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| Back To the Basics ll- Diagnostic Tests for the Clinician |
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by Bob Blumm, MA, PA-C, DFAAPA - March 14, 2011
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This is the second in a series that is designed to help clinicians make better choices for testing and for new clinicians to refresh their memories on what is available to us in the diagnostic testing universe.
Bone Radiographs: This is important for the provider who finds himself treating injuries in emergency rooms, occupational medicine, urgent care clinics and primary care. Many of our patients present with what they feel are sprains or strains, yet by their very presence there remains a question as to the reality. Unless a bone is sticking out of their leg (compound fracture) some will feel that it’s just another one of those injuries that requires a prescription and crutches or a sling. Bone x-rays are the proper test for traumatic injuries that do not meet other criteria (Ottawa Criteria) to limit or prevent radiographs. For the person who has the proper basics and has read a large number of x-rays, we can tell the difference between buckle fractures, simple fractures, comminuted fractures, spiral fractures (seen often in abuse), foreign bodies and even pathological tumors presenting coincidently because of a fracture. This is a test that all clinicians are encouraged to master as missed diagnosis on a child and a Salter-Harris fracture with deformity is reason to spend time in the Supreme Court. Many radiologists will allow a clinician to sit down, and they read and dictate their x-rays for the day.
Breast Studies: There remain a number of studies to r/o carcinoma of the breast, and depending on a patients history, there needs to be more advanced tests on certain individuals. Women’s health groups will provide the testing ages and suggested studies but dense breasts and breasts of women that have multiple family members may need more than a basic exam. Mammography is probably the best known and often feared test for women because of discomfort and has an accuracy rate of 90%. This can be interpreted as a 10% failure to diagnose rate. Sometimes these exams include an ultrasound to distinguish between hollow masses such as cysts versus more solid masses which could be fibroadenoma or possible carcinoma. There is also investigation for calcified masses which occurs more often in CA of the breast. If you have a family history and siblings or maternal relatives who have had cancer of the breast, many surgeons are now choosing MRI of the breast. Yes, this is more expensive, but we are talking about a diagnostic test that may save a patients life. Breast Scintigraphy is for those with dense fibrotic breasts who can easily mask a breast tumor. What is the best breast exam? The one that meets the need of the hour!
Cardiac testing: Cardiac catheterization is among the best known of all of these and is used predominantly to r/o CAD. This contrast exam studies defects in heart chambers, valves and in the vessels themselves. Theses exams are done in a hospital because of the possibility of stenting a person with high grade obstruction as well as treating them from possible anaphylaxis from the contrast media. It is suggested by most clinicians that the patient stop Glucophage 48 hours before and after this exam and that their renal studies are normal to prevent an acute renal failure. These tests also include stress testing with contrast and then a stress echocardiogram. For those with diseases such as HCM and the possibility of needing an internal defibrillator, it is prudent to have an MRI of the heart to have perfectly accurate indications in reference to function and thickness of the septum. Cardiac Stress tests with or without contrast are done routinely in a cardiology office. A Doppler monitor can record all activities of the heart within a 24 hour period and should be done annually on those patients with documented heart disease.
Doppler studies of the Carotids: As we age and as we develop certain cardiac problems, it is prudent to order carotid artery duplex scanning which employs Doppler and B-Mode to study vertebral and extra cranial carotid artery occlusions and stenosis. This is a manner of preventing stroke in individuals with severe narrowing and giving them a surgical alternative.
Information concerning these tests and others related to surgery and chapters dedicated to first assisting can be found in a 2009 released book; Assisting in Surgery: Patient Centered Care by Jane C. Rothrock, PhD, RN, CNOR, FAAN and Patricia C Seifert, RN, MSN, CNOR, CRNFA, FAAN. This book is published by CCI and is a multidisciplinary book meant for techs, nurses, PAs, NPs and physicians.
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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| Bob blumm (Amityville, NY) |
on 16 Mar 2011 at 6:15 am |
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Thank you for your input. My responsibility in these articles are to demonstrate the tests that are available to uncover disease and to stop its proliferation.I am not aware of the insurance prohibitions which is why we look to you, the clinician who orders these exams, to give your input so that this all can be sorted out for the good of the patient and the safety of the clinician from a medical-legal standpoint. Thanks again.
Bob |
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| C Brittsan, PA-C, RVT (South Carolina) |
on 15 Mar 2011 at 11:01 pm |
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| Note that Medicare and many other insurance companies will not pay for a random outpatient carotid duplex order without symptoms of a TIA or stroke, or without a history of a known stenosis. This is because studies showed that random testing in an aging but asymptomatic population is not cost effective. Exception: Medicare will pay if the order is placed within the first month or so of signing up with Medicare. |
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