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