Chest pain or discomfort Etiology 1 Cardiac 2

Chest pain or discomfort

Etiology 1 -Cardiac 2 -Intrathorcic Structuers aorta – PA – Bronchopulmonary tract- pleura – Mediastinum – Esophagus - diaphragm 3 -Neck Structure 4 -Thoracic wall ( Breast , ribs - spine nerve – spinal cord - thoracic cage ) 5 -Subdiaphragmatic organ (Stomach – duodenum – pancreas -gull bladder )

Common Cause 1 -Anxiety 2 -Fibromyaligia 3 -Gi – tract ( esophagus – Stomach deudenum – gall bladder – colon pancreas – Spleen – Abcess ) 4 -Pulmonary ( PTE – Pnumothorax – PH – Pleural – Pnumonia –Bronchitis )

Approach 1 - History 2 - Physical exam 3 - ECG

History of Present Illness (HPI) The following 8 elements are recognized: Location: low back pain Quality: describes discomfort as: pressure Severity: severity of condition is worsening Duration: condition has existed for one month Timing: pain is worse in the morning Context: pain occurred after lifting baby Modifying Factor: sociated signs and symptoms: pain radiating to the arm and shortness of breath

History 1 - PQRST precipitating factor 2 -Quality 3 -Radiation – relief Region repitation ( frequency ) 4 -Severity , Site 5 -Timing ( duration)

Quality 1 - Burning 2 -Sqeezing 3 -Pressing 4 -Bursting 5 -Knif like 6 -Pluretic 7 -With movement 8 -Dyspnea 9 -Stherotype

Location 1 - Precordial 2 -Substernal 3 -Superficial 4 -Deep 5 -Lochalized 6 -Area 7 -Submammary 8 -Right Lower chest

Precipitafing Factor 1 - Exertion ( Special with emotion ) Walk up – Cold _ After Meal 2 -Strong emotional stress 3 -Smoking 4 - Prinzmetal Angina 5 - Breathing 6 - Womiting 7 - Rest 8 - Bending 9 - Body movement

Duration - 2 – 10 min - < 2 min - >10 min - Proloned

IHD 1 - Asymptomatic 2 - Nonanginal CP 3 - Athypicak Angina 4 - Thypical Angina 6 - MI 7 - CHF 8 - SCD

Angina Equivalent 1 -Dyspnea 2 -Unusual Location ( Left arm , Lower Jaw , teeth , neck , Shoulders) 3 -Bleching 4 -Nausea 5 -Indigestion 6 -Dizziness 7 -Diaphouesis

Musculoskeletal 1 -Cervical Spine 2 -Thoracic Spine 3 -Myositis 4 -Synovitis 5 -Artheritis 6 -Teitze Syndrome

Review of Systems (ROS) Patient has the following complaints: nstitutional: fevers, chills and night sweats Eyes: she also complains of itchy eyes ENT: nasal congestion, drainage from ear Respiratory: she reports shortness of breath Cardiovascular: left sided chest pain Gastrointestinal: diarrhea, constipation, abdominal pain Genitourinary: blood in urine Allergies : allergic to cypress, pine nuts, peanuts “Remainder of the review of systems are negative” •

ROS For a complete ROS ten organ systems must be reviewed The attending physician may use “remainder of the review of systems are negative” when (2) pertinent positives and/or negatives are documented In absence of such a notation, all systems must be documented Applies to CPT codes: 99222, 99223, 99254, 99255 which require 10 + ROS

ENd