and structural integrity of the tissue involved. If a patient needs assistance to complete the requested movement, the test changes into an active-assisted range of motion (AAROM) exam. - Passive range of motion (PROM) testing examines inert structures around the joint. It is important to observe how motion is affected by an injury; thus, it is important to perform all the active motion tests first and then follow with all the passive motion tests. Observing the quality of movement is an important purpose of ROM measurement, for it may tell you areas of pain or difficulty. If pain makes the injury very irritable, less active motion is possible. If little active motion but full passive motion is possible, the musculotendinous structure is the likely site of injury. On the other hand, if passive movement is restricted, you will want to evaluate for the possibility of a fracture or some form of internal derangement within the affected joint that is causing a block to movement. - It is recommended that you perform the active and passive motion tests by muscle or muscle group to limit patient movement from one position to another. During ROM testing, you examine both the quality and quantity of physiological and accessory motion and also test for pain. You may also test how the joint feels at the end of the ROM (the joint's end feel). Abnormal end feels are suspicious for the presence of injury. For more information regarding the various elements of ROM testing, see Shultz and colleagues (2010)

*Clinical Examination* Observation :

- Observation is a valuable skill that is used throughout all phases and types of exami- nations and treatments. Observing how the patient responds provides useful informa- tion about the patient's perception of the injury, as well as clues about its nature and severity. - Observation begins as soon as you see the patient and continues throughout the subjective and objective segments of an examination. Facial expressions and the eyes are windows into a patient's true response; thus you should carefully watch them during the objective tests. - You also should observe the patient's general posture, the way in which he holds or protects the injured part, and his willingness to move the injured segment. Observe for contour, alignment, and discoloration, and compare the right and left sides—they should be symmetrical.

*On-site Examination* Monitor for Shock :

- Patients with severe injuries, severe pain, first-time injuries of any severity, or poor tolerance for injury are most susceptible to shock. You must understand the signs and symptoms of shock, monitor them throughout the exam, and be prepared to take immediate action if necessary. - Look for pale, cool, clammy skin; rapid, shallow breathing; and a weak, rapid pulse. Also look for nausea and falling blood pressure. Treat patients exhibiting any of these signs immediately and have them transported to an emergency medical facility.

*Clinical Examination* Strength :

- Strength examination follows the active and passive ROM tests that are typically performed in the ROM examination. Some professionals include resistive range of motion (RROM), or strength, in the ROM category; however, in this text we categorize strength separately, since if the patient has significant pain it may not be possible to perform a strength test. If this is the case, you will have to defer strength examination to a later date. - Strength tests examine the musculotendinous resistive ability, the neuromuscular integrity of the contractile tissue, and the pain level of the contractile elements. The method you use to examine strength depends on the type of injury, available equipment, time, and place of examination. - Manual muscle tests are the most convenient method of examining strength as performance requires only your hands and your knowledge. Strength tests typically begin with isometric screening for gross discrepancies in muscle function within the cardinal planes of motion, proceeding to specific muscles or muscle groups if bilateral differences are noted. Isometric tests, or "break tests," are efficient and are usually performed with the joint in a neutral midrange position for multiple-joint muscles and in an end-range position for single-joint muscles - Conduct these tests by asking your patient to maintain a predetermined position while you attempt to move or "break" the given body part away from this position. These static positions and tests limit the amount of stress applied to a joint and ensure that you test for strength without interference from inert joint structures. - If you discover a strength deficit with a break test, you may consider further examination of the muscle's strength throughout its entire ROM using instrumented equipment. Strength testing equipment is extensive and can range from isometric tensiometers to free and machine weights (isotonic equipment) to isokinetic equipment. Equipment selection depends on availability, your preference, the muscle or muscle group being tested, and the patient's condition. - While manual muscle tests are the most efficient and readily available means of examining muscle strength, instrumented strength testing provides a more objective and reproducible measure.

*Clinical Examinations* Stress Tests :

- Stress tests are special tests that specifically examine capsular and ligamentous tissue of injured joints in an attempt to determine whether structural damage has occurred to those structures. These tests are used to eval- uate whether a ligament or capsule exhibits laxity and should not be confused with ROM tests, which evaluate for tightness or mobil- ity. Laxity (or looseness) determined by stress testing is an indication that there has been actual structural damage to the structures surrounding a joint, and this is defined as a sprain. - Sprains are classified as first, second, or third degree or Grade I, Grade II, or Grade III, respectively. This classification is based on the level of severity. Grade I (first degree) sprains are the least severe and are characterized by pain but no laxity. Grade II (second degree) sprains are partial tears in capsular or ligamentous tissue; pain and laxity are present, but the laxity subsides and becomes firm after the "slack" is taken up. Grade III (third degree) sprains are complete tears of tissue and exhibit severe pain and significant laxity with no firmness at end ranges of stress. - Stress tests should be used in the exami- nation process after the history, observation, palpation, ROM, and sometimes strength tests have been completed. They should be used to eliminate or confirm suspected injuries based on information previously gained during the examination. Techniques for stress tests are specific for each joint; they involve stressing the tissue being examined in such a way that they provide clinical infor- mation about the extent and severity of the injury without causing additional irritation. Stress test force is typically applied across the joint and often perpendicular to the ligament or capsule in such a fashion that it stretches the ligament. - Presence of pain, increased laxity between involved and uninvolved sides, and increased instability of the joint are all indications of a positive stress test and liga- mentous or capsular damage.

Acute Examination :

- The acute examination either follows the on- site examination or is the initial examination of an injured patient who has walked off the field or from the workplace on his own. Both the acute and clinical examinations include a subjective and an objective segment, each of which is divided into other elements. Both segments focus on investigating the SINS—severity, irritability, nature, and stage—of an injury. - The SINS of any injury are identified through a thorough and accurate injury examination. You should identify the SINS during both the acute and clinical examinations. Use the subjective examination segment to create a profile of the injury's SINS and the objective segment to confirm or disprove your suspicions. - The purpose of the acute examination is to determine more precisely the nature and severity of the injury so that you can admin- ister appropriate treatment, provide referral, or return the patient to participation (figure 8.3). As with an on-site examination, you may have seen the injury occur and already know what segment was injured and whether the symptoms are referred from the injury site or are localized. For this reason, you usually perform palpation early in the acute exami- nation. - Because you already have a good idea of the segment injured, you also use special tests early in the examination to confirm or disconfirm your suspicions and to determine injury severity. Depending on injury severity, special tests can be used before or after ROM tests. - Perform an acute examination in the following order: 1. History 2. Observation 3. Palpation 4. Special tests 5. ROM tests 6. Strength tests 7. Neurological and circulatory tests (if necessary) 8. Functional tests (if necessary)

*Acute Examination* Subjective Segment :

- The first step in an injury examination is obtaining a history. It is very important to determine the stage of the injury at this time. Injuries typically fall into one of two major stages or classifications: acute and chronic. An acute injury results from a sudden onset of macrotrauma or a situation in which symptoms develop quickly. - Conditions are classified as chronic if they have a more gradual or insidious onset and continue to interfere with activity 6 to 8 weeks after their onset. In some cases, chronic injuries may have been present for some time, but exac- erbation during competition or activity will prompt the patient to report his symptoms to you. - You may have already obtained a partial history during the on-site evaluation, but the acute and clinical examinations typically afford you more time to gather additional information from the patient and other observers that will help you in your examination. After the initial primary examination, patients are often less agitated and able to recall information that they could not remember while on the field. Also obtain relevant medical information and previous injury history at this time. - Once you have removed a patient from the field, ask again about the chief complaint and injury mecha- nism. These complaints commonly change within minutes after injury, and you often get a clearer impression of a patient's condition once she has had the opportunity to calm down. - Likewise, if you are unaware of an injury until the patient walks into the athletic training room after practice, you will want to get a detailed picture of the chief complaint, mechanism of injury, and current signs and symptoms. - Ask questions that will help you develop a good picture of the injury so that you can pay attention to the correct body segment during the objective examination. - Taking a history is the process of learning or knowing through questioning the facts and events associated with an injury or illness. This is an opportunity for patients to describe what happened and what they are feeling or experiencing. - Obtaining an accurate record of a patient's injury or illness requires a systematic approach to learning about the events leading to the injury or illness and getting a clear description of the associated signs and symptoms. This history provides an initial impression of the severity, irritability, nature, and stage (SINS) of the condition. - You can learn a tremendous amount about a patient's condition simply by listening to the individual describe the injury. When you carefully select your questions, you obtain a useful picture of the patient's complaint and a sense of the direction your objective examination should take. - This is the patient's opportunity (or the bystanders' opportunity if the individual is unable to communicate) to describe the injury or illness, the patient's response to the injury or illness, and previous events that may affect the current situation. - Your questioning should be efficient and thorough—pertinent to the moment, but complete enough to allow you to formulate a plan for the remainder of the examination. History questions should not be leading and are used to gain useful information that will guide the rest of your examination. The history helps you focus on specific segments and determine how much force you should use when performing tests. You should ask questions that seek information in the following primary categories: chief complaint, mechanism of injury, nature of illness or injury, signs and symptoms, and previous history or contributing factors.

*Clinical Examination* Objective Segment :

- The objective examination segment of a clinical examination can be quite extensive. It is during this examination that you are attempting to obtain an accurate diagnosis and design a treatment plan and rehabilitation progression, or to determine ability to return to sport or work. You will need to perform a detailed and thorough examination in the areas of palpation, ROM, strength tests, stress tests, special tests, neurological tests, vascular tests, and functional tests to determine extent of injury. - The objective segment of an examination is a routine process, requiring specific tests and the identification of responses to confirm your suspicions regarding the patient's diagnosis. Since a goal of the objective examination is to define the injury, you must know what reproduces the patient's symptoms and what is normal for that patient. - You can obtain this information by producing a comparable sign and by comparing the injured segment to the contralateral extremity. The examina- tion process presented here is recommended since it follows a logical sequence. Whether you implement this system or develop your own, you should use a consistent, sequential system each time you perform an examination. Such a system will make you less likely to forget a test and more likely to perform a thorough examination. - *Comparable sign*: a. ) With each test you perform, you are seeking a response. All objective tests should elicit a negative response if the tissue or structure is not injured and a positive response if it is. b.) A positive response results from either a reproduction or an alteration of the patient's symptoms. The reproduction of the patient's complaint of pain through testing is called a comparable sign (Maitland 1991). It is desirable to produce a comparable sign because a test that produces the sign will reveal the problem. c.) A negative response, on the other hand, is seen when the test yields a normal result. One or more of these tests will produce a comparable sign. The information you obtain from these procedures and the procedures of the subjective segment provides a total picture of the injury: a diagnosis or clinical impression. - *Bilateral comparison* : a.) You should perform all of the objective tests bilaterally (bilateral comparison). To obtain reliable information from the tests, you need to understand the purpose of each test, compare the injured side with the uninjured side, and know the normal response for each test. b.) You must also realize how changes in the patient's position can affect results. For example, the results of strength testing of shoulder flexion may depend on whether the patient is sitting or supine. It is important to examine the patient efficiently. c.) If you do not understand the purpose of each test, you will use more tests than necessary, prolonging the examination and perhaps aggravating the condition. d.) Tests by themselves do not completely profile the injury. During the examination, every question, observation, and test progres- sively focuses the picture and narrows the injury possibilities. Be careful not to make unfounded assumptions or rush the investigation by prematurely focusing on one or two tests. e.) Before conducting the objective examination on a postacute or chronic injury, caution the patient that the examination may aggravate the symptoms. The patient may complain of pain and discomfort during the examination, but if she is able to tolerate these effects, proceed, because timely recovery depends on an accurate and complete diagnosis. f.) It is not unusual for symptoms to increase following the examination; assure the patient that these effects should quickly subside. Instruct the patient to inform you at the next visit whether or not symptoms increased. g.) The objective component of the clinical examination should include the following: 1. Observation 2. Palpation 3. ROM tests 4. Strength tests 5. Stress tests 6. Special tests 7. Neurological tests 8. Vascular tests 9. Functional tests

Secondary Survey :

- The secondary injury survey takes place when the injured individual is breathing and you have any bleeding under control. It is at this time that you perform an examination to determine the presence of other injuries. - The term secondary indicates that the primary survey either has been concluded or been deemed unnecessary. A secondary survey is a rapid examination of the seriousness of the injury, and the conclusions you formulate determine how you should remove the patient from the injury site. - A secondary survey and an on-site secondary evaluation are essentially the same, with the primary goal of determining the nature of the injury or illness and identifying positive signs that will help you make decisions about referral (see the sidebar When to Refer for Further Evaluation [Emergency Room or Physician]) and emergency care or first aid.

*On-site Examination* Goals and Purposes :

- Use on-site examinations to rule out life- threatening and serious injuries, determine the severity of the injury, and ascertain the most appropriate method of transporting the patient or worker from the scene. Your goals are to perform a quick, accurate examination and to treat the injury to minimize its effects. These initial decisions are among the most critical you must make, since an incorrect decision can have dire, even deadly, consequences. - In an on-site examination, the victim is either conscious or unconscious. On-site examination of an unconscious patient is one of the most serious situations you may find yourself in. Unconsciousness is an emergency situation that requires specific steps to ensure an optimal outcome. Although unconsciousness may result from traumatic injury, it may also result from a variety of general medical conditions or drug interactions. - Systematically examine patients who are unconscious for no known reason, proceeding from searching for life-threatening conditions to identifying potential signs and symptoms that may reveal the cause for unconsciousness. Most of the techniques you will use in a general examination of the unconscious patient are described in other chapters. - If your primary survey shows that the patient is breathing, conscious, and coherent and does not have severe bleeding, use the secondary survey to determine injury severity and the most appropriate method for removing the patient from the area of play or work - Even though an on-site examination often demands rapid decision making, you must stay calm, take your time, and yet be focused and efficient. Good examination skills and judgment along with knowledge and experience are essential. - If you are ever unsure of the severity or nature of the patient's condi- tion, it is better to err on the side of caution and refer the patient rather than assume that referral is unnecessary. Always remember to stay within the scope of your practice and training - Hippocrates said that those in medicine should do no harm. Adhere to that advice, and never hesitate to call for assistance if the best course of action is unclear or the demands of the situation exceed your training or knowledge. You must make all decisions with the person's safety in mind. The components involved or the steps that must be taken during an on-site examination include obtaining a history, observing and screening for physical symptoms, monitoring for shock, implementing your emergency action plan, and communicating your findings.

*On-site Examination* Obtain a History :

- When taking an on-site history, quickly deter- mine the mechanism, location, and severity of the injury. An on-site history is a focused history in which you investigate only the patient's major complaint and any problems that are readily apparent and in need of atten- tion before the individual is transported off the field. - If you were an eyewitness to the event, you may already have vital information regarding the mechanism and the forces involved. Witnessing the patient's initial response to the trauma can provide valuable information as well. If you did not see the injury and the patient is unconscious, ask bystanders what happened and how long the person has been unconscious. In some cases questioning the victim may be a challenge, but it may also calm her and shift her focus off the pain or fear, allowing you to proceed more easily with your examination. - To establish the mechanism, ask how the injury occurred and what happened. You may find that the patient has a different perspective from your own or from that of bystanders. For example, although observers on the sideline may not have heard a sound, the patient may have experienced a pop or snap. A patient may also have experienced torque or rotational forces that are not readily observable. - Questions regarding the location and intensity of symptoms help you determine injury severity and decide on the method of transport off the field. Does the patient experience pain? Does she complain of neck or back pain so that you suspect a spinal injury? Is there any complaint of dizziness, light-headedness, or nausea? - This type of questioning helps you quickly focus on the area of injury and make appropriate decisions about the direction of your examina- tion. Completing the entire history on-site is unnecessary. Gather the information you need to determine the general nature and extent of the injury and the best course of immediate action, and defer the rest of the history to the acute examination.

*Acute Examination* Objective Segment :

- While the patient is reporting his history, use your observation skills to notice how he moves and holds the injured part, and check for any evidence of swelling, deformity, and abnormal skin coloration. During the objec- tive segment, you perform tests to help you establish the severity and nature of the injury. These tests involve palpation, ROM, strength tests, stress tests, special tests, neurological tests, circulatory tests, and functional tests. As the name implies, this part of the examination focuses on impartial evidence provided by the various tests you perform. - At this stage of injury management, your objective evaluation is typically more thorough than your on-site examination, but it may not be as complete as your future clinical examination. If the patient is in severe pain, do not perform a complete examination but instead only one or two tests that can establish appropriate immediate treatment or referral - You may defer complete examination until pain has lessened and the injury is less irritable. However, if the patient is able to tolerate a more extensive examination, proceed—as return to participation decisions may need to be made in a timely manner. But continue your examination only as necessity and the level of pain dictate; otherwise you may aggravate the injury and lose the patient's confidence in your ability to help him. - The information you gathered in the subjective examination determines which tests you choose to perform. It is crucial that common sense, the subjective report, and your understanding of the situation dictate how aggressively to perform the objective tests during the acute examination. If previous segments of the examination have shown that the patient will not be able to participate in the sport, defer functional tests until after the injury has been treated. Perform functional tests during acute examination only if there is a possibility that the patient may return to full function.

*Clinical Examination* Palpation :

- Your sense of touch is critical to the objective portion of the examination. A palpation exam consists of feeling with your hands for changes in tissue size, contour, orga- nization, texture or consistency, tension or tone, and temperature or moisture, as well as checking for pain, swelling, muscle spasm, and tissue thickening. The goal of each palpation is to locate all pertinent structures, determine their characteristic feel, and examine them for the presence of pathology. - With concentration and practice, your sense of touch will develop just as your other clinical skills do. In addition to palpating for swelling, pain, and temperature, you will palpate for spasm, deformity, moisture, pulse, and general contour of soft tissue and bony prominences (Shultz, Houglum, and Perrin 2010). - As with the acute examination, palpation in the clinic proceeds systematically, moving from superficial to deep structures and traversing the body segment in a specific routine such as from anterior to posterior or superior to inferior. Likewise, palpation of the structures is the same in the acute and clinical examinations. Carefully note differences between the involved and uninvolved sides in soft tissue tension, spasm, restriction, temperature, moisture, swelling, thickness, texture, bony and soft tissue contours, and tenderness.

On-site Examination :

On-site examinations are performed when the patient cannot continue full participation during an athletic practice or competition or while performing his job. You may examine the patient on an outdoor field, cross country course, or indoor floor or in a warehouse, a construction site, or any other work location. - Before performing an on-site examination, put in place an emergency plan for managing and transporting the patient based on your findings from the secondary injury survey. Such plans are beyond the scope of this chapter, but whatever the emergency care plan, instruct all participants and coaching staff or coworkers not to move the patient before you have attended to her. Instruct anyone who suffers a significant injury to remain still until adequately examined. - When caring for participants in game situations, you should know the rules regard- ing on-site examination for each sport for which health care coverage is provided. Many sports have specific rules for injuries. Some sports won't allow you onto the field or court until the official has beckoned you, and other sports have very specific time frames within which a decision for care must be made before the team or patient is penalized (charged with a time-out, removed from play, or disqualified). While such rules should never compromise your care of and attention to the patient, knowing them will help you avoid unnecessary conflicts.