MODULES FOR
SCREENING PHYSICAL EXAM

HISTORY MODULE

Article

Lewis, J. (2000).  The role of the NP in the diagnosis and management of erectile dysfunction.  Supplement to The Nurse Practitioner 25 (6), 14-18

Several ideas for approaching a sexual history, including questions specific to evaluation of ED.

Lewis Article

http://www.dhep.astate.edu/physdiag/articles/LewisArticle.pdf

BREAST AND AXILLA ASSESSMENT

CARDIAC ASSESSMENT

Articles

McGrath, D. (2000). Analyzing a 12-Lead ECG-and adding other leads. The American Journal for Nurse Practitioners 4 (5) pp 9-21.

McGrath Article

http://www.dhep.astate.edu/physdiag/articles/mcgrath_article.pdf

Crotty, G.D. (2000) Right and left bundle branch blocks. Patient Care for the Nurse Practitioner 3 (6) pp 59-69.

Crotty Article

http://www.dhep.astate.edu/physdiag/articles/crotty_article.pdf

PERIPHERAL VASCULAR ASSESSMENT

THORAX AND LUNGS ASSESSMENT

Web Site for review

http://www.med.ucla.edu/wilkes/intro.html

“The Ausculation Assistant”

Site offering heart and lung sounds. The learner is assisted by a description of anatomy and physiology associated with sounds, audio examples and comparison of various sounds to help discriminate normal from abnormal and one sound from another.

Site takes a few minutes to load-good time to take a break, stretch, re-introduce yourself to people living with you, pet the dog, etc.

PEDIATRIC ASSESSMENT

Web Sites

http://www.aap.org/bpi/default.htm

“The Pediatric Internet: Reviews of Internet Resources by AAP Fellows”

Many sites. Excellent resource for references, subspecialties, organizations.

http://www.aap.org

Website for the American Academy of Pediatrics. Interesting professional education with emphasis on pediatric care and issues.

http://www.duq.edu/nursing/resick/newborn

“Physical Assessment of the Newborn”

Pictures and descriptions of examination, organized by systems.

http://www.vh.org/VCH/CommonProblems/CommonProblems.html

“Common Problems in Pediatrics”

Children’s Hospital of Iowa site. Many pediatric physical and psychosocial conditions are linked to various on-line resources; many text-based, some with slides. You will probably want to bookmark this site for future use as you enter your pediatric management clinical.

http://www.ironpanel.org.au/AIS/AISdocs/childdocs/Ccontents.html

“Iron Deficiency in Children. A Comprehensive Management Guide”

Thorough information describing the pathology, diagnosis, and treatment.

http://www.vh.org/Providers/ClinRef/FPHandbook/Chapter10/12-10.html

“Failure to Thrive”

University of Iowa Family Practice Handbook excerpt with characteristics and treatments for failure to thrive.

http://www.eatright.org/adap0199a.html

“Fitness Pyramid for Kids” at American Dietetics Association site.

Recommendations for healthy activities along with frequency and duration.

http://www.eatright.org/child/

“Child Nutrition and Health Campaign” at American Dietetics Association site

Lots of information and guidelines for childhood nutrition.

http://www.aap.org/profed/

“Online Otitis Media Case Studies and Pneumatic Otoscopy Course”

Scroll through the offerings and access this helpful course through the American Academy of Pediatrics Professional Education site.

Web Site for review

The otoscopy course is anticipated to take 45 minutes. You’ll see the case studies again in Primary Care course as you learn management of otitis media. One nice use of them now is a chance to evaluate various tympanic membranes of different colors, with and without pus and even their degree of motility-nifty!

NUTRITION OF INFANCY

EAR ASSESSMENT IN CHILDREN

Web Sites for review

http://www.tnpj.com/ce/j004b.htm

M.K. Prisco (2000).  "Evaluating Neck Masses"  The Nurse Practitioner

A continuing education program available through the journal's website.

Comprehensive description of the examination and implications

GERIATRIC ASSESSMENT

Web Sites

http://www2.kumc.edu/instruction/medicine/GeriRes/unit2/physicalexam.htm

“History and Physical Exam Findings among Older Adults: What is Normal?” Site focuses on changes on physical examination found in elders.

Organized by systems.

http://www.mayo.edu/geriatrics-rst/PFA_ToC.html

“Topics in Geriatrics. Practical Functional Assessment of Older Adults”

Mayo Clinic site with information about practical functional assessment of elders and their abilities

http://www2.kumc.edu/instruction/medicine/GeriRes/unit3/unit3.htm

“Functional Assessment of Geriatric Patients”

Functional assessment is important measure of health, especially in elders.

People age at different rates and illnesses affect us differently. Function is an objective measure that a care provider needs to understand.

Self instruction modules in geriatric medicine-wide variety of topics.

Pre-test available; you can also skip ahead to “Learning Module.”

http://www.mayo.edu/geriatrics-rst/Pearls.html

“Geriatric Care Pearls”

Mayo Clinic site. A quick read with clinical “pearls” to incorporate in physical examination.

http://www.sfu.ca/sonic-studio/Presbycusis.html

“Presbycusis”

Site with graph showing rates of hearing loss according to gender and age. Also discussion as to possible causes of presbycucis, a common hearing loss as one ages, though it is not probably not entirely related to aging processes alone.

http://www.agenet.com/aging_hearing.html

“Hearing and Older People”

Tips on recognizing signs of hearing loss and interacting with hearing-impaired individuals. Consumer-oriented, but quick read and interesting information.

http://www.urbanext.uiuc.edu/elderabuse

“Elder Abuse and Neglect: Is This Elder Abuse?”

Signs of elder abuse. A problem that parallels child abuse, though often not recognized as often or followed up as aggressively.

MUSCULOSKELETAL AND NEUROLOGICAL ASSESSMENT

Article

O’Hanlon-Nichols, T (1999). Neurologic Assessment. American Journal of Nursing 99 (6) pp 44-50.

A general overview of the multiple components of the neurologic exam.

3. Instrument

Mini-Mental State Examination (MMSE)

A classic instrument to evaluate cognitive function.

Quick and relatively easy to use; highly regarded and reliable.

Web Sites

http://www.mayo.edu/geriatrics-rst/Dementia.I.html#RTFToC2


Mayo Clinic Geriatric site. Defines a variety of cognitive disorders. Particularly note the differences between delirium (fast onset/usually reversible) and dementia (slow onset/ irreversible).

http://depression-screening.org

Information about etiology, diagnosis, and treatment of depression. There is a screening test available for you (traditionally, the need comes up just after the first pharmacology examination) or patients.

http://depression-info.com

Patient education focused site with variety of information about depression.

Additional mental health issues you may want to explore include addictions; disorders related to anxiety, behavior, eating, mood, personality; and schizophrenia. These conditions are frequently related to physical health problems and are commonly seen in health care settings.

http://www.snap.com is one of several search engines that can help you find information.

SKIN ASSESSMENT

HEAD, SCALP, FACE ASSESSMENT

HENT - EAR PORTION (ADULTS) ASSESSMENT

HENT - NOSE AND SINUSES PORTION ASSESSMENT

HENT - MOUTH AND THROAT PORTION ASSESSMENT

HENT - NECK PORTION ASSESSMENT

Web Site for review

http://nurses.medscape.com/22671.rhtml

Article:  "Primary Care Dermatology Roundtable:  Common Dermatologic Conditions Seen in Primary Care Practice"

Conditions covered are 1) sun damage, moles, and skin cancer; 2) hair loss;

Site with a wide variety of conditions; include diagnosis (pictures!!) management, and patient education information

EYE ASSESSMENT

ABDOMEN ASSESSMENT

Web Site for Review:
http://www.tnpj.com/ce/j612a.htm

Stone, R. (1996). Primary Care Diagnosis of Acute Abdominal Pain. The Nurse Practitioner.

Continuing education article, organized into sections, so you can focus on assessment and diagnosis components for this course. Has bolded “rapid read” sections that help you skim content.

HENT - HEAD AND SCALP, FACE PORTION ASSESSMENT

MALE GENITALIA ASSESSMENT

Web Site

http://medstat.med.utah.edu/WebPath/webpath.html#menu

Interesting slides of different pathologies. Some are gross anatomy, while others are sections of pathology. Have to use your imagination with sections, but helpful to see what prostate carcinoma is in situ, etc.

URL takes you to main page. Choose “Organ System Pathology Menu” which takes you to another menu of slides, organized by systems.

Recommended slides:

Female Genital Pathology Index – Slides 4, 5, 14-17

Male Genital Tract Pathology – Slides 3, 4, 11, 18, 19

Articles

Padma-Nathan, H. & Forrest, C. (2000). Diagnosis and treatment of erectile dysfunction: The process of care model. Supplement to The Nurse Practitioner

25 (6) pp 4-10.

Shinopulos, N. (2000). Bedside urodynamic studies: Simple testing for urinary incontinence. The Nurse Practitioner 25 (6) pp19-28, 33-37.

PELVIC ASSESSMENT

Pap Smear

Evaluation of Neoplasia of the Female Lower Genital Tract

http://www.oncolink.upenn.edu/classroom/colp/

National Cervical Cancer Coalition Cervical cancer information center

http://www.nccc-online.org/

Discussions in Pap Smear Screening Historical development of the Pap smear.

http://www.obgyn.net/women/features/whfv11_b.htm

Refinements and Replacements for the Conventional Pap Smear

http://www.obgyn.net/industry/articles/980422_lpap.htm

SOAP DOCUMENTATION FORMAT

WebSites

http://www.aafp.org/fpm/980400fm/lead.html

“Coding and Documentation Made Easier”

A good basic introduction to all this coding mystery. No Colonel Mustard, but a mystery all the same.

http://www.aafp.org/fpm/medicare/

“Mastering Medicare’s Documentation Guidelines”

List and links with several articles endorsed by the American Academy of Family Practice that are pretty down to earth in describing the guidelines and helping you develop documentation skills.

http://www.medicaretraining.com

Source for self-paced Medicare documentation training, sponsored by HCFA-the people who brought this misery.

http://www.medscape.com

Medscape – a free site with up-to-date information related to health care.

You will need to register to access the following article. You can also sign up for automatic updates on listserves of interest to you (Primary Care and Nursing usually have several articles of interest to me each week)

http://nurses.medscape.com/CBuppert/GreenSheet/2000/v02.n06/green0206.html

“How to Make Sure Your CPT Codes Match Your Notes”

http://cpmcnet.columbia.edu/dept/ps/guidelines/

“ Documentation Guidelines for CPT Evaluation and Management (E&M) Services”

Basic overview of documentation required by Medicare and insurance companies for reimbursement. Charts identify categories of information needed for each type/level of visit.
WebSites

http://www.aafp.org/fpm/980400fm/lead.html

“Coding and Documentation Made Easier”

A good basic introduction to all this coding mystery. No Colonel Mustard, but a mystery all the same.

http://www.aafp.org/fpm/medicare/

“Mastering Medicare’s Documentation Guidelines”

List and links with several articles endorsed by the American Academy of Family Practice that are pretty down to earth in describing the guidelines and helping you develop documentation skills.

http://www.medicaretraining.com

Source for self-paced Medicare documentation training, sponsored by HCFA-the people who brought this misery.

http://www.medscape.com

Medscape – a free site with up-to-date information related to health care.

You will need to register to access the following article. You can also sign up for automatic updates on listserves of interest to you (Primary Care and Nursing usually have several articles of interest to me each week)

http://nurses.medscape.com/CBuppert/GreenSheet/2000/v02.n06/green0206.html

“How to Make Sure Your CPT Codes Match Your Notes”

http://cpmcnet.columbia.edu/dept/ps/guidelines/

“ Documentation Guidelines for CPT Evaluation and Management (E&M) Services”

Basic overview of documentation required by Medicare and insurance companies for reimbursement. Charts identify categories of information needed for each type/level of visit.

POMRSOAP

Documentation Module

Evaluation and Management (E/M) Documentation
The Health Care Financing Agency (HCFA) has developed a standardized

set of documentation guidelines for Evaluation and Management (E/M) services.

These are services reimbursed under Medicare, Part B. Many Advanced Practice Nurse activities fall within these services.

Your documentation of activities on a visit to a patient in the clinic/office or hospital to assess (EVALUATION) health status and manage (MANAGEMENT) care is the basis for reimbursement for your services.

Even though you may think you already know how to chart, doing it for reimbursement based on that charting is now a whole new world. Fortunately many clinical settings know that providers can only keep so much in their brains before it starts to leak, so they often come up with reminder/cues for the most common activities on the patient fee tickets (some places call these the “superbill” and there are other names, but they usually make sure you learn them fast because that is where the money is.)

Diagnosis Codes (ICD-9-CM)
Each diagnosis has a code. Specificity is important-sometimes it goes to extremes. You would think it would be enough to know someone broke their leg. You probably agree it is not too picky to describe what kind of fracture and which leg. Well, diagnostic codes can be as specific to identify how the patient broke their leg-riding a horse? Car accident (driver, passenger, pedestrian)? Boating accident (at the dock, in the water, alcohol involved)? They are incredibly specific and picky. (That is why people who do this kind of billing and help us make sense of it pretty much have guaranteed jobs right out of school.)

Common Procedural Terminology (CPT) Codes
In addition to E/M codes, there are CPT (Common Procedural Terminology) codes that indicate procedures. There is another whole thick book of these codes. Many different activities are coded; everything from ear cleaning to intubation.

Objectives/Stuff you will be practicing in clinical:

1. Document care activities according to guidelines

2. Determine a level of service (how much work you documented-not necessarily everything you did, especially if you hurry through charting.) You can only bill for what you DOCUMENTED that you did. Remember that annoying saying that never seems to go away “If it’s not charted; it’s not done.” Well it applies here too!

3. Code your services. This applies to chosing the code that matches the level of documentation you have charted. There are a variety of codes you will learn. Many change just as you learn them; fortunately the basic ones have not (yet!)

4. Not finished yet-make sure you identify all the diagnoses you addressed on this visit. Rank them in order of priority (to the patient, not just you. You may be more than a bit concerned that the patient complaint of foot pain was just the tip of the iceberg. After all, the reason the foot hurt was the peripheral neuropathy, secondary to the undiagnosed diabetes, that decreased sensation and led him to put his feet in scalding water, resulting in third degree burns. You will add all those to your list, but he did have a chief complaint of foot pain and you certainly cannot argue that he must be hurting-made me hurt to look at the fellow who presented this way as a walk-in patient at the very end of a busy morning!)

5. Almost the end, link all diagnoses with the associated laboratory test and/or procedure. Billing people get very grumpy if you do not do this. You want them to like you -they know all these numbers that led to your work getting reimbursed which leads to your paycheck, which probably keeps the roof over your head, etc.

Laboratory Module

Purpose of this information is to introduce students to common laboratory tests conducted by nurse practitioners in primary care areas.

The two most common microscopic tests performed by NPs are urinalysis and wet preps.

Reading Assignment

Fischbach, Frances (1999). Manual of Laboratory and Diagnostic Tests (6th Edition). Philadelphia: Lippincott Publishing Company
Students will select readings based on needs identified during clinical experience.