Chest pain Chest pain or or discomfort discomfort
Jan 09, 2016
Chest pain Chest pain or or
discomfortdiscomfort
11--CardiacCardiac
22--Intrathorcic Structuers aorta – PA – Intrathorcic Structuers aorta – PA – Bronchopulmonary tract- pleura – Bronchopulmonary tract- pleura – Mediastinum – Esophagus - diaphragmMediastinum – Esophagus - diaphragm
33--Neck StructureNeck Structure 44--Thoracic wall ( Breast , ribs - spine nerve Thoracic wall ( Breast , ribs - spine nerve
– spinal cord - thoracic cage )– spinal cord - thoracic cage )55--Subdiaphragmatic organ (Stomach – Subdiaphragmatic organ (Stomach –
duodenum – pancreas -gull bladder )duodenum – pancreas -gull bladder )
Common CauseCommon Cause
11--AnxietyAnxiety
22--FibromyaligiaFibromyaligia
33--Gi – tract ( esophagus – Stomach deudenum Gi – tract ( esophagus – Stomach deudenum – gall bladder – colon pancreas – Spleen – – gall bladder – colon pancreas – Spleen – Abcess )Abcess )
44--Pulmonary ( PTE – Pnumothorax – PH – Pulmonary ( PTE – Pnumothorax – PH – Pleural – Pnumonia –Bronchitis )Pleural – Pnumonia –Bronchitis )
55--MVPMVP
ApproachApproach
11 - -HistoryHistory
22 - -Physical examPhysical exam
33 - -ECGECG
44 - -Other examOther exam
History of Present Illness (HPI)History of Present Illness (HPI)
The following 8 elements are recognizedThe following 8 elements are recognized : :
Location:Location: low back painlow back painQuality:Quality: describes discomfort as: pressuredescribes discomfort as: pressureSeverity:Severity: severity of condition is worseningseverity of condition is worsening Duration:Duration: condition has existed for one monthcondition has existed for one monthTiming:Timing: pain is worse in the morningpain is worse in the morningContext:Context: pain occurred after lifting babypain occurred after lifting babyModifying FactorModifying Factor::sociated signs and symptoms:sociated signs and symptoms: pain pain radiating to the arm andradiating to the arm and shortness of breathshortness of breath
HistoryHistory11 - -PQRSTPQRST
precipitating factorprecipitating factor22--QualityQuality
33--Radiation – reliefRadiation – relief Region repitation Region repitation ( frequency )( frequency )
44--Severity , SiteSeverity , Site55--Timing ( durationTiming ( duration))
QualityQuality
11 - -BurningBurning22--SqeezingSqeezing33--PressingPressing44--BurstingBursting55--Knif likeKnif like
66--PlureticPluretic77--With movementWith movement
88--DyspneaDyspnea99--StherotypeStherotype
LocationLocation
11 - -PrecordialPrecordial22--SubsternalSubsternal33--SuperficialSuperficial
44--DeepDeep55--LochalizedLochalized
66--AreaArea77--SubmammarySubmammary
88--Right Lower chestRight Lower chest
Precipitafing FactorPrecipitafing Factor11 - -Exertion ( Special with emotion ) Walk up – Exertion ( Special with emotion ) Walk up –
Cold _ After MealCold _ After Meal 22--Strong emotional stressStrong emotional stress
33--SmokingSmoking 44 - -Prinzmetal AnginaPrinzmetal Angina
55 - -BreathingBreathing66 - -WomitingWomiting
77 - -RestRest88 - -BendingBending
99 - -Body movementBody movement
DurationDuration
- -22 – – 1010 minmin
< - < -22 minmin
> -> -1010 minmin
- -ProlonedProloned
IHDIHD
11 - -AsymptomaticAsymptomatic
22 - -Nonanginal CPNonanginal CP
33 - -Athypicak AnginaAthypicak Angina
44 - -Thypical AnginaThypical Angina
66 - -MIMI
77 - -CHFCHF
88 - -SCDSCD
Angina EquivalentAngina Equivalent
11--DyspneaDyspnea
22--Unusual Location ( Left arm , Lower Unusual Location ( Left arm , Lower Jaw , teeth , neck , Shoulders)Jaw , teeth , neck , Shoulders)
33--BlechingBleching
44--NauseaNausea
55--IndigestionIndigestion
66--DizzinessDizziness
77--DiaphouesisDiaphouesis
MusculoskeletalMusculoskeletal
11--Cervical SpineCervical Spine
22--Thoracic SpineThoracic Spine
33--MyositisMyositis
44--SynovitisSynovitis
55--ArtheritisArtheritis
66--Teitze SyndromeTeitze Syndrome
77--Herpes ZosterHerpes Zoster
Review of Systems (ROS)Review of Systems (ROS)
Patient has the following complaintsPatient has the following complaints::ConstitutionalConstitutional:: fevers, chills and night sweats fevers, chills and night sweats
Eyes:Eyes: she also complains of itchy eyes she also complains of itchy eyes ENT:ENT: nasal congestion, drainage from ear nasal congestion, drainage from ear Respiratory:Respiratory: she reports shortness of breath she reports shortness of breathCardiovascular:Cardiovascular: left sided chest pain left sided chest pain Gastrointestinal:Gastrointestinal: diarrhea, constipation, abdominal diarrhea, constipation, abdominal painpain Genitourinary:Genitourinary: blood in urine blood in urineAllergies :Allergies : allergic to cypress, pine nuts, peanuts allergic to cypress, pine nuts, peanuts
““Remainder of the review of systems are negativeRemainder of the review of systems are negative””•
ROSROSFor a complete ROS ten organ systems must For a complete ROS ten organ systems must be reviewedbe reviewed
The attending physician may useThe attending physician may use “remainder “remainder of the review of systems are negative”of the review of systems are negative” when (2) pertinent positives and/or when (2) pertinent positives and/or negatives are documentednegatives are documented
In absence of such a notation, all systems In absence of such a notation, all systems must be documentedmust be documented
Applies to CPT codes: 99222, 99223, 99254, 99255 which require 10 Applies to CPT codes: 99222, 99223, 99254, 99255 which require 10 + ROS+ ROS
ENdENd