Disclosures • None related to this topic Physical Assessment Kenneth Wysocki PhD, FNP-BC, FAANP Objectives • Identify history components to establish differential diagnosis and management plan • Demonstrate advanced physical exam skills that support differential diagnosis and management plan Complete physical or focused exam? • Identify and demonstrate physical assessment components in the Medicare Advantage Program assessment visit Complete physical Focused exam • New patient • Concern, issue/problem, injury, work/DOT? • Pre surgery • History of Present Illness – OLDCARTS • Work/DOT • Onset • Location (radiation) • Welcome to Medicare • Duration • Medicare Advantage Program • Character • Aggravating factors • Relieving factors • Timing • Severity Problem Solving Chief complaint and demographics Clinical Reasoning: Differential Diagnosis Identify possible diagnoses STOP. THINK. What’s related to CC? Match possible diagnoses with - Anatomy findings that support (rule in) or - Systems/Physiology eliminate (rule out) diagnoses - Predisposing conditions Begin differential diagnosis thinking Determine top 3 most likely diagnostic hypotheses/ Guides assessments assessments - Subjective - Objective Sorting the results Subjective CC – HPI OLDCARTS • 70-75% (or more) of the diagnosis is in the history Pertinent ROS • Reasons for assessment • Problem focus • Medication reconciliation • Treatment revaluation • Complete physical • Active listening • History of present illness (HPI) • Review of systems (ROS) • Past medial history / Family history (PMH/FH) • Environmental exposure very important • Epigenetics Objective What about Genomics? • Direct to consumer genetic testing (subjective finding) • Focused exam • Parkinson's • Diagnostic tests to delineate vs. CYA • Late-onset Alzheimer's • Order diagnostic ONLY if it will change your • Celiac disease treatment • Early-onset Primary Dystonia (a movement disorder) • Alpha-1 Antitrypsin Deficiency (which elevates your risk for lung and liver disease) • Complete physical exam • Factor XI deficiency (a blood clotting disorder) • Pre surgical • Hereditary thrombophilia (another blood clot disorder. • Gaucher disease type 1 (an organ and tissue disorder) • Work / DOT • G6PD (a red blood cell condition) • Medicare/Medicaid • Hereditary Hemochromatosis (an iron overload disorder) • Diagnostic tests may be pre determined • Bloom Syndrome (elevates risk for cancer) • Clinical genetic testing (objective data through diagnostics) • Choose wisely • Pharmacogenomics • Disease risk and confirmation http://www.choosingwisely.org Beware of: Genetic blueprint or Pandora box? • Incomplete diagnostic decision making • Economic, ethical, legal, and societal impact • ignoring data that doesn’t support your diagnosis • failing to recognize other diagnostic possibilities • False reassurance in family members with undiscovered risk • failing to recognize information that confirms a • Unnecessary alarm in others with undiscovered protective factors diagnosis • Genotype that doesn’t match phenotype • Using a broad assessment term when data exists • Genetic variants with no known functional significance to identify a more specific diagnosis • i.e., epigenetics and downstream elements • Failure to discriminate between multiple • Very small genetic association effect size concurrent problems versus multiple symptoms of a single problem • Complex genome, lifestyle, environment interactions • Chronic disease may point towards environmental factors • Making assumptions • Unraveling the complete causal pathways may not be possible • Overconfidence/insecurity Complete Physical Assessment Integumentary • Hair • Abdomen • Inspect • Eyes • Musculoskeletal • Acral - affecting distal areas, hands and feet. • Extensor - extensor surfaces, elbows, knees. • Ears • Vascular • Flexural - flexural surfaces, axillae, genital areas, cubical fossa. • Nose • Neurological • Follicular - arising from hair follicles. • Mouth • Motor • Dermatomal - corresponding with nerve root distribution. • • Neck • Coordination Koebernised - arising in wound or scar. • Seborrheic - associated with areas where there are sebaceous glands, face • Pulmonary • Integumentary and scalp • Cardiac See handouts Integumentary Integumentary • Size/shape • Temperature • Annular - open circles. • Color • Discoid (or nummular) - filled circle. • Secondary change (Scaling, crusting, lichenification, keloid) • Arculate - incomplete circles. • Morphology/margin (Asymmetry, border, diameter, raised) • Recticulate - fine lace-like pattern. • Texture (Soft/rough, thin/thick, tight/supple) • Stellate - star shaped. • Digitate - finger shaped. • Turgor • Linear - straight line. • Vascularity (capillaries, petechiae, capillary refill time) • Serpiginous - snake-like. • Edema • Whorled - swirling pattern • Lesions • Hair/scalp/eyebrows/eye lashes • Nails (clubbing, thickness, fungal changes) Hands on workshop Hands on workshop • Thyroid exam • MS - knee and shoulder • CV • Knee: https://www.youtube.com/watch?v=B76oGAFKb28 • Shoulder: • Neuro Normal Abnormal • https://www.youtube.com/watch?v=TDs1IOFYnMo • Romberg • Range of motion • Nose to finger • Gait See handout Break Medicare Advantage Program • Medicare advantage program has grown from 9.3 million individuals in 2008 to over 17 million in 2015 (representing 32% of all Medicare beneficiaries. • In 2014: MA program included 3,600 plan options, 15.8 million beneficiaries (30% of all Medicare beneficiaries), and paid approximately $159 billion to cover Part A and Part B services (Medpac report to congress, March 2015) Medicare/Medicaid In-home Visits Risk Scores • Health plans with a Medicare Advantage program receive monthly capitated payments for each Medicare enrollee (and are • Improving elder care and health outcomes prospective) • Identify undiagnosed conditions • Base rate as national average health status • Expand continuum of care options with complex chronic are needs • Risk score relative to the national average beneficiary • • Remedy home health dangers (i.e., loose rugs, expired or incompatible drugs, Risk score to adjust health plan payment from Medicare abuse) • CMS-hierarchical condition category (CMS-HCC) risk adjustment • Reduced hospital readmission rate model • Demographic characteristics (i.e., age, gender, Medicaid status, • Home is Clinical Setting institutional status, eligibility based on disability, and eligibility based on • CMS Focus: “Best Practices” and Quality Scores age but originally eligible because of disability. • Medical condition (recorded on physician, hospital outpatient, and hospital inpatient claims in the base year) • Hierarchy: if diagnoses maps into more than one HCC for a specific condition only the highest cost HCC is used 79 Hierarchical Condition Categories Star rating 1-5 for MA Bonus • Plans that do not achieve an overall score of at least 4 stars run the risk of CMS canceling their contract • Examples • Healthcare Effectiveness Data and Information Set (HEDIS) • Chronic Kidney Disease • (e.g., BMI, functional status) • Major Depressive Disorder • • Congestive Heart Failure Consumer Assessment of Healthcare Providers and Systems for MA (CAHPS- MA) • Myocardial infarction • (e.g., annual flu vaccine, care coordination, getting needed care) • Colorectal cancer • COPD • Health Outcomes Survey (HOS) • Hip fracture • (e.g., improving or maintain physical health or mental health) • Cerebral Hemorrhage • CMS administrative measures • Atrial Fibrillation • (e.g., clients choosing to leave the plan, beneficiary access and • Prostate Cancer performance problems) • Part D clinical measures • (e.g., medication interaction and management of treatment) Chart Composition • Patient demographics Chart Composition (cont.) • Consent • Functional status (i.e., Katz ADL, continence, assistive devices, CPAP) • Hospice care? • Depression screen • Provider information • Review of systems • Healthcare Durable Power of Attorney (DPOA)/Proxy • Lab data • Advance directive • Nutrition / BMI • Observation of environment and safety • Fall risk assessment • Diabetes history / “interactive term” assessment • Medical history • Physical exam • Medications and allergies • Mini cognitive exam • Admission history • Diagnosis and management plan • Health maintenance (i.e., spirometry, eye exam, vaccinations, • Care management referral / patient education colonoscopy, mammogram, fecal occult blood test) • PCP communication or emergent medical need • Personal and social history • Labs obtained or left behind • Family health history (i.e., CAD, CA, DM, CKD, etc.) • Provider signature, credentials, and date of service • Health behaviors (i.e., anxiety, sleep, tobacco, alcohol, exercise) Clinical Pearls for ICD-10 Documentation Clinical Pearls for ICD-10 Documentation • Coronary Artery Disease • Morbid obesity • MI, stent or CABG trumps, but diagnosis and documentation of follow up • Include BMI >40 and calorie intake or other disease process dates with specialist will suffice • Malnutrition • Peripheral Arterial Disease • Include BMI <17.5, poor caloric intake, weakness/debilitation and signs of • document R or Left femoral stents, but diagnosis and documentation of follow cachexia or severe muscle wasting in physical exam. up dates with specialist will suffice • Diabetes with retinopathy • Alzheimer’s • Include proliferative (if had laser surgery) and if there is macular edema • document “early onset” if before age 65 and “late onset if after age 65 known • Major depression • Old MI • mild, moderate, or severe