PhysicalAssessmentKennethWysocki

PhD,FNP-BC,FAANP

Disclosures

• Nonerelatedtothistopic

Objectives

• Identifyhistorycomponentstoestablishdifferentialdiagnosisandmanagementplan• Demonstrateadvancedphysicalexamskillsthatsupportdifferentialdiagnosisandmanagementplan• IdentifyanddemonstratephysicalassessmentcomponentsintheMedicareAdvantageProgramassessmentvisit

Completephysicalorfocusedexam?

Completephysical

• Newpatient• Presurgery• Work/DOT• WelcometoMedicare• MedicareAdvantageProgram

Focusedexam

• Concern,issue/problem,injury,work/DOT?• HistoryofPresentIllness– OLDCARTS

• Onset• Location(radiation)• Duration• Character• Aggravatingfactors• Relievingfactors• Timing• Severity

Chiefcomplaintanddemographics

STOP.THINK.What’srelatedtoCC?

- Anatomy- Systems/Physiology- Predisposingconditions

BegindifferentialdiagnosisthinkingGuidesassessments

- Subjective- Objective

ProblemSolvingClinicalReasoning:DifferentialDiagnosis

Identifypossiblediagnoses

Matchpossiblediagnoseswithfindingsthatsupport(rulein)oreliminate(ruleout)diagnoses

Determinetop3mostlikelydiagnostichypotheses/

assessments

SortingtheresultsCC– HPI

OLDCARTSPertinentROS

Subjective

• 70-75%(ormore)ofthediagnosisisinthehistory• Reasonsforassessment

• Problemfocus• Medicationreconciliation• Treatmentrevaluation• Completephysical

• Activelistening• Historyofpresentillness(HPI)• Reviewofsystems(ROS)• Pastmedialhistory/Familyhistory(PMH/FH)

• Environmentalexposureveryimportant• Epigenetics

Objective

• Focusedexam• Diagnosticteststodelineatevs.CYA• OrderdiagnosticONLYifitwillchangeyourtreatment

• Completephysicalexam• Presurgical• Work/DOT• Medicare/Medicaid• Diagnostictestsmaybepredetermined

• Choosewisely

http://www.choosingwisely.org

WhataboutGenomics?• Directtoconsumergenetictesting(subjectivefinding)

• Parkinson's• Late-onsetAlzheimer's• Celiacdisease• Early-onsetPrimaryDystonia(amovementdisorder)• Alpha-1AntitrypsinDeficiency(whichelevatesyourriskforlungandliverdisease)• FactorXIdeficiency(abloodclottingdisorder)• Hereditarythrombophilia(anotherbloodclotdisorder.• Gaucherdiseasetype1(anorganandtissuedisorder)• G6PD(aredbloodcellcondition)• HereditaryHemochromatosis(anironoverloaddisorder)• BloomSyndrome(elevatesriskforcancer)

• Clinicalgenetictesting(objectivedatathroughdiagnostics)• Pharmacogenomics• Diseaseriskandconfirmation

GeneticblueprintorPandorabox?

• Economic,ethical,legal,andsocietalimpact• Falsereassuranceinfamilymemberswithundiscoveredrisk• Unnecessaryalarminotherswithundiscoveredprotectivefactors• Genotypethatdoesn’tmatchphenotype• Geneticvariantswithnoknownfunctionalsignificance

• i.e.,epigeneticsanddownstreamelements

• Verysmallgeneticassociationeffectsize• Complexgenome,lifestyle,environmentinteractions

• Chronicdiseasemaypointtowardsenvironmentalfactors

• Unravelingthecompletecausalpathwaysmaynotbepossible

Bewareof:• Incompletediagnosticdecisionmaking• ignoringdatathatdoesn’tsupportyourdiagnosis• failingtorecognizeotherdiagnosticpossibilities• failingtorecognizeinformationthatconfirmsadiagnosis

• Usingabroadassessmenttermwhendataexiststoidentifyamorespecificdiagnosis• Failuretodiscriminatebetweenmultipleconcurrentproblemsversusmultiplesymptomsofasingleproblem• Makingassumptions• Overconfidence/insecurity

CompletePhysicalAssessment

• Hair• Eyes• Ears• Nose• Mouth• Neck• Pulmonary• Cardiac

• Abdomen• Musculoskeletal• Vascular• Neurological• Motor• Coordination• Integumentary

Seehandouts

Integumentary

• Inspect• Acral- affectingdistalareas,handsandfeet.• Extensor- extensorsurfaces,elbows,knees.• Flexural- flexuralsurfaces,axillae,genitalareas,cubicalfossa.• Follicular- arisingfromhairfollicles.• Dermatomal- correspondingwithnerverootdistribution.• Koebernised- arisinginwoundorscar.• Seborrheic- associatedwithareaswheretherearesebaceousglands,faceandscalp

Integumentary

• Size/shape• Annular- opencircles.• Discoid(ornummular)- filledcircle.• Arculate- incompletecircles.• Recticulate - finelace-likepattern.• Stellate- starshaped.• Digitate- fingershaped.• Linear- straightline.• Serpiginous- snake-like.• Whorled- swirlingpattern

Integumentary

• Temperature• Color• Secondarychange(Scaling,crusting,lichenification,keloid)• Morphology/margin(Asymmetry,border,diameter,raised)• Texture(Soft/rough,thin/thick,tight/supple)• Turgor• Vascularity(capillaries,petechiae,capillaryrefilltime)• Edema• Lesions• Hair/scalp/eyebrows/eyelashes• Nails(clubbing,thickness,fungalchanges)

Handsonworkshop

• Thyroidexam• CV• Neuro Normal Abnormal

• Romberg

• Rangeofmotion

• Nosetofinger

• Gait

Handsonworkshop

• MS- kneeandshoulder• Knee:https://www.youtube.com/watch?v=B76oGAFKb28• Shoulder:• https://www.youtube.com/watch?v=TDs1IOFYnMo

Seehandout

Break MedicareAdvantageProgram

• Medicareadvantageprogramhasgrownfrom9.3millionindividualsin2008toover17millionin2015(representing32%ofallMedicarebeneficiaries.

• In2014:MAprogramincluded3,600planoptions,15.8millionbeneficiaries(30%ofallMedicarebeneficiaries),andpaidapproximately$159billiontocoverPartAandPartBservices(Medpac reporttocongress,March2015)

Medicare/MedicaidIn-homeVisits

• Improvingeldercareandhealthoutcomes• Identifyundiagnosedconditions• Expandcontinuumofcareoptionswithcomplexchronicareneeds• Remedyhomehealthdangers(i.e.,looserugs,expiredorincompatibledrugs,abuse)• Reducedhospitalreadmissionrate• HomeisClinicalSetting• CMSFocus:“BestPractices” andQualityScores

RiskScores• HealthplanswithaMedicareAdvantageprogramreceivemonthlycapitatedpaymentsforeachMedicareenrollee(andareprospective)• Baserateasnationalaveragehealthstatus• Riskscorerelativetothenationalaveragebeneficiary• RiskscoretoadjusthealthplanpaymentfromMedicare

• CMS-hierarchicalconditioncategory(CMS-HCC)riskadjustmentmodel• Demographiccharacteristics(i.e.,age,gender,Medicaidstatus,institutionalstatus,eligibilitybasedondisability,andeligibilitybasedonagebutoriginallyeligiblebecauseofdisability.• Medicalcondition(recordedonphysician,hospitaloutpatient,andhospitalinpatientclaimsinthebaseyear)• Hierarchy:ifdiagnosesmapsintomorethanoneHCCforaspecificconditiononlythehighestcostHCCisused

79HierarchicalConditionCategories

• Examples• ChronicKidneyDisease• MajorDepressiveDisorder• CongestiveHeartFailure• Myocardialinfarction• Colorectalcancer• COPD• Hipfracture• CerebralHemorrhage• AtrialFibrillation• ProstateCancer

Starrating1-5forMABonus• Plansthatdonotachieveanoverallscoreofatleast4starsruntheriskofCMScancelingtheircontract

• HealthcareEffectivenessDataandInformationSet(HEDIS)• (e.g.,BMI,functionalstatus)

• ConsumerAssessmentofHealthcareProvidersandSystemsforMA(CAHPS-MA)• (e.g.,annualfluvaccine,carecoordination,gettingneededcare)

• HealthOutcomesSurvey(HOS)• (e.g.,improvingormaintainphysicalhealthormentalhealth)

• CMSadministrativemeasures• (e.g.,clientschoosingtoleavetheplan,beneficiaryaccessandperformanceproblems)

• PartDclinicalmeasures• (e.g.,medicationinteractionandmanagementoftreatment)

ChartComposition• Patientdemographics• Consent• Hospicecare?

• Providerinformation• HealthcareDurablePowerofAttorney(DPOA)/Proxy• Advancedirective

• Observationofenvironmentandsafety• Medicalhistory

• Medicationsandallergies• Admissionhistory• Healthmaintenance(i.e.,spirometry,eyeexam,vaccinations,

colonoscopy,mammogram,fecaloccultbloodtest)• Personalandsocialhistory• Familyhealthhistory(i.e.,CAD,CA,DM,CKD,etc.)

• Healthbehaviors(i.e.,anxiety,sleep,tobacco,alcohol,exercise)

ChartComposition(cont.)• Functionalstatus(i.e.,KatzADL,continence,assistivedevices,CPAP)• Depressionscreen• Reviewofsystems• Labdata• Nutrition/BMI• Fallriskassessment• Diabeteshistory/“interactiveterm” assessment• Physicalexam• Minicognitiveexam• Diagnosisandmanagementplan• Caremanagementreferral/patienteducation• PCPcommunicationoremergentmedicalneed• Labsobtainedorleftbehind• Providersignature,credentials,anddateofservice

ClinicalPearlsforICD-10Documentation

• Morbidobesity• IncludeBMI>40andcalorieintakeorotherdiseaseprocess

• Malnutrition• IncludeBMI<17.5,poorcaloricintake,weakness/debilitationandsignsofcachexiaorseveremusclewastinginphysicalexam.

• Diabeteswithretinopathy• Includeproliferative(ifhadlasersurgery)andifthereismacularedemaknown

• OldMI• consideredif>4weeksago,includessilentMIifdocumenteddateofEKG

ClinicalPearlsforICD-10Documentation• CoronaryArteryDisease• MI,stentorCABGtrumps,butdiagnosisanddocumentationoffollowupdateswithspecialistwillsuffice

• PeripheralArterialDisease• documentRorLeftfemoralstents,butdiagnosisanddocumentationoffollowupdateswithspecialistwillsuffice

• Alzheimer’s• document“earlyonset” ifbeforeage65and“lateonsetifafterage65

• Majordepression• mild,moderate,orsevereandifsingleepisode,recurrentorunknown)

• Chronicrespiratoryfailure• documentrespiratorydisease,unspecifieddiseaseofthelung,orCHF,andongoingoxygenuse24/7

ClinicalPearlsforICD-10Documentation• Alcohol,Tobacco,orSubstanceabuse• Evidencethatingestioncontributedtophysicalorpsychologicalharmwhichmayleadtodisabilityoradverseconsequences(clearlystated)• Patternofusehaspersistedforatleast1monthorrepeatedlyover12months• Symptomsdonotmeetcriteriaforothermentalorbehavioraldisorderrelatedtoingestioninthesametimeperiod• Documentifuncomplicated/complicated,currentintoxication,alcoholinducedmooddisorder(i.e.,depression),psychosis(delusionorhallucination)

• Osteoarthritis(includelimb,sideandregionofspine)• Ingeneral:• documentlocation,limb,laterality(i.e.,rightupperlobe,partiallungresection)

PEARLS

• Meningealsigns• Kernig’s sign• Brudzinski’s sign

PEARLS• Acuteabdomen• McBurney's sign

• Referredpaininepigastrium• Markle sign

• Jarringlanding• Psoassign

• Extendingthighoractiveflexingofleg• Rovsing's sign

• PalpationinLLQ=paininRLQ• Obturatorsign+/-

• Movementofobturatormusclecausespaintoinflamedappendix

PEARL:Fx determination- Ottawarules

•Kneehttp://www.mdcalc.com/ottawa-knee-rule/

• Age55yearsorolder• Tendernessatheadoffibula• Isolatedtendernessofpatella• Inabilitytoflexto90°• Inabilitytobearweightbothimmediatelyandattimeofexam

(4steps)

PEARLS:Fx determination- Ottawarules•Ankle http://www.mdcalc.com/ottawa-ankle-rule/• paininthemalleolarzoneandanyofthefollowingfindings:• bonetendernessatAorB(Blue)• inabilitytobearweight(foursteps)immediatelyafterinjuryandattimeofexam• Footradiographyisindicated

• Ifpain/bonetendernessinthemidfootzone(Green,CorD)ortheinabilitytobearweight(foursteps)immediatelyafterinjuryandattimeofexam

Otherconsiderations

• Infant– Pediatric• Growthcharts• DenverDevelopmentalExam

• Teen• Sportsphysical

• Olderadult• Multiplechronicdiseases

• Male• Prostate,herniaandscrotal

• Female• Breast,cervicalandovary

Maleexamissues

• Testicularexam• Orchitis?Epididymitis?Varicocele?• Cancertypicallynontender

• Cremasteric reflex• Absentintesticulartorsion,L1-L2spinalinjury,ornerveinjuryfromherniarepair

• Torsionshouldbetreatedwithin6hours,orderultrasound• Expectnormalfindinginepididymitis

• Transillumination ofscrotum• Hydroceleormass?

• Prostateexam• Age50andolder(age45iffirstdegreerelativewithprostatecancerorAfricanAmerican)

• Herniaexam• Paintypicallyresolveswhenreclined,unlessstrangulated• Abdominalpain?

FocusedPhysicalAssessment

• Casescenario• Headache• Earpain• Cough• Backpain• Rightarmnumbness/weakness

References• Choosingcarethatisevidencebased,trulynecessaryandwithoutharm:http://www.choosingwisely.org• Clinicalconceptsforcoding:https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConce• Computer/phoneApp– DXSaurus:http://medicalappreview.blogspot.com/2013/04/dxsaurus.html• Directtoconsumergenetictesting:http://www1.cbn.com/cbnnews/health/2017/april/new-at-home-test-tells-you-if-youre-at-risk-for-these-diseases• Exampleofonewayofbuilding/findingthecorrectICD10code.https://www.webpt.com/blog/post/icd-10-quick-clips-how-to-find-the-correct-diagnosis-code (Justclicknoonthepopupforshort2minuteoverview)• Geekymedicsclinicalskillsoutlinesandvideos:https://geekymedics.com• Growthcharts:https://www.cdc.gov/growthcharts/clinical_charts.htm#Set1• HelpfulsitetotypeindiagnosisandfindcorrectICD10code:http://www.icd10data.com

References• Kneeexamvideo:https://www.youtube.com/watch?v=B76oGAFKb28• Medicalandpharmaceuticalinformationanddecision-supporttools:http://www.pepid.com/primary-care-plus/• Neurologicalexam:http://library.med.utah.edu/neurologicexam/html/home_exam.html

(willrequireyouregisterforapasswordtodownloadthevideos)• OttawaRulesankle:http://www.mdcalc.com/ottawa-ankle-rule/• OttawaRulesknee:http://www.mdcalc.com/ottawa-knee-rule/• Practicalguidetoclinicalmedicine:https://meded.ucsd.edu/clinicalmed/history.htm• RhoadsandJensen(2014).DifferentialDiagnosisfortheAdvancedPracticeNurse• Shoulderexamvideo:https://www.youtube.com/watch?v=TDs1IOFYnMo

Thankyou