1. Chest pain or discomfort

2. 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 )

3. Common Cause 1-Anxiety2-Fibromyaligia 3-Gi – tract ( esophagus – Stomach deudenum – gall bladder – colon pancreas – Spleen – Abcess ) 4-Pulmonary ( PTE – Pnumothorax – PH – Pleural – Pnumonia –Bronchitis ) 5-MVP

4. Approach 1- History 2- Physical exam 3- ECG 4- Other exam

5. History of Present Illness (HPI) The following 8 elements are recognized: 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

6. History 1- PQRST precipitating factor precipitating factor2-Quality 3-Radiation – relief Region repitation ( frequency ) 4-Severity, Site 5-Timing ( duration )

11. Quality 1- Burning 2-Sqeezing3-Pressing4-Bursting 5-Knif like 6-Pluretic 7-With movement 8-Dyspnea9-Stherotype

12. Location 1- Precordial 2-Substernal3-Superficial4-Deep5-Lochalized6-Area7-Submammary 8-Right Lower chest

13. 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

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

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

16. Angina Equivalent 1-Dyspnea 2-Unusual Location ( Left arm, Lower Jaw, teeth, neck, Shoulders) 3-Bleching4-Nausea5-Indigestion6-Dizziness7-Diaphouesis

17. Musculoskeletal 1-Cervical Spine 2-Thoracic Spine 3-Myositis4-Synovitis5-Artheritis 6-Teitze Syndrome 7-Herpes Zoster

18. Review of Systems (ROS) Patient has the following complaints: Patient has the following complaints: Constitutional: 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 ” “ Remainder of the review of systems are negative ”

19. 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

20. ENd