Cardiac emergencies and it's nursing managementRakhiYadav53
This presentation discusses cardiac emergencies and the nursing responsibilities in managing them. It defines cardiac emergencies as life-threatening conditions requiring immediate recognition and treatment. The main types covered are angina pectoris, myocardial infarction, congestive cardiac failure, cardiac tamponade, cardiogenic shock, and cardiac arrest. For each, it discusses pathophysiology, signs and symptoms, diagnosis, treatment and nursing management. The presentation concludes that cardiovascular emergencies must be promptly recognized and treated to minimize morbidity and mortality.
The document discusses various postoperative complications including:
1) A case of shortness of breath and chest pain in a 78-year-old man after surgery where the differential includes myocardial infarction, heart failure, arrhythmias, and pulmonary embolism.
2) Risk factors, prevention, and treatment of myocardial infarction and heart failure in the postoperative period.
3) Causes, diagnosis, and treatment of venous thromboembolism including pulmonary embolism.
4) Infectious complications like pneumonia, wound infections, and urinary tract infections along with appropriate workup and management.
This document presents a case study of a 56-year-old man with type 2 diabetes presenting with a non-healing ulcer on his right foot following toe amputation. It provides details of his medical history, examination findings, lab investigations, and discusses diabetic foot ulcers and complications. The key points are:
1) The patient had type 2 diabetes for 10 years and was non-compliant with medication, presenting with a non-healing ulcer on his right foot post amputation of toes.
2) Examination found an irregular ulcer on his right foot with signs of infection. Investigations showed renal dysfunction and hyperglycemia.
3) Diabetic foot ulcers are a major complication
Non Cardiac Chest Pain is a common problem in both primary care and hospital settings. This presentation provides a simplified approach to non cardiac chest pain. It uses a case study to cover the evaluation, differential diagnosis, investigations and management for this common medical problem.
The document discusses the clinical approach to assessing patients presenting with non-cardiac chest pain. It outlines key objectives in rapidly and accurately evaluating these patients to form an accurate differential diagnosis and provide initial therapy. Chest pain is a common complaint, with cardiac and non-cardiac potential etiologies discussed. A focused history and physical exam can help differentiate causes like pulmonary embolism, pneumothorax, esophageal disorders, and musculoskeletal issues. Appropriate diagnosis and treatment depends on the suspected condition and patient stability.
This document contains lecture slides from Dr. J.D. McCourt on various thoracic and respiratory topics. It includes practice questions, discussions of conditions like asthma, COPD, foreign body aspiration, and ARDS. For one practice question, the document indicates that an ABG with a pCO2 of 55 mmHg would indicate respiratory failure in a patient with COPD presenting with shortness of breath. It also provides overview information on the definitions, pathophysiology, presentations, treatments and more for several common pulmonary conditions.
An assignment to write a case study for medical terminology as if I were responsible for writing the patient\'s medical record. An assignment at Colorado Technical University online.
Prevalence of hypertension and its associated risk factors among school age c...Azad Haleem
Hypertension is a major public health problem globally and its prevalence is increasing. This study aimed to determine the prevalence of hypertension and associated risk factors among 2009 school-aged children in Duhok and Erbil, Iraq. The overall prevalence of prehypertension was 5.5% and hypertension was 3.7%. Hypertension was associated with increasing age, male sex, obesity, smoking, physical inactivity, and family history of hypertension. The study recommends regular screening of blood pressure, weight, and height in children to identify at-risk individuals. Preventing risk factors through health promotion programs targeting nutrition, physical activity, and smoking could help reduce future noncommunicable diseases.
Cardiac emergencies and it's nursing managementRakhiYadav53
This presentation discusses cardiac emergencies and the nursing responsibilities in managing them. It defines cardiac emergencies as life-threatening conditions requiring immediate recognition and treatment. The main types covered are angina pectoris, myocardial infarction, congestive cardiac failure, cardiac tamponade, cardiogenic shock, and cardiac arrest. For each, it discusses pathophysiology, signs and symptoms, diagnosis, treatment and nursing management. The presentation concludes that cardiovascular emergencies must be promptly recognized and treated to minimize morbidity and mortality.
The document discusses various postoperative complications including:
1) A case of shortness of breath and chest pain in a 78-year-old man after surgery where the differential includes myocardial infarction, heart failure, arrhythmias, and pulmonary embolism.
2) Risk factors, prevention, and treatment of myocardial infarction and heart failure in the postoperative period.
3) Causes, diagnosis, and treatment of venous thromboembolism including pulmonary embolism.
4) Infectious complications like pneumonia, wound infections, and urinary tract infections along with appropriate workup and management.
This document presents a case study of a 56-year-old man with type 2 diabetes presenting with a non-healing ulcer on his right foot following toe amputation. It provides details of his medical history, examination findings, lab investigations, and discusses diabetic foot ulcers and complications. The key points are:
1) The patient had type 2 diabetes for 10 years and was non-compliant with medication, presenting with a non-healing ulcer on his right foot post amputation of toes.
2) Examination found an irregular ulcer on his right foot with signs of infection. Investigations showed renal dysfunction and hyperglycemia.
3) Diabetic foot ulcers are a major complication
Non Cardiac Chest Pain is a common problem in both primary care and hospital settings. This presentation provides a simplified approach to non cardiac chest pain. It uses a case study to cover the evaluation, differential diagnosis, investigations and management for this common medical problem.
The document discusses the clinical approach to assessing patients presenting with non-cardiac chest pain. It outlines key objectives in rapidly and accurately evaluating these patients to form an accurate differential diagnosis and provide initial therapy. Chest pain is a common complaint, with cardiac and non-cardiac potential etiologies discussed. A focused history and physical exam can help differentiate causes like pulmonary embolism, pneumothorax, esophageal disorders, and musculoskeletal issues. Appropriate diagnosis and treatment depends on the suspected condition and patient stability.
This document contains lecture slides from Dr. J.D. McCourt on various thoracic and respiratory topics. It includes practice questions, discussions of conditions like asthma, COPD, foreign body aspiration, and ARDS. For one practice question, the document indicates that an ABG with a pCO2 of 55 mmHg would indicate respiratory failure in a patient with COPD presenting with shortness of breath. It also provides overview information on the definitions, pathophysiology, presentations, treatments and more for several common pulmonary conditions.
An assignment to write a case study for medical terminology as if I were responsible for writing the patient\'s medical record. An assignment at Colorado Technical University online.
Prevalence of hypertension and its associated risk factors among school age c...Azad Haleem
Hypertension is a major public health problem globally and its prevalence is increasing. This study aimed to determine the prevalence of hypertension and associated risk factors among 2009 school-aged children in Duhok and Erbil, Iraq. The overall prevalence of prehypertension was 5.5% and hypertension was 3.7%. Hypertension was associated with increasing age, male sex, obesity, smoking, physical inactivity, and family history of hypertension. The study recommends regular screening of blood pressure, weight, and height in children to identify at-risk individuals. Preventing risk factors through health promotion programs targeting nutrition, physical activity, and smoking could help reduce future noncommunicable diseases.
This case presentation discusses a 30-year old female patient with diabetic foot ulcer on the right foot. She has a history of type 2 diabetes for 9 years and a burn on her right great toe that developed into an ulcer and was later amputated. Her laboratory investigations show hyperglycemia, proteinuria, and pseudomonas infection in the foot ulcer culture. Her treatment includes antibiotics, insulin, oral hypoglycemics, wound dressing, and patient education on foot care and diabetes management to prevent recurrence.
This document summarizes a 28-year-old Indonesian male patient who presented with abdominal pain, fever, and vomiting. On examination, he was found to have jaundice and tenderness in his right hypochondrium and epigastrium. Laboratory tests showed elevated liver enzymes and bilirubin. Ultrasound revealed gallbladder sludge and dilation of the bile ducts due to a large stone. ERCP confirmed choledocholithiasis with multiple stones in the common bile duct. The provisional diagnoses were ascending cholangitis and cholecystitis.
This document provides information on cardiovascular disorders and two case studies involving patients presenting with chest discomfort.
The first case involves an elderly male patient at a nursing home with chest pain and difficulty breathing. After assessment, the patient is diagnosed with a spontaneous pneumothorax.
The second case involves a young male camper with chest pain that has worsened over 36 hours. Additional information reveals recent recreational drug use. Assessment findings include subcutaneous emphysema and early repolarization on ECG. He is diagnosed with pneumomediastinum from increased intrathoracic pressure from holding in marijuana smoke.
Both cases demonstrate use of the AMLS assessment pathway to evaluate patients with chest discomfort and identify differential diagnoses
Approach to a patient with cardiovascular diseasedrfarhatbashir
This document provides guidance on evaluating patients presenting with cardiovascular complaints such as chest pain, shortness of breath, palpitations, syncope, and edema. It emphasizes taking a thorough history as the key to diagnosis, as initial investigations may be normal. Common life-threatening causes of these symptoms include myocardial infarction, aortic dissection, pulmonary embolism, and tension pneumothorax. The document outlines approaches to categorizing different types of chest pain, dyspnea, palpitations, syncope, and edema. It provides diagnostic criteria and recommends focused physical exams and initial tests such as ECG, CXR, and cardiac enzymes.
This document discusses neonatal hypertension. It begins by outlining topics to be covered, including defining neonatal hypertension, measuring blood pressure in neonates, evaluating causes of hypertension, and managing hypertension. The document then focuses on questions about properly measuring blood pressure in neonates and common causes of neonatal hypertension such as renal issues. Evaluation and treatment of neonatal hypertension is also discussed, including initial testing, choosing antihypertensive medications, and considering long term outcomes. Blood pressure measurement techniques and normal ranges are emphasized.
Clinical tips in cardiovascular emergencies copyAhmed Mohsen
This document provides guidance on evaluating and managing common cardiovascular emergencies. It outlines the leading causes of cardiovascular emergencies, including acute chest pain, dyspnea, syncope, and hemodynamic instability. For patients presenting with chest pain, the priority is to differentiate life-threatening etiologies like pulmonary embolism, acute coronary syndrome, and aortic dissection from less serious conditions. The initial evaluation involves vital signs, ECG, CXR, labs including cardiac enzymes and D-dimer, and potentially CT imaging. Prompt diagnosis and treatment are essential given the high mortality associated with cardiovascular emergencies like out-of-hospital cardiac arrest.
Clinical tips in cardiovascular emergenciesAhmed Mohsen
This document provides guidance on evaluating and managing common cardiovascular emergencies. It outlines the leading causes of cardiovascular emergencies, including acute chest pain, dyspnea, syncope, and hemodynamic instability. For patients presenting with chest pain, the priority is to differentiate life-threatening etiologies like pulmonary embolism, acute coronary syndrome, and aortic dissection from less serious conditions. The initial evaluation involves obtaining vital signs, performing a physical exam, 12-lead ECG, chest x-ray, and cardiac biomarker tests. Emergent conditions require urgent diagnostic testing and treatment to reduce mortality. Timely diagnosis and management is critical for improving outcomes in cardiovascular emergencies.
Surgery case presentation. femoral hernia.Elixir Pokhrel
A 49-year-old female presented with a right inguinal swelling and pain for 15 days. On examination, a 2.5 x 2.5 cm globular swelling was found in the right femoral region that was firm, non-reducible, and dull on percussion. Ultrasound revealed a right femoral hernia. The patient underwent open surgery using the Lockwood approach under spinal anesthesia, which found a right femoral hernia containing 20 ml of peritoneal fluid. Femoral hernias occur when abdominal contents protrude through the femoral canal, presenting as a groin lump with exacerbated pain on bending or lifting. Diagnosis is made through history, exam, and ultrasound, with differential diagnoses including inguinal
This document provides guidance on preoperative care and assessment. It outlines the objectives of preoperative care, which include organizing care and the operating list, understanding surgical, medical and anesthetic assessments, optimizing the patient's condition, obtaining consent, and organizing the operating list. It describes evaluating the patient's history, examination, investigations, preoperative conditions and treatment, and documenting the assessments. Key areas of focus for the patient assessment include cardiovascular, respiratory, gastrointestinal, genitourinary, neurological, endocrine and metabolic conditions. The document provides guidance on identifying and managing preoperative problems, obtaining informed consent, conducting a pre-anesthetic airway assessment, and arranging the operating theater list.
The perioperative period involves preoperative, operative, and postoperative care. During the preoperative phase, the nurse prepares the patient both emotionally and physically for surgery through principles like assessment, education to avoid fears, honesty, and orientation. Physical preparation includes following preoperative orders, enemas, baths, identification bands, and exercises. Postoperative care focuses on monitoring vital signs, fluid balance, pain management, and preventing complications through measures like positioning, deep breathing, and restraining. Education of parents is important for discharge and home care.
The document discusses the specialized care provided to patients in the post-anesthesia care unit (PACU) after surgery. It outlines that the PACU should be located near the operating theater and have sufficient space and monitoring equipment to care for postoperative complications. Common complications addressed include hypoxia, hypotension, pain, nausea and the importance of fluid management. Vital signs and urine output must be monitored closely in the PACU to optimize patient recovery.
The document discusses the pre-operative preparation of patients for surgery. It describes evaluating patients' medical history and health status, conducting physical examinations and medical tests, assessing surgical risks, providing pre-operative treatments as needed, obtaining informed consent, and explaining the procedure and potential complications to the patient. The goal is to carefully prepare the patient and reduce risks prior to surgery.
The document discusses preoperative fasting guidelines and the risks of pulmonary aspiration during surgery. It summarizes a study that compared gastric fluid volume and pH in patients who either fasted overnight or drank 150mL of water 2 hours before surgery. The study found that patients who drank the water had significantly lower gastric fluid volumes (5.5mL vs 17.1mL) after surgery, but similar pH levels. This suggests that allowing clear fluids like water 2 hours before surgery may be safe and help reduce patient discomfort from long fasting times.
Case Report : Integrating Review Inflammation and Commorbid diseasesSoroy Lardo
Diabetes is associated with atherosclerosis and COPD contributed to the chronic inflammation within the systemic vascular. Management of CVI with diabetes and COPD requires multi-disciplinary approach
The document discusses postoperative care in the post-anesthesia care unit (PACU). It outlines assessments and potential complications to monitor for various body systems, including respiratory (atelectasis, hypoxemia), cardiovascular (hypotension, arrhythmias), neurological, pain, hypothermia, nausea and vomiting. Nursing diagnoses and interventions are provided to manage complications and optimize recovery, such as deep breathing exercises to prevent atelectasis, monitoring vital signs and urine output, providing pain relief, and addressing psychological needs before discharge.
This document discusses the preoperative process, which includes physical and psychological preparation of the patient before surgery. It outlines the steps to be followed, including taking a thorough medical history, conducting examinations and investigations to optimize the patient's condition and plan for risks. The principles of obtaining valid informed consent are also described. The preoperative orders, medications and preparations like nothing by mouth, shaving and catheterization are explained.
preoperative preparation and postoperative care Sabrina AD
The document discusses preoperative preparation and postoperative care. It covers patient assessment, risk assessment and consent, arranging the theatre list, preoperative problems and referrals, and management of specific medical conditions like cardiovascular disease, respiratory disease, gastrointestinal disease, genitourinary disease, endocrine disorders, and more. The goal is to optimize patients medically, identify and address risks, and ensure safe surgery.
1 evaluating the patient before the anesthesia(2009.2.23 27)Sumit Prajapati
1. The document discusses the importance of preoperative evaluation of patients before anesthesia to assess risks, establish rapport, obtain medical history, perform examinations, order tests, discuss plans, and optimize patient health and safety.
2. Key parts of the evaluation include reviewing systems, medical history, medications, allergies, ASA physical status classification, vital signs, investigations like blood tests and imaging, and informing patients about anesthesia procedures and risks.
3. The goals are to reduce perioperative morbidity and mortality by identifying issues, instituting management, and ensuring patients are in the best condition possible for anesthesia and surgery.
Back to the Bedside: Internal Medicine Bedside Ultrasound ProgramAllina Health
David Tierney, MD. How bedside ultrasound is changing the practice of medicine and how Abbott Northwestern Hospital has become a national leader in integrating bedside ultrasound in its Internal Medicine Residency Program. "As internal medicine physicians, we are finding that everything we do with our hands, eyes and stethoscopes can be done a little better with ultrasound. That means our physical exam, which we consider our bread and butter, has more sensitivity and specificity. This gives us better diagnostic ability and results in earlier and more appropriate treatment."
chest pain 2015 what else you want me to write hereShahOzair1
This document provides an overview and guidance on evaluating and managing patients presenting with chest pain. It reviews the differential diagnosis and initial management steps for life-threatening causes of chest pain like acute coronary syndromes, pulmonary embolism, aortic dissection, and pneumothorax. Specific cases are presented and managed, focusing on history, exam, testing, diagnosis, and treatment of conditions like NSTEMI, pulmonary embolism, and continued chest pain in ACS. Key reminders and order sets are referenced.
This case presentation discusses a 30-year old female patient with diabetic foot ulcer on the right foot. She has a history of type 2 diabetes for 9 years and a burn on her right great toe that developed into an ulcer and was later amputated. Her laboratory investigations show hyperglycemia, proteinuria, and pseudomonas infection in the foot ulcer culture. Her treatment includes antibiotics, insulin, oral hypoglycemics, wound dressing, and patient education on foot care and diabetes management to prevent recurrence.
This document summarizes a 28-year-old Indonesian male patient who presented with abdominal pain, fever, and vomiting. On examination, he was found to have jaundice and tenderness in his right hypochondrium and epigastrium. Laboratory tests showed elevated liver enzymes and bilirubin. Ultrasound revealed gallbladder sludge and dilation of the bile ducts due to a large stone. ERCP confirmed choledocholithiasis with multiple stones in the common bile duct. The provisional diagnoses were ascending cholangitis and cholecystitis.
This document provides information on cardiovascular disorders and two case studies involving patients presenting with chest discomfort.
The first case involves an elderly male patient at a nursing home with chest pain and difficulty breathing. After assessment, the patient is diagnosed with a spontaneous pneumothorax.
The second case involves a young male camper with chest pain that has worsened over 36 hours. Additional information reveals recent recreational drug use. Assessment findings include subcutaneous emphysema and early repolarization on ECG. He is diagnosed with pneumomediastinum from increased intrathoracic pressure from holding in marijuana smoke.
Both cases demonstrate use of the AMLS assessment pathway to evaluate patients with chest discomfort and identify differential diagnoses
Approach to a patient with cardiovascular diseasedrfarhatbashir
This document provides guidance on evaluating patients presenting with cardiovascular complaints such as chest pain, shortness of breath, palpitations, syncope, and edema. It emphasizes taking a thorough history as the key to diagnosis, as initial investigations may be normal. Common life-threatening causes of these symptoms include myocardial infarction, aortic dissection, pulmonary embolism, and tension pneumothorax. The document outlines approaches to categorizing different types of chest pain, dyspnea, palpitations, syncope, and edema. It provides diagnostic criteria and recommends focused physical exams and initial tests such as ECG, CXR, and cardiac enzymes.
This document discusses neonatal hypertension. It begins by outlining topics to be covered, including defining neonatal hypertension, measuring blood pressure in neonates, evaluating causes of hypertension, and managing hypertension. The document then focuses on questions about properly measuring blood pressure in neonates and common causes of neonatal hypertension such as renal issues. Evaluation and treatment of neonatal hypertension is also discussed, including initial testing, choosing antihypertensive medications, and considering long term outcomes. Blood pressure measurement techniques and normal ranges are emphasized.
Clinical tips in cardiovascular emergencies copyAhmed Mohsen
This document provides guidance on evaluating and managing common cardiovascular emergencies. It outlines the leading causes of cardiovascular emergencies, including acute chest pain, dyspnea, syncope, and hemodynamic instability. For patients presenting with chest pain, the priority is to differentiate life-threatening etiologies like pulmonary embolism, acute coronary syndrome, and aortic dissection from less serious conditions. The initial evaluation involves vital signs, ECG, CXR, labs including cardiac enzymes and D-dimer, and potentially CT imaging. Prompt diagnosis and treatment are essential given the high mortality associated with cardiovascular emergencies like out-of-hospital cardiac arrest.
Clinical tips in cardiovascular emergenciesAhmed Mohsen
This document provides guidance on evaluating and managing common cardiovascular emergencies. It outlines the leading causes of cardiovascular emergencies, including acute chest pain, dyspnea, syncope, and hemodynamic instability. For patients presenting with chest pain, the priority is to differentiate life-threatening etiologies like pulmonary embolism, acute coronary syndrome, and aortic dissection from less serious conditions. The initial evaluation involves obtaining vital signs, performing a physical exam, 12-lead ECG, chest x-ray, and cardiac biomarker tests. Emergent conditions require urgent diagnostic testing and treatment to reduce mortality. Timely diagnosis and management is critical for improving outcomes in cardiovascular emergencies.
Surgery case presentation. femoral hernia.Elixir Pokhrel
A 49-year-old female presented with a right inguinal swelling and pain for 15 days. On examination, a 2.5 x 2.5 cm globular swelling was found in the right femoral region that was firm, non-reducible, and dull on percussion. Ultrasound revealed a right femoral hernia. The patient underwent open surgery using the Lockwood approach under spinal anesthesia, which found a right femoral hernia containing 20 ml of peritoneal fluid. Femoral hernias occur when abdominal contents protrude through the femoral canal, presenting as a groin lump with exacerbated pain on bending or lifting. Diagnosis is made through history, exam, and ultrasound, with differential diagnoses including inguinal
This document provides guidance on preoperative care and assessment. It outlines the objectives of preoperative care, which include organizing care and the operating list, understanding surgical, medical and anesthetic assessments, optimizing the patient's condition, obtaining consent, and organizing the operating list. It describes evaluating the patient's history, examination, investigations, preoperative conditions and treatment, and documenting the assessments. Key areas of focus for the patient assessment include cardiovascular, respiratory, gastrointestinal, genitourinary, neurological, endocrine and metabolic conditions. The document provides guidance on identifying and managing preoperative problems, obtaining informed consent, conducting a pre-anesthetic airway assessment, and arranging the operating theater list.
The perioperative period involves preoperative, operative, and postoperative care. During the preoperative phase, the nurse prepares the patient both emotionally and physically for surgery through principles like assessment, education to avoid fears, honesty, and orientation. Physical preparation includes following preoperative orders, enemas, baths, identification bands, and exercises. Postoperative care focuses on monitoring vital signs, fluid balance, pain management, and preventing complications through measures like positioning, deep breathing, and restraining. Education of parents is important for discharge and home care.
The document discusses the specialized care provided to patients in the post-anesthesia care unit (PACU) after surgery. It outlines that the PACU should be located near the operating theater and have sufficient space and monitoring equipment to care for postoperative complications. Common complications addressed include hypoxia, hypotension, pain, nausea and the importance of fluid management. Vital signs and urine output must be monitored closely in the PACU to optimize patient recovery.
The document discusses the pre-operative preparation of patients for surgery. It describes evaluating patients' medical history and health status, conducting physical examinations and medical tests, assessing surgical risks, providing pre-operative treatments as needed, obtaining informed consent, and explaining the procedure and potential complications to the patient. The goal is to carefully prepare the patient and reduce risks prior to surgery.
The document discusses preoperative fasting guidelines and the risks of pulmonary aspiration during surgery. It summarizes a study that compared gastric fluid volume and pH in patients who either fasted overnight or drank 150mL of water 2 hours before surgery. The study found that patients who drank the water had significantly lower gastric fluid volumes (5.5mL vs 17.1mL) after surgery, but similar pH levels. This suggests that allowing clear fluids like water 2 hours before surgery may be safe and help reduce patient discomfort from long fasting times.
Case Report : Integrating Review Inflammation and Commorbid diseasesSoroy Lardo
Diabetes is associated with atherosclerosis and COPD contributed to the chronic inflammation within the systemic vascular. Management of CVI with diabetes and COPD requires multi-disciplinary approach
The document discusses postoperative care in the post-anesthesia care unit (PACU). It outlines assessments and potential complications to monitor for various body systems, including respiratory (atelectasis, hypoxemia), cardiovascular (hypotension, arrhythmias), neurological, pain, hypothermia, nausea and vomiting. Nursing diagnoses and interventions are provided to manage complications and optimize recovery, such as deep breathing exercises to prevent atelectasis, monitoring vital signs and urine output, providing pain relief, and addressing psychological needs before discharge.
This document discusses the preoperative process, which includes physical and psychological preparation of the patient before surgery. It outlines the steps to be followed, including taking a thorough medical history, conducting examinations and investigations to optimize the patient's condition and plan for risks. The principles of obtaining valid informed consent are also described. The preoperative orders, medications and preparations like nothing by mouth, shaving and catheterization are explained.
preoperative preparation and postoperative care Sabrina AD
The document discusses preoperative preparation and postoperative care. It covers patient assessment, risk assessment and consent, arranging the theatre list, preoperative problems and referrals, and management of specific medical conditions like cardiovascular disease, respiratory disease, gastrointestinal disease, genitourinary disease, endocrine disorders, and more. The goal is to optimize patients medically, identify and address risks, and ensure safe surgery.
1 evaluating the patient before the anesthesia(2009.2.23 27)Sumit Prajapati
1. The document discusses the importance of preoperative evaluation of patients before anesthesia to assess risks, establish rapport, obtain medical history, perform examinations, order tests, discuss plans, and optimize patient health and safety.
2. Key parts of the evaluation include reviewing systems, medical history, medications, allergies, ASA physical status classification, vital signs, investigations like blood tests and imaging, and informing patients about anesthesia procedures and risks.
3. The goals are to reduce perioperative morbidity and mortality by identifying issues, instituting management, and ensuring patients are in the best condition possible for anesthesia and surgery.
Back to the Bedside: Internal Medicine Bedside Ultrasound ProgramAllina Health
David Tierney, MD. How bedside ultrasound is changing the practice of medicine and how Abbott Northwestern Hospital has become a national leader in integrating bedside ultrasound in its Internal Medicine Residency Program. "As internal medicine physicians, we are finding that everything we do with our hands, eyes and stethoscopes can be done a little better with ultrasound. That means our physical exam, which we consider our bread and butter, has more sensitivity and specificity. This gives us better diagnostic ability and results in earlier and more appropriate treatment."
chest pain 2015 what else you want me to write hereShahOzair1
This document provides an overview and guidance on evaluating and managing patients presenting with chest pain. It reviews the differential diagnosis and initial management steps for life-threatening causes of chest pain like acute coronary syndromes, pulmonary embolism, aortic dissection, and pneumothorax. Specific cases are presented and managed, focusing on history, exam, testing, diagnosis, and treatment of conditions like NSTEMI, pulmonary embolism, and continued chest pain in ACS. Key reminders and order sets are referenced.
This document provides an overview of preoperative evaluation and preparation. It discusses taking a thorough patient history and conducting a physical exam, with a focus on assessing the airway and risk factors. Preoperative tests and investigations are recommended based on patient age and type of surgery. Risk stratification tools like the ASA classification and cardiac risk indices are presented. Guidelines are provided for medication management and NPO restrictions prior to surgery. The goals of preoperative evaluation are identified as optimizing patient health and reducing perioperative risks.
This document discusses a case of hypertension in a child. It provides details of the child's medical history and symptoms. On examination, elevated blood pressure and signs of end organ damage including retinal changes were found, indicating a hypertensive emergency. Initial investigations revealed mild left ventricular hypertrophy and dysfunction. Biochemical tests supported a diagnosis of pheochromocytoma as the underlying cause of the child's hypertension. The document outlines the goals of treatment for hypertensive emergencies in children and managing the specific case.
The document discusses guidelines for pre-anesthetic evaluation. It outlines the objectives of pre-anesthetic evaluation as assessing the patient's medical condition, optimizing risks for anesthesia, and obtaining informed consent. Key components of evaluation include medical history, physical exam assessing airway and cardiovascular/respiratory systems, lab tests, and ASA physical status classification. Guidelines are provided for pre-op fasting, medication management, documentation, and conducting evaluations via interview or questionnaires.
This document provides information on evaluation and management coding. It discusses the three key factors that evaluation and management codes are based on: place of service, type of service, and patient status. It also reviews the three key components of patient services - history, examination, and medical decision making complexity. The history includes elements like history of present illness, review of systems, and past, family, and social history. The examination discusses the levels of examination from problem focused to comprehensive. Medical decision making complexity is based on factors like number of diagnoses or management options, amount and complexity of data reviewed, and risk of complication if not treated.
The document discusses evaluation and management coding. It covers the three factors that E/M codes are based on: place of service, type of service, and patient status. The three key components of E/M coding are also reviewed: history, examination, and medical decision making. Examples are provided for assessing the level of history, examination, and medical decision making complexity. The document provides an overview of the main components and guidelines for E/M coding.
The document summarizes the activities and case presentation of a pediatric intern at a hospital department, including following 11 cases and providing drug information for 6 cases, with a focus on the case of a 13-year old male patient diagnosed with rheumatic fever and rheumatic heart disease who presented with swelling, chest pain, and breathlessness. The patient's medical history, lab results, echocardiogram findings, assessments, treatment goals, medications, and standard treatment for rheumatic fever and rheumatic heart disease are outlined.
Cardiovascular assessment involves evaluating factors that influence cardiovascular health such as high cholesterol, smoking, diabetes, and hypertension. It should include examining the patient's past medical history, current lifestyle, family history, and performing a physical exam. Laboratory tests such as cardiac enzymes, lipid profile, and imaging studies like ECG, echocardiogram, and cardiac catheterization are used to diagnose cardiovascular conditions. Risk scores can help predict the risk of future cardiovascular events based on multiple risk factors. A thorough cardiovascular assessment is important for identifying risks and managing cardiovascular disease.
This document provides an overview of respiratory disorders and management of shortness of breath. It discusses respiratory anatomy and physiology, normal ventilation and how it is affected by obesity and aging. It also covers respiratory assessment, distinguishing respiratory distress from failure, and two case studies where emergency medical responders use the AMLS Assessment Pathway to evaluate and treat patients presenting with shortness of breath.
Preanesthetic evaluation of patients in oral and maxillofacial surgeryPunam Nagargoje
The word is derived from the Greek words an, which means “without” and aithesia which means “feeling”
The use of medical anesthesia was first reported in 1846
The development of anesthesia has made today’s modern surgical techniques possible
• Basic Principles of Anesthesia
• “Triad of General Anesthesia”
need for unconsciousness
need for analgesia
need for muscle relaxation and loss of reflexes
• Preoperative Evaluation
• The preanesthetic evaluation has specific objectives including:
- Establishing a doctor-patient relationship,
- Becoming familiar with the surgical illness and
- coexisting medical conditions,
- Anticipating potential complication
Developing a management strategy for perioperative anesthetic care,
- Obtaining informed consent for the anesthetic plan.
The overall goals of the preoperative assessment are to reduce perioperative morbidity and mortality and to allay patient anxiety.
• Pre-operative
This applied both in evaluation & investigations
• General
This include the following:
1-General condition of the patient.
2-Psychological condition. ( Specially in major operations).
• Specific
This include the following:
1-Related to anaesthesia.
2-Related to the surgery.
• Medical History
1. Review the chart
2. Review previous records
3. Interview the patient
• Demographic Data
Height / weight
Vital signs
Diagnosis
History and Physical Exam
Note any abnormalities
Don’t assume that all problems are listed
• Steps of the preoperative visit :
• Preoperative testing should be performed on a selective basis for purposes of guiding or optimizing perioperative management.
• Pre-op Testing Schema Example
• Preoperative Laboratory Testing:
• only if indicated from the preoperative history and physical examination.
• "Routine or standing" pre operative tests should be discouraged
• -CBC anticipated significant blood loss, suspected hematological disorder (eg.anemia, thalassemia, SCD), or recent chemotherapy.
• -Electrolytes diuretics, chemotherapy, renal or adrenal disorders
• -ECG age >50 yrs ,history of cardiac disease, hypertension, peripheral vascular disease, DM, renal, thyroid or metabolic disease.
• -Chest X-rays prior cardiothoracic procedures ,COPD, asthma, a change in respiratory symptoms in the past six months.
• -Urine analysis DM, renal disease or recent UTI.
• -tests for different systems according to history and examination
• Disease-based indications
Alcohol abuse
CBC, ECG, lytes, LFTs, PT
Anemia
CBC
Bleeding disorder
CBC, LFTs, PT, PTT
Cardiovascular
CBC, creatinine, CXR, ECG, lytes
• Disease-based indications
Cerebrovascular disease
Creatinine, glucose, ECG
Diabetes
Creatinine, electrolytes, glucose, ECG
Hepatic disease
CBC, creatinine, lytes, LFTs, PT
• Disease-based indications
Pregnancy (controversial)
Serum B-hCG- 7 days, Upreg 3 days
Pulmonary disease
CBC, ECG, CXR
Renal disease
CBC, Cr, lytes, ECG
RA
CBC, ECG, CX
02. Diagnosis and Treatment Manual author Patestos Dimitrios.pdfsarfaraz ahmed
This document is the 2016 Diagnosis and Treatment Manual from Doctors of the World Greece. It was edited by Dr. Patestos Dimitrios and represents the views and recommendations of the organization. The manual provides guidelines for health professionals to use in making treatment decisions for patients, while allowing for clinical judgment based on each individual case. It includes protocols, definitions, and summaries of diagnosis and treatment for various medical conditions like shock, seizures, and status epilepticus.
This document provides information on neurologic disorders and conducting a neurologic exam. It describes the anatomy and physiology of the brain and nervous system. It then presents two case studies of patients presenting with neurologic complaints. The first case involves a 66-year-old woman experiencing difficulty speaking, which upon assessment is determined to likely be an acute ischemic stroke. The second case involves a 68-year-old man who fell while walking and is complaining of a mild headache, with the differential diagnosis including intracranial hemorrhage or elevated intracranial pressure. The document stresses using the AMLS assessment pathway to evaluate patients with potential neurologic issues.
1
15
Academic Clinical History & Physical Notes for Cerebral Ischemia
I am presenting the academic clinical history and physical notes for the patient of ischemic stroke. Ischemic stroke or cerebral ischemia occurs when one of the cerebral arteries is blocked by the clot leading to diminished blood supply and oxygen to brain cells resulting in damage or death of brain cells (Celik et al., 2020)
History and Physical Note
1.Chief complaint/reason for admission/visit/consult.
A 52 years old male patient came to the acute care hospital with the chief complaint of sudden severe headache, dizziness, and slurred speech.
HPI for the H&P or consult notes.
The patient felt a severe burning and shooting pain in the frontal region of the head while he was reading the newspaper in the morning. The patient said that he developed blurred vision during reading. The patient felt numbness when the pain started (Harriot et al., 2020). The patient said that the pain was not subsiding with the time as it persisted since its onset. The pain scale was nine by 10, started in the frontal region, and radiated towards the temporal region. The associated symptoms with pain are nausea, vomiting, aphasia, dysarthria, apraxia, and vertigo (De Cock, et al., 2020). The symptoms become aggravate in a standing position and become alleviating when he lay down on the bed with 3 pillows. The patient felt a significant change in body posture. He is positive for facial drooping while negative for fever and chills. He finds difficulty in sitting and maintaining coordination. The patient stated that he had a medical history of neck trauma in a road accident. He was hospitalized for 3 weeks after neck surgery.
2.Medical, surgical, family, social, and allergy history.
Medical history
The patient has hypertension and hypercholesterolemia (Haegens, et al., 2018).
Surgical history
The patient underwent neck surgery after neck trauma at the age of 42.
Family history
The patient’s mother is alive and diabetic. The father of the patient died due to a cardiac stroke. His sister is normal. One of the two brothers has hypertension, and the other is normal. Currently, the patient is living with his normal wife.
Social history
The patient has a long history of smoking and boozing, coupled with a sedentary lifestyle.
Allergy history
· Raw fruits and vegetables, Shellfish, Soy.
· Amoxicillin and aspirin.
3.Home medications, including dosages, route, frequency, and current medications, if a consultation note.
Antihypertensive drugs Edarbi & Hygroton.
40 mg oral Edarbi once a day, as the patient is on diuretics, Hygroton. Oral 50 mg Hygroton once in the morning.
Hypercholesterolemic drugs Lipitor
Oral tablet 40 mg once a day. He takes this tablet at night.
4.Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).
General appearance
The patient shows facial we ...
1
15
Academic Clinical History & Physical Notes for Cerebral Ischemia
I am presenting the academic clinical history and physical notes for the patient of ischemic stroke. Ischemic stroke or cerebral ischemia occurs when one of the cerebral arteries is blocked by the clot leading to diminished blood supply and oxygen to brain cells resulting in damage or death of brain cells (Celik et al., 2020)
History and Physical Note
1.Chief complaint/reason for admission/visit/consult.
A 52 years old male patient came to the acute care hospital with the chief complaint of sudden severe headache, dizziness, and slurred speech.
HPI for the H&P or consult notes.
The patient felt a severe burning and shooting pain in the frontal region of the head while he was reading the newspaper in the morning. The patient said that he developed blurred vision during reading. The patient felt numbness when the pain started (Harriot et al., 2020). The patient said that the pain was not subsiding with the time as it persisted since its onset. The pain scale was nine by 10, started in the frontal region, and radiated towards the temporal region. The associated symptoms with pain are nausea, vomiting, aphasia, dysarthria, apraxia, and vertigo (De Cock, et al., 2020). The symptoms become aggravate in a standing position and become alleviating when he lay down on the bed with 3 pillows. The patient felt a significant change in body posture. He is positive for facial drooping while negative for fever and chills. He finds difficulty in sitting and maintaining coordination. The patient stated that he had a medical history of neck trauma in a road accident. He was hospitalized for 3 weeks after neck surgery.
2.Medical, surgical, family, social, and allergy history.
Medical history
The patient has hypertension and hypercholesterolemia (Haegens, et al., 2018).
Surgical history
The patient underwent neck surgery after neck trauma at the age of 42.
Family history
The patient’s mother is alive and diabetic. The father of the patient died due to a cardiac stroke. His sister is normal. One of the two brothers has hypertension, and the other is normal. Currently, the patient is living with his normal wife.
Social history
The patient has a long history of smoking and boozing, coupled with a sedentary lifestyle.
Allergy history
· Raw fruits and vegetables, Shellfish, Soy.
· Amoxicillin and aspirin.
3.Home medications, including dosages, route, frequency, and current medications, if a consultation note.
Antihypertensive drugs Edarbi & Hygroton.
40 mg oral Edarbi once a day, as the patient is on diuretics, Hygroton. Oral 50 mg Hygroton once in the morning.
Hypercholesterolemic drugs Lipitor
Oral tablet 40 mg once a day. He takes this tablet at night.
4.Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).
General appearance
The patient shows facial we ...
Jane Doe, a 69-year-old female, presented for a follow up appointment for COPD. Her exam was normal and her vital signs were stable. Her labs showed elevated potassium and TSH, which the doctor reviewed with her. The doctor ordered repeat labs and a stool sample and instructed Jane to return in 3 months or sooner if needed.
Daily practice in medicine in general need awareness of critical signs and symptoms that can be the presentation of life threatening and fatal conditions
This document provides guidance on evaluating chest pain and discusses the approach to diagnosing aortic dissection. It emphasizes maintaining a high index of suspicion for aortic dissection as the symptoms can mimic other conditions. Aortic dissection often presents with sudden, severe chest or back pain and may migrate. Examination findings like pulse/blood pressure differences between limbs can help but have low sensitivity. The document reviews risk factors and recommends promptly ordering tests like CT scans to diagnose this dangerous condition given the high mortality if left untreated.
This document provides information on cardiovascular disorders and their emergency management through a series of case studies:
1. A 10-day-old boy presented with not breathing and color change. Initial assessment found abnormal vital signs. The general impression was cardiopulmonary failure. Priorities were ABCs, oxygen, cardiac monitoring, and vascular access.
2. A 2-year-old girl experienced unresponsive episodes while eating. Exam found normal vital signs. The general impression was syncope. Priorities were to exclude life-threatening causes through history, exam, and testing.
3. A 6-month-old presented with chickenpox, fever, and not feeding well. Exam found abnormal vital
TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd...Donc Test
TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Chapters Download Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Download Stuvia Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Study Guide Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Ebook Download Stuvia Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Questions and Answers Quizlet Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Studocu Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Quizlet Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Chapters Download Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Download Course Hero Community and Public Health Nursing: Evidence for Practice 3rd Edition Answers Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Ebook Download Course hero Community and Public Health Nursing: Evidence for Practice 3rd Edition Questions and Answers Community and Public Health Nursing: Evidence for Practice 3rd Edition Studocu Community and Public Health Nursing: Evidence for Practice 3rd Edition Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Pdf Chapters Download Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Pdf Download Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Study Guide Questions and Answers Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Ebook Download Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Questions Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Studocu Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Stuvia
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
2. 2 most common EHR documentation
practices used to commit fraud:
1. Copy and paste
2. Over-documentation/Up Coding
3. • Post payment reviews and audits are
increasingly prevalent
• Good documentation is the only defense for the
physician
• The auditor’s motto is “Not documented, not
done!”
In Today’s Regulatory Environment . . .
5. it's not the quantity of documentation that
matters, it's the quality.
6. 1995 vs. the 1997E/M Guidelines
OPQRST (6 ELEMENTS)
STATUS OF 3 CHRONIC CONDITIONS
HPI
PE
general multi-system exam OR single
organ system examinations
(BULLET SYSTEM)
10. Physical Exam
Detailed
12 bullets from any
organ system
Comprehensive
At least 2 bullets from 9
organ systems
(Bullet system)
Constitutional
(1 bullet for three vital signs)
(1 bullet for general appearance)
Eyes
(1 bullet for inspection of conjunctivae and lids)
(1 bullet for examination of pupils and irises)
Ears, Nose, Mouth and Throat
(1 bullet for external inspection of ears and nose)
(1 bullet for examination of oropharynx)
Neck
(1 bullet for examination of neck)
(1 bullet for examination of the thyroid)
Respiratory
(1 bullet for auscultation of lungs)
(1 bullet for assessment of respiratory effort)
Cardiovascular
(1 bullet for auscultation of heart)
(1 bullet for examination of extremities for edema or varicosities)
Gastrointestinal
(1 bullet for examination of the abdomen)
(1 bullet for examination of liver and spleen)
Lymphatic
(1 bullet for examination of lymph nodes in neck)
(1 bullet for examination of lymph nodes in extremities)
Skin
(1 bullet for inspection of skin and subcutaneous tissues)
(1 bullet for palpation of skin and subcutaneous tissues)
Psychiatric
(1 bullet for description of patient’s judgment and insight)
(1 bullet for brief assessment of mental status—orientation)
11. Example Comprehensive
Vitals: 120/80, 88, 98.6 #1
General appearance: NAD, conversant #2
Eyes: anicteric sclerae, moist conjunctivae; no lid-lag;
PERRLA #3 #4
HENT: Atraumatic; oropharynx clear with moist mucous
membranes and no mucosal ulcerations; normal hard and
soft palate #5 #6
Neck: Trachea midline; FROM, supple, no thyromegaly or
lymphadenopathy #7 #8
Lungs: CTA, with normal respiratory effort and no
intercostal retractions #9 #10
CV: RRR, no MRGs, no edema or varices #11 #12
Abdomen: Soft, non-tender; no masses or HSM #13 #14
Lymph nodes: No cervical or extremity lymphadenopathy
#15 #16
Skin: Normal temperature, turgor and texture; no rash,
ulcers or subcutaneous nodules #17 #18
Psych: Appropriate affect, alert and oriented to person,
place and time #19 #20
Example Detailed
Vitals: 120/80, 88, 98 . #1
General appearance: NAD, conversant #2
Neck: FROM, supple #3
Lungs: Clear to auscultation #4
CV: RRR, no MRGs; normal carotid upstroke
and amplitude without bruits #5 #6
Abdomen: Soft, non-tender; no masses or
HSM #7 #8
Extremities: No peripheral edema or
digital cyanosis #9 #10
Skin: no rash, lesions or ulcers #11
Psych: Alert and oriented to person,
place and time #12
12 bullets from any
organ system
At least 2 bullets from 9 organ systems
12. MDM
2/3
OVERALL MDM PROBLEM POINTS DATA POINTS RISK
LOW COMPLEXITY
2 2 LOW
MEDIUM COMPLEXITY
3 3 MODERATE
HIGH COMPLEXITY 4 4 HIGH
13. PROBLEM POINTS
Established problem, stable or improving 1
Established problem, worsening 2
New problem, with no additional work-up planned (maximum of 1) 3
New problem, with additional work-up planned 4
Hypertension – Stable
Hypothyroidism- Stable
Atrial fibrillation with RVR- Uncontrolled
COPD exacerbation- Uncontrolled
Acute Hyponatremia- New
Acute hypokalemia- New
Acute respiratory failure
Acute blood loss anemia
14. Data Reviewed Points
Review or order clinical lab tests 1
Review or order radiology test (CXR, CT, MRI, Cartoid US, Doppler) 1
Review or order medicine test (PFTs, EKG,V/Q, cardiac echo or cath) 1
Discuss test with performing physician (radiologist, ER, GI) 1
Independent review of image, tracing, or specimen 2
Decision to obtain old records 1
Review and summation of old records 2
15. Risk Level Presenting Problems Diagnostic Procedures Management
Low Risk
•2 or more self-limited or minor problems
•1 stable chronic illness
•Acute uncomp injury or illness (cystitis)
•PFTs, ABI, Echo
•Non-cardiovascular imaging
studies with contrast (barium
enema)
•Superficial needle biopsy
•ABG
•Skin biopsies
•Over the counter drugs
•Minor surgery, with no
identified risk factors
•Physical therapy
•Occupational therapy
•IV fluids, without additives
Each Risk level Requires only ONE of these elements in ANY of the three categories listedRISK LEVEL
CLINICAL EXAMPLE:
1. Patient with OA of the knees, severe pain, which is no longer controlled with tylenol. You examine the
patient and switch to OTC ibuprofen. No labs are reviewed. Admit for PT eval
OVERALL MDM PROBLEM POINTS DATA POINTS RISK
LOW COMPLEXITY 2 2 LOW
16. Moderate
Risk
•1 or > chronic illness, with mild
exacerbation, progression, or side effects of
treatment
•2 or > stable chronic illnesses
•Undiagnosed new problem, with uncertain
prognosis, e.g., lump in breast
•Acute illness, with systemic symptoms
•Acute complicated injury, e.g., head injury,
with brief loss of consciousness
•Tests under stress (cardiac
stress test)
•Scopes without risk factors
•Deep needle or incisional bx
•Cardiac catheterization
•Obtain fluid from body
cavity, LP/thoracentesis
•Minor surgery
•Elective major surgery (open,
percutaneous, or endoscopic),
with no identified risk factors
•Prescription drugs
•Therapeutic nuclear medicine
•IV fluids, with additives
•Closed treatment of fracture
Clinical example: 78 yo M with hx of COPD and HTN, with severe SOB for
5 days, found to be in mild respiratory distress due to COPD exacerbation,
started on IV solumedrol and IV Ceftriaxone, his BP is stable
OVERALL MDM PROBLEM POINTS DATA POINTS RISK
MEDIUM COMPLEXITY 3 3 MODERATE
17. Risk Level Presenting Problems Diagnostic Procedures Management
High Risk
•1 or > chronic illness, with severe
exacerbation or progression
•Acute or chronic illness or injury, which
poses a threat to life or bodily function,
e.g., multiple trauma, acute MI, PE,
severe respiratory distress, psychiatric
illness, with potential threat to self or
others, peritonitis, AKI
•An abrupt change in neurological status,
e.g., seizure, TIA, weakness, sensory loss
•Cardiac catheterization with
identified risk factors
•Cardiac EP studies
•Diagnostic endoscopies, with
identified risk factors
•Discography
•Emergency Hemodyalisis
•Elective major surgery (open,
percutaneous, endoscopic)
with risk factors
•Emergency major surgery
(open, laparoscopic)
•Parenteral controlled
substances (IV opioids)
•Drug therapy requiring
intensive monitoring for
toxicity
•Decision not to resuscitate, or
to de-escalate care because of
poor prognosis
Clinical example: 78 yo M with hx of COPD and HTN, with severe SOB for 5 days, found to be acute respiratory failure due to
COPD exacerbation, intubated, started on IV solumedrol and IV Ceftriaxone, his BP is stable, IV morphine for pain. CT angio
to r/o PE pending.
OVERALL MDM PROBLEM POINTS DATA POINTS RISK
HIGH COMPLEXITY 4 4 HIGH
18. CC : Chest pain
HPI : The patient is a 65 year old male who comes w the CC of sudden onset(1) chest pain, which began
early this morning (2), described as “crushing”(3) and 9/10 intensity (4)
PMH : GERD and hypertension
FH . : Mother died at 78 of breast cancer, Father at 75 of CVA.
SH : Negative for tobacco abuse; consumes moderate alcohol; married for 39 years
ROS : 10 point ROS reviewed and are negative except as noted in HPI
Vitals: 120/80, 88, 98.6 (1)
General appearance: NAD, conversant (2)
Eyes: anicteric sclerae, moist conjunctivae; no lid-lag (3); PERRLA (4)
HENT: Atraumatic (5), oropharynx clear with moist mucous membranes and no mucosal ulceration (6)
Neck: Trachea midline; FROM, supple (7), no thyromegaly (8) or lymphadenopathy of neck area(9)
Lungs: CTA(10), with normal respiratory effort and no intercostal retractions(11)
CV: RRR, no MRGs (12), no pedal edema (13)
Abdomen: Soft, non-tender(14); no masses or HSM (15)
Extremities: No deformities or extremity lymphadenopathy (16)
Skin: Normal temperature, turgor and texture; no rash, ulcers (17) or subcutaneous nodules (18)
Psych: Appropriate affect,(19) alert and oriented to person, place and time (20)
Plan: 1. Chest pain R/O ACS: Trop x3, lovenox 1mg/kg/BID, Morphine IV for pain, stress test and echo
2. Uncontrolled HTN: prn hydralazine, continue acei and metoprolol
3. Uncontrolled diabetes w hyperglycemia: glycemia protocol
20. Subjective
ROS
PFMSH
1-3 pt HPI
No
No
HISTORY
(Subjective and ROS)
CC 1
Subsequent visits always follow up something from the day before or new
events that occurred overnight
1
1-3 pt HPI
1
No
1
4 pt HPI
Or Status
3 chronic/inactive prob
2-9
No
21. CC : Follow-up Shortness of breath
S: Persistent SOB, severe intensity (1), associated to
wheezing (2), not improving w RT TID (3), worse at night time
(4)
ROS
General--Negative for fatigue, weight loss, anorexia
Cardiovascular--Negative for CP, orthopnea, PND
Endocrine--Negative for polyuria, polydipsia, cold intolerance
22. 1-5 bullets from
At least 1 system
Example
Vitals: 120/80, 88, 98.6
General: NAD, conversant
Lungs: CTA
CV: RRR, no MRGs
99231
Focused exam
99232
Expanded
exam
Example
Vitals: 120/80, 88, 98.6
General: NAD, conversant
Lungs: Clear to auscultation
CV: RRR, no MRGs
Abdomen: Soft, nontender
Extremities: No edema
6 bullets from
1> systems
99233
Detailed exam
Example
Vitals: 120/80, 88, 98.6
General: NAD, conversant
Neck: FROM, supple
Lungs: Clear to auscultation
CV: RRR, no MRGs; normal carotid
upstroke without bruits
Abd: Soft, NTTP; no masses or HSM
Extr: No edema or cyanosis
Skin: no rash, lesions or ulcers
Psych: AAOx3
12 bullets from any
organ system
23. MDM
2/3
OVERALL MDM PROBLEM POINTS DATA POINTS RISK
LOW COMPLEXITY
2 2 LOW
MEDIUM COMPLEXITY
3 3 MODERATE
HIGH COMPLEXITY 4 4 HIGH
24. CC : Follow-up Shortness of breath
S:
SOB overnight, severe, associated wheezing
Hyponatremia noted in AM labs
Persistent hyperglycemia in POCT
Tolerating diet, afebrile
ROS
General--Negative for fatigue, weight loss, anorexia
Cardiovascular--Negative for CP, orthopnea, PND
Endocrine--Negative for polyuria, polydipsia
Or 10 point ROS done and negative except for HPI
Vitals: 120/80, 88, 98.6
General: NAD, conversant
Neck: FROM, supple
Lungs: +wheezing, mild resp distress
CV: RRR, no MRGs; normal carotid
upstroke without bruits
Abd: Soft, NTTP; no masses or HSM
Extr: No edema or cyanosis
Skin: no rash, lesions or ulcers
Psych: AAOx3
Valid Alternatives:
1. No acute distress
2. No acute events overnight
Not valid Alternatives:
1. Doing well
2. In CT suit during my exam
3. much improved
Plan: 2/3 MDM : 4 PP + 4 DR + HIGH RISK
Acute Hypoxic resp Failure - uncontrolled
Acute COPD exacerbation- worsening
Hyponatremia – new
Diabetes w hyperglycemia- Uncontrolled
CT angio to rule out PE
CXR independently reviewed w/o acute findings
Continue IV solumedrol 125 BID, monitor for worsening
hyperglycemia, delirium,
Continue IV vancomycin and zosyn, monitor vanco
through daily due to risk for toxicity
Replace electrolytes as needed
25. Admission – Patient with shortness of breath and chest pain, comorbidities present, diagnosed with
congestive heart failure and known ischemic cardiomyopathy treated medically, IV meds given, complexity is
high.
CPT code 99223
Day 2 – Patient improved, meds changed to PO, home meds restarted, no invasive tests planned, continuing
to monitor.
CPT code 99232
Day 3 – Kidney function worsens, meds held and changed appropriately, concern for cardiac output being low,
nephrology consulted, situation worsened from prior day.
CPT code 99233
Day 4 – Echo reviewed, cardiac function worse than thought, thinking about right heart cath, dobutamine
started on floor, IV diuresis ongoing, discussed with consultants.
CPT code 99233
Day 4 – Situation improves, renal function stabilizes with inotropic support and renal recommendations,
breathing improved, meds regimen stable, labs and CXR stable, patient likely to be discharged in next few
days.
CPT code 99232
Not every day can be a 99233 day
Editor's Notes
1. Copy and paste, by which a healthcare provider copies and pastes information from a patient's record multiple times, often failing to update the data or ensure accuracy, andover-documentation, which involves adding false or "irrelevant documentation to create the appearance of support for billing higher level services."
There are not too many differences between the 1995 and the 1997 guidelines and there are some similarities. Let’s discuss both of the guidelines now.
Two major differences exist between the 1995 and 1997 E/M guidelines: HPI and the exam element.
The following criteria are the same for the 1995 and 1997 E/M guidelines, including: The Review of Systems; Past, Family and Social History; and Medical Decision Making.
eginning for services performed on or after September 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness (HPI) along with other elements from the 1995 guidelines to document an evaluation and management service.”