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physio therapist in situ

Micki Cuppett – Clinical Pearls to Enhance Your Medical Examination Skills – Injury Rehab Network

The August Injury Rehab Network event with BASRaT featured a presentation from Micki Cuppett. The online event took place on the evening of Wednesday 7th August with 120 sports rehabilitation practitioners in attendance.

Micki discussed the examination of medical conditions. The recording is available to watch here.

 

Micki Cuppett, EdD, LAT, ATC, FNAP

Micki Cuppett has over 30 years of experience as an athletic trainer, medical educator, and administrator. She is self-employed as a consultant in strategic planning, leadership, interprofessional education, accreditation, AT education, medical simulation, and innovation.

Known internationally for her work in instructional technology, simulation, and clinical encounter documentation, she has published numerous works in interprofessional education and co-authored Medical Conditions in the Athlete, a widely used textbook now in its fourth edition. In addition to her consulting business, Micki has held adjunct/courtesy faculty positions at numerous universities in the U.S. and was recently inducted as a Distinguished Fellow in the National Academies of Practice.

 

Clinical Pearls to Enhance Your Medical Examination Skills

physio therapist in situ

This session reviewed the examination of medical conditions, including differences from a ‘focal’ orthopaedic examination and provided tips and clinical pearls to help improve examination techniques of common medical conditions. Signs, symptoms, and red flags for medical conditions were reviewed, along with examination techniques for various systems and comorbidities.

Background and Introduction

Micki provided a summary of her career and some disclosures in relation to her work with Cuppett Consulting and as co-author of “Medical Conditions in the Physically Active,” Human Kinetics, 2024.

Micki works at the University of South Florida in the College of Medicine.

Micki described the key learning points for those who joined the presentation:

  1. Differentiate between a focal orthopaedic examination and a medical examination of conditions that may affect the organ system.
  2. Recognize common pathological conditions, including signs and symptoms, differential diagnosis, and standard medical treatment for common non-musculoskeletal conditions in the physically active.
  3. Identify appropriate initial management of common disorders, conditions that may preclude the athlete from participation, and those that need referral and recognize which symptoms are self-limiting.
  4. Develop a plan with online resources to practice the examination of medical conditions.

Micki’s presentation focused on respiratory and cardiac issues.

Why a talk on Medical Conditions?

Micki considered some important points about examining a patient with a medical condition. Often, there may be no identifiable onset and few signs that anything is wrong. Practitioners should begin with a thorough history and an overall systemic review. The examiner must rely heavily on the patient’s history to guide the examination.

Micki described that 75% of conditions are non-musculoskeletal (MSK), but 90% of athletic trainers/sports rehabilitators focus on MSK. Micki believes that if practitioners can understand medical terminology, patient outcomes will be better through collaboration with medical professionals.

Comprehensive History

Micki described taking a comprehensive history, which is typically completed during a physical examination contains:

  • Past medical history
  • Current health status
  • Family history

Micki considered how the history-taking process drives the examination, diagnosis, and treatment. Micki stated the importance of listening to the patient and letting them tell you their story.

Micki discussed important points for taking a medical history, including:

  • Duration of signs and symptoms
  • Onset
  • Do symptoms occur at a specific time?
  • Do symptoms come and go, or are they constant?
  • Disability from symptoms

Practitioners should not focus on just one system and need to consider comorbid conditions.

Listen to what your patient tells you

Micki described the differences between systemic and musculoskeletal conditions. Patients may use several types of descriptors to explain issues that may affect different symptoms. For example, pulsing pain may be vascular, whereas shooting pain could be neurologic.

Red flags

Micki provided a list of symptoms that practitioners should treat as red flags and need follow-up. For example, constant pain, heart palpitations, and blood in urine are all red flags.

Physical Exam

Micki described how a physical examination should follow the universally accepted cephalocaudal (head-to-toe/ long axis) sequence. Micki considered how a general survey includes observation of the patient’s apparent state of health, level of consciousness and signs of distress.

The physical assessment is performed in the same order as a review of systems, and Micki stated that it should begin with the vital signs. Practitioners should use palpation.

Auscultation

Auscultation image

Micki described auscultation as the skilled listening by a trained ear for bodily sounds. Most body sounds are not audible without the use of a stethoscope. Auscultation takes practice so that the sounds can be identified and isolated from each other. Therefore, a quiet environment is a must.

Stethoscope

Micki recommends investing in a good acoustic or digital stethoscope if possible. Micki described how the diaphragm is used to hear high pitched sounds, and the bell is used to hear low pitched sounds. Micki advised practitioners to align the stethoscope to their ears and to ideally place the stethoscope directly on skin. Practitioners should learn to listen to the presence and absence of sound but also intensity, pitch, duration and quality.

Innovation

Micki described how an auscultation device using AI, now has FDA clearance. Technology enables practitioners to record and send digital sounds. Tele-health offers remote monitoring of patient health.

Lung Auscultation

Micki described the suggested sequence for lung auscultation and the normal lung sounds to listen for. Micki recommended that practitioners should listen for the duration, pitch and intensity of sounds.

Micki played recordings of vesicular, bronchovesicular and bronchial sounds. Micki also played recordings of adventitious breath sounds to help practitioners identify sounds linked to crackles, wheezes, rhonchi, stridor and pleural rub.

Micki discussed physical findings associated with common respiratory conditions, including asthma, bronchitis, pneumonia and pneumothorax. Micki described findings associated with different examination techniques, including inspection, palpation, percussion and auscultation.

Micki considered red flags for respiratory conditions, such as laboured breathing with the use of accessory muscles and/ or adventitious breath sounds.

Cardiac Auscultation

For the assessment of cardiac conditions, Micki described the process for understanding cardiac history. A cardiac questionnaire is used to identify any issues or red flags.

Micki described how to complete a cardiac auscultation where a good stethoscope is a must. The patient should be supine, and the order of auscultation should be aortic, pulmonic, tricuspid, and mitral. The environment must be quiet.

Micki recommends that practitioners learn what normal sounds like to identify any abnormal sounds better. Micki discussed differentiating signs and symptoms of myocarditis, aortic stenosis and mitral valve prolapse. Micki described a range of cardiac red flags. For example, palpitations, chest pain and exercise intolerance should all be investigated immediately.

Case Study

Micki presented a case study about a 19-year-old football player who was suffering from fatigue, tightness in his chest, and difficulty catching his breath.

A thorough patient history was considered in relation to the symptoms, past medical history, family history, and medications. The pertinent patient history found that symptoms had lasted for a few weeks with mild dyspnea, which increased with exertion. This had increased in frequency to one to two times per week. There was no fever, palpitations, family history, or medications. The physical examination showed painful and puffy sinuses.

Micki described the differentials, including allergic rhinitis, mild asthma/ EIB, and GERD. The next steps were to consider over-the-counter allergy medications, monitor the patient’s condition, and, if no improvement was seen, have a chest X-ray. Micki described the algorithm/ process for treating the patient.

Online Resources

Micki recommended some useful online resources for practitioners.

Auscultation

Easy Auscultation

Fundoscopy

Stanford 

Dermatology

Skinsight

DermNet NZ

Open Evidence

Open Evidence

The Bottom Line

Micki summarised her presentation with the following advice for practitioners:

  • Listen to your patient!
  • Just as you train your fingers to feel subtle differences during palpation, you must train your ear to hear subtle differences during auscultation.
  • Know what ‘normal’ sounds, looks and feels like.
  • You should be able to describe what you are seeing, hearing, or feeling using the same terminology used by medical professionals, such as doctors.
  • Don’t focus on just one system – consider comorbidities.
  • Practice, practice, practice!
  • Simulators
  • Task trainers

Follow Micki Cuppett

Website

Q&A

Micki kindly answered questions put forward by practitioners who attended the session. Please see the presentation recording for the insights from Micki to the questions.

Presentation Recording

The recording of Micki’s presentation is available to watch here.

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