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CHAPTER 3 Pre-Exercise Evaluations 43BOX 3.1Components of the Medical HistoryAppropriate components of the medical history may include the following:• Medical diagnosis. Cardiovascular disease, including myocardial infarctionand other acute coronary syndromes; percutaneous coronaryartery procedures, including angioplasty and coronary stent(s); coronaryartery bypass surgery; valvular surgery(s) and valvular dysfunction(e.g., aortic stenosis/mitral valve disease); other cardiac surgeries, suchas left ventricular aneurysmectomy and cardiac transplantation; pacemakerand/or implantable cardioverter defibrillator; presence of aorticaneurysm; ablation procedures for dysrhythmias; symptoms of anginapectoris; heart failure; peripheral vascular disease; hypertension;diabetes; metabolic syndrome; obesity; pulmonary disease, includingasthma, emphysema, and bronchitis; cerebrovascular disease, includingstroke and transient ischemic attacks; anemia and other blooddyscrasias (e.g., lupus erythematosus); phlebitis, deep vein thrombosisor emboli; cancer; pregnancy; osteoporosis; musculoskeletal disorders;emotional disorders; eating disorders.• Previous physical examination findings. Murmurs, clicks, gallop rhythms,other abnormal heart sounds, and other unusual cardiac and vascularfindings; abnormal pulmonary findings (e.g., wheezes, rales, crackles);plasma glucose, hemoglobin A1c, serum lipids and lipoproteins, or othersignificant laboratory abnormalities; high blood pressure; edema.• History of symptoms. Discomfort (e.g., pressure, tingling, pain, heaviness,burning, tightness, squeezing, numbness) in the chest, jaw, neck,back, or arms; light-headedness, dizziness, or fainting; temporary lossof visual acuity or speech, transient unilateral numbness or weakness;shortness of breath; rapid heart beats or palpitations, especially ifassociated with physical activity, eating a large meal, emotional upset,or exposure to cold (or any combination of these activities).• Recent illness, hospitalization, new medical diagnoses, or surgicalprocedures.• Orthopedic problems, including arthritis, joint swelling, and any conditionthat would make ambulation or use of certain test modalities difficult.• Medication use, drug allergies.• Other habits, including caffeine, alcohol, tobacco, or recreational(illicit) drug use.• Exercise history. Information on readiness for change and habituallevel of activity: type of exercise, frequency, duration, and intensity.• Work history with emphasis on current or expected physical demands,noting upper- and lower-extremity requirements.• Family history of cardiac, pulmonary, or metabolic disease, stroke,or sudden death.Adapted from Bickley LS. Bate’s Pocket Guide to Physical Examination and History Taking. 4th ed.Philadelphia (PA): Lippincott Williams & Wilkins; 2003.
44 GUIDELINES FOR EXERCISE TESTING • www.acsm.orgBOX 3.2Components of the Pre-exercise Test PhysicalExaminationAppropriate components of the physical examination may include thefollowing:• Body weight; in many instances, determination of body mass index(BMI), waist girth, and/or body composition (percent body fat) isdesirable• Apical pulse rate and rhythm• Resting blood pressure, seated, supine, and standing• Auscultation of the lungs with specific attention to uniformity ofbreath sounds in all areas (absence of rales, wheezes, and otherbreathing sounds)• Palpation of the cardiac apical impulse, point of maximal impulse(PMI)• Auscultation of the heart with specific attention to murmurs, gallops,clicks, and rubs• Palpation and auscultation of carotid, abdominal, and femoral arteries• Evaluation of the abdomen for bowel sounds, masses, visceromegaly,and tenderness• Palpation and inspection of lower extremities for edema and presenceof arterial pulses• Absence or presence of tendon xanthoma and skin xanthelasma• Follow-up examination related to orthopedic or other medical conditionsthat would limit exercise testing• Tests of neurologic function, including reflexes and cognition (asindicated)• Inspection of the skin, especially of the lower extremities in knowndiabetes patientsAdapted from Bickley LS. Bate’s Pocket Guide to Physical Examination and History Taking. 4th ed.Philadelphia (PA): Lippincott Williams & Wilkins; 2003.high-risk subjects (see Fig. 2.4). Appropriate components of the physical examinationspecific to subsequent exercise testing are presented in Box 3.2. Anexpanded discussion and alternatives can be found in ACSM’S Resource Manualfor Guidelines for Exercise Testing and Prescription.Identification and risk stratification of persons with CVD and those at highrisk of developing CVD are facilitated by review of previous test results, such ascoronary angiography or exercise nuclear or echocardiography studies (6). Additionaltesting may include ambulatory electrocardiogram (ECG) (Holter) monitoringand pharmacologic stress testing to further clarify the need for and extentof intervention, assess response to treatment such as medical therapies and revascularizationprocedures, or determine the need for additional assessment. As outlinedin Box 3.3, other laboratory tests may be warranted based on the level ofrisk and clinical status of the patient. These laboratory tests may include, but are
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