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HCC Guide Fixed

EMS uses monthly per person capitated rates to pay Managed Care Plans. The old methodology was based on the Adjusted Average Per Capita Cost methodology. EMS implemented a risk-adjustment payment system for Medicare health plans in 2000.

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0% found this document useful (0 votes)
571 views98 pages

HCC Guide Fixed

EMS uses monthly per person capitated rates to pay Managed Care Plans. The old methodology was based on the Adjusted Average Per Capita Cost methodology. EMS implemented a risk-adjustment payment system for Medicare health plans in 2000.

Uploaded by

Kulmeet Kundlas
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
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Table of Contents

Preface 3

Risk-Adjusted Payment to Managed Care Plans By Thomas A. Scully

Chapter 1 5

Introduction to Risk Adjustment, HCCs, and Accurate Coding

Chapter 2 1 2

General Principles of ICD-9 Coding and Documentation

I. Only Doctors and Approved Clinicians Can Make Diagnoses II. A Valid Medical Record Has Very Specific Criteria

III. Official Outpatient Coding Guidelines,

Effective October 1, 2007

IV. Keys to Successful Documentation and Coding for Medicare Patients

Chapter 3 27

The Medical Record Review Process

Chapter 4 31

Use of the Problem list and the Value Proposition

Chapter 5 37

Diagnostic and Coding Criteria of Geriatric Conditions

Appendix 1 1 37

CMS-HCC Risk Adjustment Factors (Community & Institutional Models)

Appendix 2 142

CMS-HCC Hierarchies

Appendix 3 144

Approved Physician Specialties for Risk Adjustment

Appendix 4 145

Clinical Abbreviations for the Medical Record

A GUIDE TO RISK ADJUSTMENT AND THE CMS-HCC MODEL

I PAGE 1

Preface

Risk-Adjusted Payment to Managed Care Plans

By Thomas A. Scully Former Administrator

Centers for Medicare & Medicaid Services (CMS) U.S. Department of Health and Human Services

eMS uses monthly per person capitated rates to pay managed care plans. In the last decade, Congress has made several changes to how eMS calculates these rates. The old methodology was based on the Adjusted Average Per Capita Cost methodology, or U MPCC. U Under MPCC, eMS projected average ccunfv-level fee-for-service spend-

ing for the coming year and set reimbursement rates at 95% of the full MPCCamounl.

Pursuant to the Balanced Budget Act of 1997 (BBA!. Congress required eMS to implement a risk-adjustment payment system for Medicare health plans by January 2000. This initial risk-adjustment model based payment on hospital inpatient diagnosis and various demographic factors such as gender, age, and Medicaid eligibility.

Going a step further, with the Benefits and Improvements Protection Act IBIPAI of 2000, CMS implemented a new risk-odlusfment model that uses additional diagnosis data in calculating payment. This phase-in will be completed in 2007 for most health plans, and in 200B for PACE/SHMOs.

I am pleased to see that one of the leaders in geriatric care, SCAN Health Plan, has taken the initiative to write a coding and HCC gUidebook that will undoubtedly assist the physician community in understanding this new payment model. In addition, it will help connect the dots between financial reimbursement and quality of care for other interested parties.

A GUIDE TO RISK ADJUSTMENT AND THE CMS·HCC MODEL

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The goal of the new CMS risk-adjustment model is to improve the accuracy af payments ta Medicare Advantage [MAl plans and ta establish incentives for plans to enroll and treat Medicare beneficiaries who are less healthy. Historically, demographic-based payment madels did nat accaunt for the patient's health status. These madels treated all patients equally, assuming that they were of a similar age and lived in the same or similar geographies. Thus, in the old system, plans were rewarded for avoiding the older and sicker beneficiaries. Congress and CMS very consciously wanted to create incentives to serve the frail elderly, as MA plans such as SCAN do in their programs.

The current risk-adjustment model draws a very clear parallel between the chronicity of a patient's health conditions and the costs associated with treating these diseases. In the absence of such a model, MA plans would have a financial incentive to continue to avoid our oldest, sickest, and disabled seniors. For our nation's elderly, this translates into too

few options for health care coverage. President Bush, HHS Secretary Tommy G. Thompson, and I worked diligently to make sure that this would not happen. We took a very expansive view of risk adjustment that truly changes the paradigm-and drives new coverage options for the sick and frail.

In order for the risk-adjustment payment model to succeed, it is important that the physician community understands the importance of documentation, coding, and data submission. The quality and exactness of the diagnosis, as well as the supporting documentation, are critical to the success of the program. More importantly, the accuracy and completeness of coding required by the new model will help physicians provide consistent treatment and higher quality care to their patients. This is in everyone's best interest-especially the patients.

The new risk-adjusted payment model paves the way for better information gathering and data sharing. I want to thank SCAN Health Plan and their associates for understanding the importance of adopting the risk-adjusted payment model and for bringing a guidebook to the physician and coding community. Well done.

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ACCURACY IN DOCUMENTATION AND CODING:

CHAPTER 1

INTRODUCTION

CMS-HCC Risk Adjustment Capitation Payment System

The Balanced Budget Act of 1997 directed the Centers for Medicare and Medicaid Services (CMS) to replace the demographic-based capitation payment system to Medicare Advantage [MAl plans with one that took enrollees' health status into account. After evaluating several riskadjustment models, CMS adopted the Hierarchical Condition Categories IHCC) model, developed with CMS funding by researchers ot RTI International and Boston University, with clinical input from physicians at Harvard Medical School. Before implementation, CMS staff and HCC model developers simplified the original model with fewer HCCs and used Medicare subpopulotions to develop weights, resulting in the CNlSHCC model. This risk-adjusted payment methodology stratifies Medicare beneficiaries on the basis of the number and severity of concomitant chronic diseases.

Diagnostic classification systems aggregate ICD-9-CM codes into broader categories for various purposes. Although HCC looks like other diagnostic classification systems, such as the major diagnostic categories (MDC) or the clinical classification system (CCS), it is a risk-adjustment model. It not only classifies ICD-9-CM codes to clinically similar groupings but also assigns weights to each grouping to account for severity. CMS-HCC is an attempt to capture the beneficiaries' health burden so that MA plans caring for these beneficiaries will be reimbursed accurately.

Commonly within a group of HCCs, several conditions are more severe than the others. Under the CMS-HCC model, the more severe manifestation of a given disease process will be weighted more heovlly than the less severe one. To address how the more severe condition

has a greater impact on cost of care, the model imposes a hierarchy

A GUIDE TO RISK ADJUSTMENT AND THE CMS-HCC MODEL

I PAGE 5

among related HCCs, such that an enrollee is only assigned the most severe manifestation among the related diseases. For unrelated HCCs, the model treats them as additive. Each HCC carries a weighted score, relative to the cost of care. A more severe HCC would have a higher weighted score, and a less severe HCC would have a lower weighted score. Weighted scores are then summed for the individual poflent. Although the original model includes 189 HCCs using all the IDC-9-CM codes, only 70 HCCs are currently included in the CMS-HCC payment model. In addition to the diagnosis categories, the CM5-HCC model also has demographic and eligibility/enrollment adjusters, including 24 mutually exclusive age/sex demographic adjusters and indicators of Medicaid and disability status.

Currently, approximately 3200 of 15,000+ ICD-9 codes are used in the CM5-HCC model for coding the diagnoses listed in pcfients' medical records. These 3200 ICD-9 codes carrespond to 70 HCCs, which are used, along with its weighted score, to reimburse Medicare Parts

A and B services to MA plans. Medical information used in assigning HCCs for payment is derived from any of the following 3 sources: hospital inpatient, hospital outpatient, and face-to-face physician (including clinically trained nonphysicians such as chiropractors, podiatrists, PAs, and psychologists) visits.

ICD-9 Coding System

Assigning numerical codes to diagnoses is no easy task. Because of the complexity of diseases, etiology, manifestation, and complications, different ways of classifying diseases exist. The International Classification of Diseases (ICD) is the most commonly used format in the United States. The ICD system is developed and revised by the World Health Organization and 10 international centers approximately every 10 years.

It was originally used to code and classify mortality data from death certificates. Currently, most health care professionals are familiar with ICD-9-CM (International Classification of Diseases, 9th Edition, Clini-

cal Modification) and use it to code and classify disease information

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ACCURACY IN DOCUMENTATION AND CODING:

(signs, injuries, diseases, and symptoms) in both inpatient and outpatient settings. Different from the other dominant coding system, Current Procedure Terminology, or CPT (which is used primarily to address procedures], ICD-9-CM primarily focuses on the clinical reasons for which a medical service is necessary (Figure 11.

Figure 1. Basic Structure of an ICD·9·CM Code
250.43
-> i -.
lhese3digitsprovidebcsic Tnefourlndigitidenlifies Tnefifthdigilidenlifies
dicgncsisootegcries(e.g., rompliccffcnsrelctedto cddilicncl specific evclucffcn
250.0D,dicbeteswiihcut iheprimcrydisecse cltheprimcrydisecse
rompliccffcns) (e.g., 25D.4,dicbetes (subclcssilkcffcns)
wiihnepnrcpclny) (e.g., 25D.43,unccntrolled
type2dicbetes) The ICD-9-CM manual is made up of 3 major sections (or volumes):

A numerical list of the disease code numbers and descriptions;

2. An alphabetical index to the disease entries; and

3. An alphabetic index of surgical, diagnostic, and therapeutic procedures and descriptions used solely by hospitals.

To properly and accurately assign codes to diagnoses, providers are required to follow the ICD-9-CM coding and reporting guidelines [Table 1[.

A GUIDE TO RISK ADJUSTMENT AND THE CMS-HCC MODEL

I PAGE 7

Table 1. General Cading Guidelines

1. Use both theAlphobeticIndex ondthe Tllbulorlistforloclltinglind IIssigning 0 code to

improve specificity.

1. locote eoch term in the Alphobenc Indexond venly the code selected in the To bulorlist.

3. (ode the diognosis and procedures ot their highest number of digils available.

4. Use corle rrom OOI.OthroughV84.8Ioidennlydiognoses,symptoms,condinons, problems, compillinls, or other resens for the oulpotientencDunter/visi t.

5. Codes thlltdescribesigns lind symplnms, os opposed In dillgnoses, ore II cceptllble for reporting purposes when 0 related definitive diagnosis has not been e stublished (confirmed) by the provider.

6. Signs and symptoms thot ore integml to the disease process should no tbe assigned os additional codes, unless atherwise inslruded by the daS5ifilatian.

7. Code signs ond symptoms thot moy not be ossocillted routinely with 0 di saaseperess.

8. In the case of multiple coding for 0 single condition (for loteeffects on dcomplicotion corles),onoddinonolsecondo~corleshouldbeodderl.

9. In 0 cose of conditions described os bothocute,hubocute ond chronic wi thsepomte olphobefic subentries ot the someindentDfion level, code both ond sequen cethe ocute,hubocutecodefirst.

lO.Assignonlythecombinotioncodewhenthotcodeful~idenfifiesthediognostic conditions (e.g., 0 single codeclossifying two diognoses, n diognosis with on ossocio tedsecondory process such os monifestDfion, oro diognosiswith on ossocioted complic ofion).

II. (oding lote effects genemllvrOluires Iwo corleswith the condinon 01 the lot eeffect sequencoo first, followed by the loteeffectcode.

Accurate Codes

Maintaining an accurate coding practice not only facilitates better care for pofients but also helps physicians maintain more accurate reimburse-

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ACCURACY IN DOCUMENTATION AND CODING:

ment. Accurate coding facilitates the capture of conditions underlying the manifested symptoms and helps determine the overall disease burden that might affect the care of the patient. As an example, under section 250-259, Disease of Other Endocrine Glands, 250 is the code for diabetes mellitus, and the 4th and 5th digits describe the complications, type, and control level of the disease in the individual patient diagnosed. From a medical coding perspective, physicians need to specify the condition by adding a 4th or 5th digit to the preceding 3-digit code (250). Just coding 250 is incomplete. At the 4th digit level, providers are able to specify the manifestation of the condition, but 250.0-250.9 still requires a 5th digit to be billable. At the 5th digit level [the highest level), providers can accurately capture the condition of the patient. In this example, at the 5th digit level, it specifies if the diabetic condition

is type 1 or type 2, and/or if the condition is controlled or not. At this level, the code documents to the highest level of specificity and is most accurate. Starting January 1, 2008, CMS will no longer accept codes not submitted at the highest level of specificity.

Challenges to the Physician Community

The new CMS-HCC system [and HIPAA) mandates accurate coding,

but more importantly, an accurate retrospective and prospective analysis of each patient's acute and chronic conditions may lead to better care. Although most MA plans argue that this system is a Ncoding challenge, W

it is actually a challenge for the physician community, which must more accurately understand and manage the complex array of chronic diseases of each patient. Physicians will be challenged to work with their respective delivery systems, including fellow physicians and specialists,

to collect the most accurate and complete assessment of each poflenfs acute and chronic conditions and to develop a comprehensive and individualized treatment plan. Through this approach, quality of care will be markedly improved, and the need for comprehensive patient care will be reinforced. In addition, accurate and complete collection and documentation of these diagnosis data drive an enhanced revenue engine, which

A GUIDE TO RISK ADJUSTMENT AND THE CMS·HCC MODEL

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in turn will support the additional cost of providing high-qualiiy care.

Because the CM5-HCC system is designed to reimburse health plans more accurately, plans have been working aggressively with physician partners to collect accurate and timely encounter data. Significant efforts are being devoted to accurately coding diagnoses and procedures and effectively documenting the clinical rationale for these codes in the medical chart. Health plans and physicians should note the following:

1. Although /1M plans submit diagnosis codes to CMS, only those with the most severe manifestations of each disease within a specific disease category will be considered in the final risk score according to the CMS-HCC system.

2. Accurate diagnoses-related documentation yields accurate reimbursement.

3. Current-year reimbursement is based on encounter data from last

year. If no encounter data are submitted, payment in the following year will be based only on demographic data, resulting in decreased reimbursement. CMS does not carryover chronic diagnoses, so these diagnoses must be reported at least yearly.

4. Because physician diagnostic data account for approximately 80% of the entire encounter submission, physician documentation drives the amount CMS fXlys on behalf of each member.

The message of needing more specific and more accurate coding is very clear. At a broader level, the physician communiiy is challenged to: 1 . Understand and manage the complex array of chronic diseases of each patient;

2. Work with respective delivery systems, including fellow physicians and specialists, to collect the most accurate and complete picture of each patient's acute and chronic conditions;

3. Develop a comprehensive and individualized treatment plan;

4. Maintain a balance between generating a thorough record for better continuiiy of care and treatment and an enhanced revenue engine that in turn supports the additional cost of providing high-qualiiy care.

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ACCURACY IN DOCUMENTATION AND CODING:

An accurate, improved diagnosis coding and documentation practice has many benefits to physicians in the clinical management of their patients, as well as in the financial management of their practice. Accurate diagnosis documentation and coding improves:

1 Patient medical record problem lists

2. Tracking of patient's current diagnosis

3. Patient risk stratification for care management

4. Risk management

General Approach to Proper Coding

1 Good and accurate coding starts with accurate documentation.

Make sure the disease/condition is documented in the medical record: Nlf it is not documented in the medical record, it didn't exlstl"

2. Fully assess all chronic conditions annually in face-to-face patient visits. Remember to code not only the conditions related to the symptoms for the immediate visit but also any chronic condition that affects the care of the poflent. Conditions may be coded for face-to-face physician data from inpatient hospital visits, outpctlent hospital visits, and visits to the ponenrs home.

3. Thoroughly document in the medical chart all conditions evaluated during each visit.

4. Code to the highest level of specificity; fully utilize the ICD-9 diagnosis coding system.

5. Document and code the most comprehensive or all inclusive diagnoses for the patient's condition.

Document and code for all secondary or associated diagnoses when possible.

Whether to improve quality of patient care, reduce the exposure

to risk-related liabilities, or achieve more accurate reimbursement, the physician's responsibility is to provide accurate coding and documentation of the pctlents' health-related conditions. This quldebook provides coding criteria and tips on medical record documentation designed to assist physicians and their practices.

A GUIDE TO RISK ADJUSTMENT AND THE CMS·HCC MODEL

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CHAPTER 2

GENERAL PRINCIPLES OF ICD-9 CODING AND DOCUMENTATION

I. Only Doctors and Appraved Clinicians Can Make Diagnoses

• If the doctor' documents clearly that a patient has a specific diagnosis, the correct ICD-9 diagnosis codes can be selected.

• If an ICD-9 code has been submitted for a patient visit, then the medical record must include language that supports the diagnosis in a signed and dated progress note. The progress note must also include the patient's name, date of birth or medical record number, the physician's signature, and the physician's credentials.

• It is not enough for the doctor to know the patient's diagnosis; the doctor must write it down (or dictate) clearly in a progress note for an ICD-9 diagnosis code to be valid. If you know a patient has congestive heart failure (CHF), but do not mention it anywhere in your note, you cannot submit the diagnosis code for CHF (428.0).

• A medical record progress note signed by a nurse practitioner (NP), a certified clinical nurse specialist, or physician's assistant (PA) is also a valid source for diagnosis coding. (A complete list of valid specialties appears in the Appendix 3.)

• A note from a nurse, wound specialist, marriage family therapist, medical assistant, or other health care worker cannot be used for coding purposes.

• A licensed clinical psychologist or social worker (LCSW), PhD, PA, or NP may code mental health diagnoses resulting from a face-to-face patient visit.

• A lab test, order for a test, authorization for a service, or other admini-

strative record cannot be used for coding purposes. The physician must interpret a test and document the resulting diagnosis in the progress note.

• The written report of an anatomic pathology service may be used for coding purposes. This report is an exception to the requirement for a face-ta-face visit.

• Only information recorded in a progress note as the result of a faceto-face patient visit that has been signed by a doctor or approved clinician can be used for coding purposes.

• In addition to stating that a patient has a particular diagnosis, evidence in the medical record should support that diagnosis.

o For example, a patient who is newly diagnosed with "motor depression, single episode" should have some documentation of the criteria necessary for making that diagnosis.

o Suspicions or "rule cuts" cannot be coded as diagnoses. If a definitive diagnosis has not been made, the symptoms or signs should be coded.

Note that most symptoms have diagnosis codes. These codes are found in the 78X series of ICD-9.

• ALL chronic conditions must be fully assessed annually to properly report the member's health status.

• Physicians must thoroughly document in the chart all conditions evaluated during each visit and code to the highest level of specificity to fully utilize the ICD-9 Diagnosis Coding System.

• Each encounter in the medical record must stand alone, and only conditions evaluated during the encounter should be documented and coded.

• Terms that support evaluative documentation and treatment are as follows:

o Stable on meds

o Condition worsening-medication adjusted

o Tests ordered-documentation reviewed

o Condition improving

A GUIDE TO RISK ADJUSTMENT AND THE CMS·HCC MODEL

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• Listing medications and prescriptions in a medical record does not meet documentation requirements to indicate that an evaluation for a condition was performed.

• Checking off a code on an encounter form or listing a diagnosis on a medical record problem list does not meet documentation requirements. A diagnosis must be in the medical record progress note to fully meet documentation requirements.

II. A Valid Medical Record Has Very Specific Criteria

• leg ibilily:

o The medical record must be legible. A reviewer must be able to read what is written.

o If others cannot read your writing, you should dictate.

o The physician has the responsibility of reviewing dictated notes, making any corrections, and signing them.

• Patient Name and ID:

o For a medical record to be valid, every page must clearly identify the patient by last name, first name, and some other form of identification, such as a medical record number, an account number, or date of birth.

• Visit Date:

o The medical record documentation must include the date of the patient visit with month, day, and year clearly stated.

• Standard Abbreviations:

o Only standard abbreviations should be used to ensure clear understanding. (See a brief listing of some of the most common abbreviations for significant diagnoses in the back of this workbook.) The use of symbols is discouraged because they cannot be used for coding purposes. For example, tlipids cannot be coded as hyperlipidemia.

• Organized Note:

o The visit note should be organized in a logical fashion and clearly demonstrate that this visit was a face-ta-face visit (usually identified

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by documenting the presence of physical findings). The most common example is the use of the SOAP format [Sesubjectlve:

Oeobjectlve: Aeossessmenf P=Plan). Diagnoses should be clearly noted as part of the assessment.

• Patient Diagnoses:

o All the patient's diagnoses should be documented at least once each year in a progress note, with a brief update of the status of each diagnosis.

• Follow-up Pian:

o The medical record should include the follow-up plan comprising tests ordered, referrals made, patient instructions, and when the next cppo'ntrrent should be scheduled.

• Signature and Credential:

o The progress note must include a clear clinician signature, with a credential after the name. Knowing which clinician is responsible for the note is important. If signatures are difficult to read, the practice should maintain a Signature log.

III. Official Outpatient Coding Guidelines

Effective October 1, 2007"

Diagnostic Coding and Reporting Guidelines for Outpatient Services These coding guidelines for outpatient diagnoses have been approved for use by hospitals/providers in coding and reporting hospital-based outpatient services and provlder-bosed office visits.

Information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the ICD-9-CM Tabular List [code numbers and titles), can be found in Section IA of these guidelines, under "Convenfions Used in the Tabular list." Information about the correct sequence to use in finding a code is also described in Section I.

The terms encounter and visit are often used interchangeably in describing outpatient service contacts and, therefore, appear together

'Althoogh the,eguidelines are called the outpatient coding guideline, ,theycpplytc all ,ervices perimmed by a phy'ician, bc,ed on Cading Clinic. Q3. 2000 fXl9es &7

A GUIDE TO RISK ADJUSTMENT AND THE CMS-HCC MODEL

I PAGE 15

in these guidelines without distinguishing one from the other.

Though the conventions and general quidellnes apply to all settings, coding guidelines for outpatient and provider reporting of diagnoses will vary in a number of instances from those for inpatient diagnoses, recognizing that:

• The Uniform Hospital Discharge Data Set (UHDDS) definition of prtnclpal diagnosis applies only to inpatients in acute, short-term, long-term care, and psychiatric hospitals .

• Coding gUidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients.

A. Selection of 6rs~/isted condition

In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.

In determining the hrsthsted diagnosis, the coding conventions of ICD-9-CM, as well as the general and disease specific guidelines, take precedence over the outpatient gUidelines.

Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.

The most critical rule involves beginning the search for the correct code csslqnrrent through the AlphabetiC Index. Never begin searching initially in the Tabular list as this will lead to coding errors.

B. Codes from 001.0 through VB4.B

The appropriate code or codes from 001 .0 through VB4. B must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reosonls] for the encounter/visit.

C. Accurate reporting of ICD-9-CM diagnosis codes

For accurate reporting of ICD-9-CM diagnosis codes, the documentation should describe the patient's condition, using terminology that includes

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specific diagnoses as well as symptoms, problems, or reasons for the encounter. ICD-9-CM codes describe all of these.

D. SelecHon of codes 001.0 through 999.9

The selection of codes 001.0 through 999.9 will frequently be used to describe the reason for the encounter. These codes are from the section of ICD-9-CM for the classification of diseases and injuries (e.g., infectious and parasitic diseases, neoplasms, symptoms, signs, and ill-defined conditions, etc).

E. Codes that describe symptoms and signs

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 16 of ICD-9-CM, Symptoms, Signs, and III-defined Conditions [cedes 780.0·799.91 contain many, but not all, codes for symptoms.

F. Encounters for cirt:umslances other than a disease or injury ICD-9-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Supplementary Classification of Factors InfluenCing Health Status and Contact with Health Services (V01.0-VB4.B) is provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.

G. level of Detail in Coding

1 ICDYCM codes with 3, 4, or 5 digits

ICD-9-CM is composed of codes with either 3, 4, or 5 digits. Codes with three digits are included in ICD-9-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits, which provide greater specificity.

2. Use of full number of digits required for a code

A three-digit code is to be used only if it is not further subdivided. Where fourth-digit subcategories and/or fifth-digit subclassifications

A GUIDE TO RISK ADJUSTMENT AND THE CMS-HCC MODEL

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are provided, they must be assigned. A code is invalid if it has not been coded to the full number of digits required for that code.

See also discussion under Section l.b.3., General Coding GUidelines, Level of Detail in Coding.

H. ICD-9-CM code lor /he diagnosis, condition, problem, or o/her reason for encounter/visit

list first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. list additional codes that describe any coexisting conditions. In some cases, the ftrs+hsted diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.

I. "Probable," "suspected," "questionab/e," "rule out," or "working diagnosis"

Do not code diagnoses documented as "proboble," "suspected, H "questionoble, H "rule out, H or Nworking diagnosis.H Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Please note: This differs from the coding practices used by shortterm, acute care, long-term care, and psychiatric hospitals.

1. Chronic diseases

Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s)

K. Code all documented conditions that coexist

Cede all documented conditions that coexist at the time of the encounter/Visit and require or affect patient care treatment or management.

Do not code conditions that were previously treated and no longer exist. However, history codes (Vl O-V19) may be used as secondary codes if

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the historical condition or family history has an impact on current care or influences treatment.

L. Patients receiving diagnostic services only

For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible

for the outpatient services provided during the encounter/viSit. Codes for other diagnoses [e.g., chronic conditions! may be sequenced as additional diagnoses.

For outpatient encounters for diagnostic tests that have been interpreted by a physician and the final report is available at the time of coding, code any confirmed or definitive diagnosis[es! documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.

M. Patients receiving therapeutic services only

For patients receiving therapeutic services only during an encounter/ visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/viSit. Codes for other diagnoses [e.g., chronic conditions! may be sequenced as additional diagnoses.

The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy, radiation therapy, or rehabilitation, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.

N. Patients receiving preoperative evaluations only

For patients receiving preoperative evaluations only, sequence first a code from category V72.8, Other Specified Examinations, to describe

A GUIDE TO RISK ADJUSTMENT AND THE CMS·HCC MODEL

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the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation.

O. Ambu/alory surgery

For ambulatory surgery, code the diagnosis for which the surgery was performed. If the posloperoflve diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.

IV. Keys to Successful Documentation and Coding for Medicare Patients

See each Medicare patient at least once each year and document and code every significant diagnosis in your medical record note for that visit. According to coding guidelines, you cannot submit a code based only on what is written in a patient problem list. Following are some tips for specific significant diagnoses:

• Cardiology

o Be specific. If the patient has stable angina or a history of myocardial infarction (MI), document this condition as opposec to a less specific or concomitant diagnosis such as coronary artery disease ICADI or atherosclerotic heart disease IASHDI.

o Documenting myocardial infarction. For coding purposes. an acute MI occurs within the first 8 weeks-after that, you should document an old MI. Also, for an acute MI, the initial episode of care (hospitalizationl has a different diagnosis code from subsequent episodes of care (re-admission).

o Arrhythmias. Do not forget to document and code ongoing chronic conditions such as atrial fibrillation or arrhythmias, whether symptomatic or asymptomatic due to pharmacologic treatment.

o CHE Once diagnosed, CHF exists as a chronic condition and should be documented, coded, and treated as such. Consider

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echocardiograms for the evaluation and documentation of diastolic heart failure.

• Endocrine

o Complications of diabetes are the most frequently omitted conditions in physician medical records.

• If you simply document DM or diabetes in your progress note in the medical record, the correct code is the code for uncomplicated diabetes [250.00[.

o Only the doctor can make a diagnosis of a manifestation of diabetes-the person coding the medical record cannot assume anything. For example, if a patient has diabetes and a lab test with a creatinine of 3.0, the coder can only code diabetes unless the doctor documents diabetic nephropathy.

• Even the clinician cannot code something he or she did not write.

o Additional codes. For many manifestations of diabetes, a second diagnosis code is required along with the primary diagnosis. For example, for a patient with adult diabetic nephropathy, you should submit the code 250.4X for Diabetes with Nephrcpohy as well as Diabetic Nephropathy 583.9 or Chronic Kidney Disease [CKD) Stages 1- V 585X.

o Evaluate every patient with diabetes, especially those with renal disease, for the presence of malnutrition [see below/monitor the patient's albumin and/or weight loss/BMI) and anemia and code appropriately.

o Evaluate every patient with diabetes for all manifestations and comorbldltles of the disease. Therefore, all pctlents should be evaluated for complications of diabetes, including reohrcpcnv neuropathy, peripheral vascular disease, and ophthalmologic compromise or other diabetic complications. Even though only the highest weighted code will count toward the risk-adjusted model, all should be listed when applicable. This practice is also critical so that the associated diagnoses and codes can be documented and applied.

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The diagnoses can include CKD, Diabetic Nephropathy, Autonomic Peripheral Neuropathy, Peripheral Angiopathy, and Vitreous Hemorrhage, among others.

o Diabetic control. The 5th digit in diabetes coding is used to refer to the level of diabetic control where 250.00 is uncomplicated adult diabetes, not stated as uncontrolled, and 250.02 is uncomplicated adult diabetes, stated as uncontrolled. In addition, remember to use the V code when a patient is on insulin .

• Neurology

o Documenting and coding stroke. Patients with acute cerebrovascular accident (CVA) usually present in an ER or hospital setting. Patients who recover from CVA without sequelae should be documented as "hlslorv of CVg and assigned code V12.54 as

an additional code for history of cerebrovascular disease when no neurologic deficits are present. Unless the patient is still hospitalized for the CVA, you should not be using codes in the 434.XX series.

o Late effects of stroke. Assess and document all late effects

of CVA Late effects such as aphasia, aphagia, hemiparesis, hemiplegia, etc., should be documented and coded using codes from the 438.XX series.

o Epilepsy and Parkinson's disease are chronic diseases and should be documented, coded, and treated as such .

• Nutritional

o Physicians often neglect nutritional deficiency assessment in patients with chronic illnesses such as cancer, COPD, CHF, or renal failure. Assuming they do assess, physicians often neglect to document and code nutritional deficiency in patients with chronic illnesses.

o Malnutrition and cachexia. Typically, malnutrition or cachexia results from involuntary weight loss as the result of a chronic illness. Be sure to look for diagnoses, and document these conditions when they occur in your patients. Regularly check on the patient's albumin,

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ACCURACY IN DOCUMENTATION AND CODING:

weight, and BMI trend/loss, especially in the frail, older adult, patients with dementia, and in patients with CKD.

• Oncology

o The ICD-9 quidellnes for oncology are often counterintuitive to physicians and do not follow current thinking on oncology. Review them to code malignancies properly.

o Malignancies are considered active disease until the patient has completed "dehnltive treatment, N which includes surgical excision and/or chemotherapy and/or radiation, and shows no sign of the disease. This criterion means that patients who are not treated still have active disease.

D Patients with no sign of the disease [e.g., those under post treatment surveillance with no evidence of recurrence or me-ostosesl must be documented and coded as having a history of the malignancy.

o Note any metastases and code them as metastatic disease, not as a new primary malignancy.

o Patients on adjuvant therapy for breast and prostate cancer [e.g., tamoxifen, Lupron®) continue to be coded as having an active malignancy, even in the absence of any sign of the disease. This guideline is an exception to the general rules.

o Metastatic disease. Document and code the primary as well as the metastatic sites of the cancer.

• Psychiatry

o Making the specific diagnosis is the key to appropriate documentation.

• Many physicians are hesitant to document psychiatric disorders because of concerns that this information will be shared with a clearinghouse that provides medical information on people who apply for insurance. Diagnoses submitted to SCAN Health Plan are not shared with any agency except CMS.

o Depression. If you simply document 'oepresslon" in the medical

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record, then the correct code is a 311, depression not otherwise specified. However, if your patient meets the clinical criteria for major depression, then you should document with "motor depression, single episode" or "motor depression, recurrent episode" as appropriate. Patients on long-term antidepressant or talk therapy for major depression should also be documented appropriately.

o Once bipolar disorder, obsessive-compulsive disorder [OCD), alcoholism, dementia, or schizophrenia is diagnosed, it is a lifetime diagnosis as long as it is documented.

o Alcohol dependence. Dependence on alcohol is common in Medicare patients, so be sure to document these conditions at least once each year in your progress notes and then code them. A CAGE questionnaire can be completed to screen for alcohol dependence.

o Sleep disorders are very common in geriatric patients. Patients must be screened for sleep disorders as well as having their medications reviewed for long-term hypnotics. Also, alcohol-induced sleep disorder is common and should be evaluated when patients are screened positive for alcohol dependence.

o Delirium is also a common condition in the elderly. The diagnosis is made when the patient has active symptoms or is asymptomatic as a result of the treatment .

• Pulmonary

o Do not forget to document and code chronic pulmonary diseases at least once each year.

o COPD, chronic bronchitis, and emphysema. These chronic conditions must be documented and coded at least once each calendar year. Be sure to include chronic respiratory failure for those patients who meet the clinical criteria of Pa02 value of less than 60 mm Hg [oxygen saturation of less than 88%) while breathing air or PaC02 of more than 50 mm Hg.

o Do yearly spirometry screening for all at-risk patients. Review all patients for recurrent acute bronchitis and multiple-inhaler

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ACCURACY IN DOCUMENTATION AND CODING:

prescriptions for possible chronic bronchitis and COPD.

o For bacterial pneumonia, be sure to document the causative organism and/or the radiologic findings.

• Renal

o CKD coding (585.X) has been changed to conform with the stages of CKD. These changes include stages I-V based on a potent's glomerular filtration rate (GFR), which is estimated from a urinalysis and/or serum creatinine and basic patient demographics. Remember that some Medicare patients with "rormo!" creatinine levels may still have significantly impaired renal function. For people at risk, creatinine clearance or GFR should be estimated at least twice per year.

o Note that stages I and II of CKD must have 3 months of reduced GFR or evidence of kidney damage documented.

• Skin and Orthopedics

o Chronic skin ulcers. Be sure to document and code chronic skin ulcers as either decubitus or caused by other factors. If caused by vascular disease, this finding should be documented and coded as well.

o Amputations are chronic conditions and permanent and should be documented and coded on a yearly basis.

• Status Codes

o Common status codes. A number of important codes that describe a patient's status are often overlooked during documentation and coding. Physicians know the patient has these conditions, but because they are often long-standing, annual documentation is omitted. The most common status conditions include:

• Gastrostomy, ileostomy, tracheostomy, or colostomy status (V44.x)

• Cystostomy or nephrostomy status (V44.X)

• Renal dialysis status IV45.11

• Lower limb amputation status, including toes (V49.7X)

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• Vascular

o Peripheral vascular disease IPVD).PVD is relatively common in elderly patients, especially where it may be a manifestation of diabetes. When PVD is associated with diabetes, code the diabetic code first 1250.701 and then the PVD code 1443.811

o Atherosclerosis. Aortic atherosclerosis and peripheral atherosclerosis are chronic conditions that require documentation and coding each year. These conditions may be findings on CXR and KUB. To code these conditions, the diagnosis must be stated in the progress note. They cannot be coded from the radiology report.

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ACCURACY IN DOCUMENTATION AND CODING:

CHAPTER 3

THE MEDICAL RECORD REVIEW PROCESS

Significant value is placed in the physician medical record review process as a vehicle for improving medical record documentation and ultimately improving patient care.

In addition to a description of how a physician should conduct a medical record chart review, we have also included a sample of a revised medical chart review summary. The summary is always the product derived from the chart review. It records all potential and confirmed diagnoses that were found by the reviewing physician. The diagnoses fall into 3 categories: (1) diagnoses that are documented and were previously coded; (2) diagnoses that are documented and not coded [l.e.. have not been received by SCAN); and (3) diagnoses that are implied, embedded, or inferred but require a patient visit to the physician to confirm or contradict the diagnostic suspicion through further analysis of the patient and the medical data.

The attached summary is organized in ICD-9 numerical order. Each diagnosis contains the corresponding ICD-9 and HCC number and HCC Risk Adjustment Factor, the category of evidence supporting the diagnosis, the diagnosis definition, and a comment regarding why the physician reviewer believes the patient data support the existence of the diagnosis. ICD-9 codes are used only to facilitate communication with the primary care physician.

The treating physician uses this problem list to guide the patient visit and develop a definitive problem list for the patient-treatment plan in the future. The treating physician will submit the complete encounter data reflecting this evaluation.

Goal. The purpose of the medical record review is to generate an

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accurate problem list for Medicare Advantage members that includes all significant acute and chronic medical diagnoses.

End Product. The product of the medical record review is a list of definite and probable diagnoses to help the member's physician improve documentation and coding of progress notes. This problem list will be reviewed by the member's physician, who will determine which of the diagnoses apply and will then document them in a signed and dated progress note based on a patient visit.

Process. For most members, a clinician looks at every page in the patient's medical record and collects a list of significant diagnoses that are documented or suggested.

I. The review should be conducted in the following order:

• Extract information from any existing problem list from both the HMO and the patient's medical record.

• Review medication lists or other pharmacy information from the

HMO and physician patient list.

• Review any consultation notes.

• Review any hospital admission and discharge summaries.

• Review any attached hospital records.

• Review labs, pathology, and x-ray reports.

• Review any patient completed histories.

• Review notes from other providers-e.g., home health, PT, etc.

• Review any authorizations, referrals, or requests for services such as DME.

• Review progress notes beginning with the most recent.

• Review any other documents that might have pertinent clinical information.

II. Rules for capturing diagnoses:

• Record a diagnosis on an encounter that is properly signed and

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ACCURACY IN DOCUMENTATION AND CODING:

dated when a diagnosis is clearly stated, and include the date.

• Do not guess at a diagnosis when trying to directly submit a diagnosis. All patients on ACE inhibitors do not have CHF. Diagnoses that are suspected should be recorded as embedded and inferred diagnoses.

• Record each diagnosis once. Select the most recent, most clear, and most specific diagnosis.

• Record multiple complications of the same diagnosis if they are documented or suspected; e.g., for diabetes, list all diabetic complications that apply, such as diabetes with reo-ropcohv as well as CKD or nephropathy, diabetes with PVD, and peripheral angiopathy.

• Look for disconnects to identify suggested diagnoses; e.g., low ejection fraction with no mention of CHF, vertebral fracture on KUB with no mention of pathologic vertebral fracture, proteinuria, or abnormal GFR with no mention of CKD.

• Understand and apply basic coding rules; e.g., definition of an old MI vs. acute MI, pathologic fractures are only coded once unless new treatments are initiated, etc.

• Use the diagnoses from the HMO encounter data and/or medical group to help deduce other diseases and/or pathologic processes to suggest more complete or comprehensive relevant diagnoses. An example would be in a pctlent with diabetes without complications, concomitant hyperlipidemia, history of stroke, coronary artery disease, chest pain, and ACE/ARB, beta blocker, and spironolactone medication regimen. A suggested list of probable diagnoses would include diabetes with PVD, peripheral angiopathy, diabetes with neurooojhy autonomic peripheral neuropathy, CHF, stable angina, and checking a GFR and the patient's urine to assess for diabetic nephropathy and CKD.

• Use clinical judgment to question correct documentation under comments:

o e.g., patient with diabetes and elevated creatinine, proteinuria, microalbuminuria, or decreased GFR. This finding may be

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diabetic nephropathy and CKD, but requires documentation of both conditions to code for both .

• Ignore minor or acute illnesses not likely to require ongoing care, such as sore throat, skin laceration, ankle sprain, etc., when developing a comprehensive problem list of chronic conditions.

III. The column for ICD-9 coding is available for coders to provide and is not required of the physician reviewer.

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ACCURACY IN DOCUMENTATION AND CODING:

CHAPTER 4

USE OF THE PROBLEM LIST AND THE VALUE PROPOSITION

The purpose of the CM5-HCC reimbursement system for Medicare managed care plans is to accurately pay for patient care on the basis of the acuity of the individual patient. Physicians who work in managed care have not traditionally emphasized the importance of accurate ICD-9 coding for a patient because they believed it affected neither the reimbursement for the care of that patient nor the quality of care.

With the advent of the CM5-HCC reimbursement system, this situation is changing. It is critical to develop a comprehensive medical record problem list for every patient in an attempt to improve the care of that patient. If the physician did not document the disease or treatment plan for a patient, in essence, the condition (according to CMS) does not exist. This concept drives both the quality of care and the level of communication with the patient. Equally importcnt is the concept that the physician will need to accurately document the condition and care to the patient to be reimbursed appropriately. The HCC system that CMS has developed will address this shortfall in the prior delivery system and assist physicians with these new administrative and patient challenges.

The physician must be able to interpret the medical record problem list and translate it into an active treatment plan that can both medically address the needs of the patient and be utilized to translate this feature into an active form of communication with the patient.

The goal of the problem list is not only to focus the course of treatment for the patient but also to ensure that all of the patient's needs are being met concurrently and proactively. Therefore, the physician should not only address the upper respiratory infection (patient's chief complaint) but also address the patient's diabetes and all of the associated

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complications. If the physician has appropriate medical records and coding submissions reflecting this broad array of problems (not just the chief complaint), improved care and improved reimbursement make this a win-win-win proposition for the patient, physician, and health care system.

The physician must evaluate the patient because many of the diagnoses on the medical record problem list are suggested (not confirmed) and need clinical confirmation that can only occur in a face-ta-face physician-patient visit. This visit is not a coding exercise, but an attempt to improve patient care and document the improvement.

Intended actions by the primary care physicians include the following:

1 . Review all previously recorded diagnosis in the medical record and ensure that they are correct, comprehensive, and exhaustive.

2. Review all medications that the patient is taking and ensure that they are correct, necessary, and related to confirmed diagnoses that they are treating and that those diagnoses are documented and coded.

3. Review all laboratories, radiology, and supportive documentation, including physician consultants notes, and ensure that this information is integrated into the patient's problem list and medical record so the "chor- tells a story" that everyone understands and can take action on, including the patient.

4. The data in the medical record lead to a comprehensive individualized treatment plan for the patient that improves care and is reflected in the ICD-9 coding for that patient's encounter. This treatment plan must also be communicated to everyone participating in the care of the patient, including the patient. Implementation of the treatment plan should result in improved care.

5. Perform any necessary further clinical evaluations to verify the existence of suggested diagnoses. These clinical evaluations are generally simple and fairly straightforward but may be overlooked in the day-to-day care of the patient.

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ACCURACY IN DOCUMENTATION AND CODING:

6. Finally, develop a new comprehensive medical record problem list that is utilized and updated for the next year until this yearly [or more often, based upon the clinical needs of the patient) evaluation is repeated.

By doing the aforementioned, the primary care physicians are taking an active leading role in the coordination of the care for their patients and realizing their rewards for their entire teams, especially the patients.

Avoiding Errors in Documentation

Over the past 4 years, CMS has audited thousands of /1M members' charts. The results have been both alarming and encouraging. They

are alarming because the error rate hovers around 30%. This 30% is actually lower than the actual error rate because CMS allows health plans to cull a year's worth of medical records in search of the 1 record that supports the submitted diagnosis. In the fee-for-service Medicare program, error rates above 5% are considered problematic, so it is easy to see why the MA experience is alarming. But what is the encouraging aspect of this situation?

Physicians should be encouraged by the knowledge that a small number of errors in documentation make up the vast majority of coding errors. Better yet, these errors are easily corrected once physicians understand the underlying ICD-9 coding rules.

First and foremost, physicians must understand that the ICD-9 and clinical medicine have little in common. Second, physicians must distance themselves from their clinical knowledge, both in general and specifically, about the patient at hand. The ICD-9 does not allow assumption and relies solely on what is written in the progress nole.:' At this point the ICD-9 begins to make no sense to the practicing physician, who often writes a note, and then chooses a code reflecting what's wrong with the patient, not what they've documented in the medical record.

So, what are the most common mistakes made, and more importantly, what can physicians do to support their diagnosis code selections?

'Cod;ng rule, do not ollow choming a code on the ba,;, of lab or rcdiology re port"unles,thephy'icion referenc:e, them in the bady of the r=se= nole. Further. such references m"'tbe'peci~<:-noting thotthe resolrts cbnormcl orwrit;ng 0 lob value does not support ICD-Q selection

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Problem: No causal relationship has been established in the medical record.

Example: Diabetes with renal failure.

Solution: If you are trying to describe renal failure caused by the diabetes [which is what ICD-9 250.4 represents], then your note must establish the causal relationship. Wording such as N2Q, W "caused bv," or "dicbetlc renal fmlure" all establish that causal relationship. Explanation: Under ICD-9 rules, a causal relationship is not assumed, and diagnoses listed together are considered to be unrelated. Although this split seems to be a hypercritical distinction, the ICD-9 requires that physicians specifically state the causal relationship because the diseases can be merely coexisting.

Problem: You are trying to use ICD-9 titles to support a code selection or simply writing the ICD-9 code medical record.

Example: Diabetes with renal manifestations [250.401.

Solution: Document both diseases in a brief narrative. As in the first example the word "wuh" does not establish a causal relationship, even if you mirror what the code descriptor is. So, if you believe the diabetes caused the renal problem, describe that problem accurately [e.g., diabetes mellitus, CKD stage 3, 2Q to DM). Because coding

is derived from a narrative description of the disease state, writing 250.40 in the chart cannot be coded.

Problem: You are documenting and coding CVA in the office setting. A CVA is an acute event. Once the patient is discharged from the hospital or rehabilitation setting, the diagnosis of acute CVA is inaccurate and leads to miscoding.

Example: Each time a status post CVA patient is evaluated, the physician documents NCVN in the record and codes 434.91 [CVA, ischemic or unspecified].

Solution: Document that the patient is status post-CVA or has a history of eVA IVI2.S41. What is often overlooked ore the sequelae of eVA,

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ACCURACY IN DOCUMENTATION AND CODING:

because they have often been present many years. When assessing the patient, document and code these sequelae as well. ICD-9 codes are available for all of the common and pertinent sequelae of CVA in the 438.XX series of ICD-9.

Problem: Malignancy was coded when the correct coding would be

personal history of malignancy of . In the case of ma-

lignancies, the ICD-9 again differs from current clinical thinking. The ICD-9 allows coding of the malignancy until definitive treatment is finished (unless there are signs of active disease). Definitive treatment is that aimed at eradicating the cancer, such as surgery, chemotherapy, and/or radiation therapy. Patients with biopsy proven malignancies who are not treated continue to be coded as current cancer. Example: Patient is status post pneumonectomy for lung cancer 5 years ago. The patient is on no therapy, but surveillance is continued for the patient's lifetime.

Solution: Document and code personal history of the cancer. These codes are found in the Vl O.XX series of the ICD-9.

Problem: You are documentating multiple primary sites of malignancies when the poflent has metastatic disease.

Example: Patient has primary breast cancer that has metastasized to the brain.

Solution: If the patient is being assessed or treated for both, then coding for the breast cancer would be in the 174.X (depending on area of the breast) and 198.3, secondary neoplasm of brain or spinal cord.

Problem: You are not restating and coding long-standing disease.

The ICD-9 and the CMS-HCC risk-adjustment model have no inherent memory. A disease only exists at the time it is assessed, documented, and coded. All chronic diseases disappear from the risk-adjustment model each year and must be resubmitted.

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Example: A pofient is 10 years status post-colon resection for carcinoma, with colostomy.

Solution: When your attention is directed to the illness, or in this case the site (assessing skin integrity or signs and symptoms of a recurrence of the cancer), document and code these conditions. Codes are available for artificial openings (tracheostomy, colostomy, ileostomy, etc.)

in the V44.X series.

Problem: "History o]" means the disease is in the past. You cannot code a disease you have listed as a "history ol.'

Example: History of CHF.

Solution: Remember to use the term "history of" only for diseases that have resolved. In the case of chronic conditions such as CHF and atrial fibrillation, use the terms "compensated" or "controlled" to reflect their ongOing status.

Although the ICD-9 coding system has thousands of rules, following the few simple changes in documentation will help you accurately document and code your patient's illnesses.

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ACCURACY IN DOCUMENTATION AND CODING:

CHAPTER 5

DIAGNOSTIC AND CODING CRITERIA OF COMMON GERIATRIC CONDITIONS

This chapter is a dictionary of the most common diagnoses utilized in the practice of medicine for seniors in Southern California. Every diagnosis has the necessary ICD-9 coding criteria as well as validated diagnosis criteria.

This chapter is not definitive nor is it meant to replace any of the valuable reference texts available for physicians. The purpose is to provide a quick but accurate gUide for the practicing physician to assist in the accuracy of making a diagnosis and the use of specific ICD-9 codes.

A GUIDE TO RISK ADJUSTMENT AND THE CMS·HCC MODEL

I PAGE 37

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OX DESCRIPTION OX HCC HCC DESCRIPTION I DOCUMENTATION REQUIREMENTS CLINICAL CRITERIA
CODE FOR CODE USE
AM, NOT RUPTURED 4414 105 Vascular Disease This code is used when the documenta- Abnormally large abdominal aorta often
tion indicates that the patient has found as a large pulsating abdominal mass,
an abdominal aortic or descending diagnosed by US, CT, angiogram or other
abdominal aneurysm that has not image studies
ruptured and has not been repaired.
ABDMNAL PAIN 78906 This code is used when the documenta- Epigastric pain/discomfort, diagnosed
EPIGASTRIC tion indicates that the patient has clinically
epigastric abdominal pain.
ABDMNAL PAIN 78907 This code is used when the documenta- Generalized abdominal pain/discomfort,
GENERALIZED tion indicates generalized abdominal diagnosed clinically
pain.
ABDMNAL PAIN OTH 78909 This code is used when the documenta- Abdominal pain/discomfort, diagnosed
SPCF ST tion describes abdominal pain in an clinically
area of the abdomen that does not
have a specific code. This includes
descriptive terms such as abdominal-
gia, or colic.
ABDMNAL PAIN 78900 Used when documentation states Non-specific abdominal pain, diagnosed
UNSPCF SITE abdominal pain and a quadrant is not clinically
specified.
ABN BLOOD CHEMIS- 7906 This code is assigned when the docu- Abnormal blood test value, diagnosed based
TRY NEC mentation indicates an abnormal (blood) on lab value
laboratory test, but the significance or
related diagnosis is not determined or
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lI1,mi';UOIDc:anco,ocn"i*Etic <'~gldloch'mlitD'nt<~9'IL;"

~"":~~~~~=tn m~~I~':te fem'*' <1~ g/d or 31%, dLl! to IIIIIIIgnoo"

ocn"i*Etic;i" .. , .. IW-9_ not .. ,"m •• 'iU'~ "latilu:I'i~,lho ~~molllJ'on'Y'hOU!OoI"'be

Anii1._rIIl!O lII;,lI/h,ndorumontal"".,.liIljjn .. ~n",,,muIJpi::BICllldi"'oh'oIlliin.

Mymrdlol_on ooglmpeottJ1., HelB'deno oyndl!Jlle, d!liln",edd~oal~ LklfI"lI'jI1dmm',Schllllenoter

kIII1lf1'it.lII1lin"'"' .... nooard ..

... maliia,ocoliH'liIlii1·

lII;,;lItlooth,dooumonlatil1inli::atoo Aneml.d~ed ... lllllle"lthhenrVo~n

ooeml.ofohml'l,dI"""eorlne" <'lgldl ... hemmn,ntd9%;or

g;~:;:"":ul:~il:'"':~th, ~u~:~,~~r:'~';~,::,Ii""'''

ooeml.l.du.tn'h ..... 'dI"""." lin ..... ICD-!l d"",nm ... une.

=~i::~,~:~i~:~:du::..~:n~lDj.

lIoedlltlenthedooum_ ......

~~:~~'1ID~""bII

~n"'''m'l'"''IIlC~IIHgb<lBfa' IIIII1;Hgb<'4fDrllOOlll1j,;ililJ1,tlIldby lIIIl,ratnryYlllJ"

lIG'IIIh'noowmantaloo''''liIllialJ,Coodiloo~by.pottamof

neu","I',nl!lJ'Otj'IItDte,lIIlnornllll frnI1uentlllll"YandmD!tyllllout""" ... ItI'-

""i>"I!'''n~on,''''l>"I!I'en....,n ... , fermtl!'len_,dl"ll""edot.l,oIly

pilY!11'i,li:;nalJ,if'llialJ_,psJ-

dmaurofi::n'1J,"li1jC1i::if'llialJoc

Irnil!tydlmer

Thl.ome' .... ed""enthedoou_ COOd~oo"""retmtvmm:e""".li!po_

tm'nd_oorlo!lthe","d"""~, ~the""'l.oflrltD""dlngto_g,

"1'rofi::i<I1B,irtaOO"I'rofi:: ..... ,or l1irdani1ililllViJrllb::llaga,dilgn",d

_1iIJr1a. di1i'~lyocbylll1li'i"rMlIIIIl,oIuji"

lIG,dlltlonth,dooumontatil1inli:at&o Ilmer dllm"lll!ml~nglrltt:_

IDJJlredm'VIlill!dlm"',oortt: ltenool 'noumdenoymgurgltmjon

delmnl~emooord""lIIhhoortt:_ Iililln""dlly,d1',liI1li'ilBmoroth"

_mant.IlflaM""I,rofi::lilJrti:: iIIIg,oIuji"

_,liIJrio_inouffi,ian<:y;i<I1i:: _""lItnJotm,oIItt:lIIM!ltenool'

Thi.om,j .... ,d""anth,d,,,_oIpCN!!l 1iI1jndi::at&othlitth'lIIlonIil ...... POIltOOrml'jIlypoB •• urgery.Wthere ~"'lliJoIdl" ... ,thl.lltaJld""fIJ~ d,o::ribadarnom,d,

lIG,dlltlonth,dooumontatil1inli:at&o lIafno::IiooomJroftho,,..c:hIractJlMzOOby BRtjgllllltlBm,""1ulred_m;tj.m, on"'rtm,oIoo""",leodll'1ltod_ <D'1lenltlllBRtjgllllltlBm,refmctIvI!BRtjg- hlBge,d"lln",eddlrl""l~

..... moc<D'1lanilllllElii ..... m

-.;~o_~""'I'di ........ lIti1ifillmlill"''lli::_tofmliin .ullRmn"",u"""'vqlor,..,lIen,1!tt: d"lln",edd~""I~lI'l1/a'byPFT"''''''ng

oIlmu::IMlpottam(FEV1lFVG<aD'IL)liIld .... "ibility

SIl"m,dHOIIf! lIG,dlltlondooum,_otato .. 1Ii~ IIBPdi""iulllrh,artIIoIItlililln""dlly

Arrhyth_ fIlnlmlon_II1!.Urellol"dooument .... m,ECGorrl'¥thmmorlttr ond",delol'1ltl!lmorourrm!u"of

1IIlIi"'liIlulilltV!ia61

lIBedlltlendooume_lltate.bool<a::ho,or ...... I ... Voni'oyndrom'

lIG,dlltlonth,dooumontatil1inli:at&o AIl'oardio::"nlilionduotoHlN,i"<iJdi"!l

benlgnhyt&ten....,h_dl ..... oardlomeg~,<D'dI..,.".,,_,OIIdIO\"'''"-

hyJ&ten....,h_d .... eorlurt IIIrdl ..... lllthoutCHF,dlBgnooed'lInbty

di ..... o"",nd".,tohyp,rIonoion

BENIGNHYPHTIlS W,{lHF

Do,,"men_muIltM_llerign or IITN (SIP >'4ll,00P> 00 oo~ oo""'m~

baniin .. "nlllltwortoniU1.lfd=- lIiIIwt""orno'llIl1(ayo,~dnoy,oc",,-

lIIIIlIliIiononfyinli ...... hyportllroioo, li,...wlar)d_"dilgn""d'liri::lll~

.ee4ll19,1IetlII

BENIIlNNEOPlA\1II lGBOIIIEl

lIG,;lItlontl1,dooumonlBtil1inli:at&o ~n-""n"rwl"ionin",*".;ilgn"';by

adenom_I.,CrmId1Ite-Cenad. "'1....,""ll'Ion;krmdologlolltlJdI ..

oyn; ..... .".on;Uip.""l"m~;Uip

c:opJtoolip'I!Il.,,,umiDll>.il""'~

p'ilIl.h'lB1i:fIaIu"'lDlPocfllniliil

adenomllttl.l!;Uip

lIBedlltlentl1edooum_ln_ ~n",,,m'.lI1mnoiltymt.1nglmeond

boneleolon._olyd,leom,lme oortIDge,d"lln",edd~I'oIly

...... ' ... '~i'pain.'otoOOynil

_'jIII'i .. lm,p~n.CllftiIIill·llin. tIll.pain.lIIIlholOpoln."O!UoIglII

lI;talyrIo,q,holdlllgl .... bone

c:hini",

lIG,;lItlondooum,_oIita.BPH EnIIifljllll,ntol'p"_lIiII1out,boIruc:tivo

.... (lJMl1IIJrotantion.dMRlingoch' .. mn~.dl"ll""edollnl'oIly

Thl.<lldel .... edlltlenlrmm~.~ _o,lnfllmnailonol_",

the"'~deo~onlnmedl'oIre"'rd m"'-byooughond/a"CXRnmnoi

~~~":'d==;:'Ii:"". (n' inltlritajdilill,"",'d,*,i'~ly

~'I"",,ormnttn notelllhioh tnrmol'the dI .... el';reoent

lIBedlltlentl1edooum_ln_~n",,,m'non_'ln ... rl'¥thmdlBGno"dby

..,~lIIIIIJthmi .. Cildi"''''rllthmi. EllGocrllJthmmonita-

ocCllftiio::onhJIhIi .. Whontl1,lYIIO oflllt1ytlml.l.kmIIIn,~.houlObe dotlJmented.m"'ded!lAlrnll1are~_

lIG,;lItlontl1,dooumonlBtil1inli:at&o ~n"n",rhythm;illlJ1'tlIldbyEGGor

.... laoarrhyt!1m111.'ardlBodyortTyth- rhythmnmltn,

mlo,galoprl'¥thm,nodolrl'¥thm

dim".iltarnotinijJJ ... ~goni",. bii'mi1~rhythm.tJii'mi",.tJii_~

rtTyttm,jIJB ... oItemon •.• -vnedoi rtTyttm,eoto~'rhythm,.""I_

h'ortrhythm • .....-rhythm. bnid""--;i.oc~ardil,Whon •

..... ",erfll,1YI"oIarrhyt!1mlll.I. _(eg.atr101flll1l1mm42731,

~=~=::i~~~':;'~

rermjond<llded~;rIIIteIy.

Thl.<lldel .... edllhentl1edoou_Enlargedheort.dl"ll""edollnl'oIlyorby

tm.tata • ..,lyCllftii,mogoly.lIIith,ut iIIIg,otuji"

=~:::!~I:~n~;:d:":"

lIBedlltlendooume_lndt:ateo QjEdllOIlIj..,oflen.I ... lng tn Impaired

CIItln::t.lon.chlni"'.intlJm,o:;ont 1itU1.liIIin"";'liriOlll~

Ion •. orl .... 'po::ityllill1,utllJrthor

de .... jljon

Thi'c:od'i'''''dlll1anth'd'''_~'ofnockpaiY'dil''mflJrt.dlill-

tmlnd_oeNc:oIglII,neokpoinor .... edot.lc:oIly

OI!I\'t8Ipnln and",,,,,,,,eofthe ill*'

ild<>::Ulllllltad.

lIG,d ""anth,dooumanlBlil1 oiBIa. ~n",,,m'nonc:ordi"'d1'oIpoilI'dil"m-

c:haotpm, 'h,oIdio::mJiat illIiOlli fiJrt,dililJ1,tlIlddinic:al1y

"""'tjU1,mu",ul .. kelemJc:helltpoin

<rnonc:ordlood1elltill*'

lIG,d""andooum,_..,. :~oin',.,rn"m.,GHForhOllf!

LlBed""end"ume_lnd_ ~n",eomc:",nonc:ordlood1elltlll*ll

do::omklt,dililJ1,tlIlddinic:dy

LlBed""end"ume_lnd_ Il1rnnt:ollRtru:tlvelungdl ..... often

·G(J'D·,Whankmlln.th.typooflli"- dlilln""dllill1.m'~l1lhll,III1'ElliI1l.PFT

lIIIY,bslruction.houklbodooulllllll&d .hOllot1lobslruottvepattl!mJ{VllfVC<

andtDdedle_g_,c:hrmlc:_~~ aO'll)

Thl.c:odel.",edlll1enthed"u_ ~n",eomc:d1rnnt:l",hemt:lurtdl ..... tmindi::atooio::l1,mi'tD"nlllJ dlilln""ddi'i""I~III11I<rCllldi"'tooli1i c:hini".".....,domlill·,ilc:honi'

heort,tDrmorydl ..... ,I"""""Ic:he""

dl ...... ,Cllldloolo::l1eml.,<mlnory

::::';d'::~~n:':rmotm

~glven

Glirdil'llll'jIqlIJJm'inoludo5(JI"dOlllll,or ~dilllJ1'tlIld",di1i'~fi"'.'i'·nd+PVG "'CXR ... eohomoy,"",oIb11Ef(o:SO~ 1II11ID''''rm~Efllill1di~i'dyofundi'''

GHRIWNEYIltS STAGE II

Thi,c:od'i,,,,,d<l1ylllhanth, dorumenml..,M_._11I

~:::~to~ci:;:e:~gthere~ •

Ghroni,(J]oInJoIioo lIG,d""anth,dooumanlBlil1inli::Btoo ~n",,,m'd1"ni::bllm'hi"

PlJlm<l1llJIl ...... c:hlmi::brm,hil'.jlllibrm<11i1,

~~n":. ~::~::'~~..,

thol!ll,ofllilWllYoooinJctiont:ltouldb, d,rumantodorntDd,dl'-Il·.,hr<l1i' OOIltllJc:t1veIm1<11~~

LlBelllhenthedorumenml..,i1dlcllte. ~n",eomc:d1rnnt:renoldyofurctm

c:trnnt:~dreyd~e .. e,c:hr<l1lc:renal <11lnCte11zedllylmpM'edGll

:~~=~:.oy:=~~

IdOneyd ..... ecodll1llltaJldMud. ad"llnORlc:lltatl!lll!ntofth'lIIIlIleof kijn"d ..... 'IIIh ....... 'Ill"il*'

Thl.c:odel.",ed<l1ylllhenthe dorumenml..,M_._1

~=m~:~:~:~~th=

Il1rnnt:renoldyofurctm",,"rectenzedlly ",."nng c:reati1ln.> t.s,<rjrOlei1urlll <rh,mliturill,ormi::mllliIJninuli a, orc:oslo i1thoun",..,~,findi1i'..,psth'*0ti ~,ormdl~lc:ftndi1g.~VP<rt.RICT; 1.'.c:yIItO,jIIIjlllllllJn""""lB)andudne jIlJduc:li..,(so,.II!vol.c:hIiotorizodlly IH>gD-(GA!l=114D-liQOofpotionl) (Ilodylll!lghtofpotjentlnll!l)l(Creati1ln.ln rrVdll(72)IIIJ~~yllyt_Z3lfmol.""dlly us ~fom~.

Th;,cm,;,,,,,d<l1ylllhantl1, dorumenml..,Moate._11 a.rn,*,lCImeylll!"",eANDtI1ere~. d,rumanladGFAfromOO-B9

Th;,cm,;,,,,,d<l1ylllhantl1, d,rumanlil..,i1d;oate.SligaIV

~::~m~~:=el~~9Tl1ere~ •

5im'''oIiQ.lorulinoprOOuction(soo 1IIll¥o).,hono::lolilodbyGFAof15-211

Thl.cmel.",ed<l1ylllhentl1e d,rumanlil..,i1d;oate.SligaV

~:::~m~~:<,:'ANDtl1,roE •

Seme"oIiQol"udneprOOuction(Jee 1IIll¥o).,hono::lolilodbyGFA< 15,n"d;11l liilyo;.ortran.pBlIi1ion

Thl.cmel.",edll11enTl1ed"u_ Preoen"'ofmollttJlrJ~enll1lof"'*"'l tm;ndi::atooTl1littl1,polonll1E.

=m~TllE;'.hwyo,......-.jary

lIBelllhendorumenml..,otme. ..... Ipmtln

NonllJl"m,...,,,,,odon,dl"ll,,,,edby ,.,

lIBelllhendorumenml..,i1dloam. cmI1aryiil11,,,,,,I,,,,,;,orartoril "1,,,,,;.~ywh ... _tI1littl1' podenth .. lritI1natlveondn..,.."atlve .... e~--lIJtywh ... mtMoamd 1I11;'htpoof .... "I;'lIfI8::tod,ryour d,rumanlil..,i1d;oate.only"CN)' ttmtl1ermeotdllV'o~.~41401

AthemllderndBoftmlnll'lorterieoli!flned bylll'itivootro"motocp'_'artio' c:lithllitlwt.jlGCili::Btmofll11ii111"n""

ocgml't III!I~I"""llI!dln.jllltmtlllth

1JUI't ...

Th;,cm';'''''dll11anTl1'd"u_~of~h.lililln''''ddi1;'~ly tm;ndi::atoo "Uih, laryngool''''''PO

octIJ ..... oyn~e

I.meml,,, Thl • .mel.",edll11enTl1ed"u_ I:I!veI~entofbl"ddotlnthe"'lI!bml

Unol",medStmke tmlndt:ateoCllA, ... otmke _eolllthb,,*,tlBouedlllllllleleodi1g

1IIlta" ... n....,.iI11IDr.poo::hdofi::il,d;1iII,"",'d,*,;'~IYll1d1a"by;IIIIIl'oIW;"

Th;,cm,;,,,,,dll11anTl1,doou __ orunl1l1lJmlonIIJllintfromTl1,

tm;ndi::atooTl1littl1,polonll1E. .~ntotl1,~IIIij",Ganbo,.;thocllith'ut

~:'::'~::=noftl1':~W: ~~:~:'~=:n:=.' .. tI1etenz-

C)OtolitlJrny;.II101111'l,tti,.h,lijbo cOOodand do::un,ntod,T11'E" ... oondll'l",do

Thl • .mel.",edll11end"u_ loB.offUdfrnmTl1elmyleodi1gm\lleak-

tm • .,.Luoto,h,r,.,rnrnm. ""'.tl1iot.flEth'artboot,p,or.~ntu'lJlr,

luoloc:horildohyliilion,d,hjljrol..,oc IlII'motromill,oII;,d;lV',tlIldd;n;CiIy II1l1ydrolon

lII;,;lI!lantl1,dooumanlBtil1inli:at&o ~n",,,m'd'IIIl"'ionl;,pra .. ';m<m

an..,I,,;eoflnvolLJljol'lllldeprao~on lo"of~rellt,monge~~,.I"",

melon'h ... ,d ...... lvepllY'ho~. dlltUrtEn"",behovl",honge,de""",,e

malon,holill.inwluIOCllllm,lorai .. i1an''llY,guin,inibililJlDoon,,_

lIIII1'jIIILO ....... noh'liII, ,""or,,, OCOUi::ij,tI1OUihl>jllith;,I"'D1I11d/a"

melon,h"',og_deprao.lon hIIIluolmtion

poyrnotj,deprao.lon,melon,holt: d'lIIl"t:ionlllithwt._man''"IjIIflJ

i1ith'l .... of",....,oclllllllionof

prevlou • ..,llIOdeo

DEPRES~DIOORlER 311 .CO

LIoetl1l • .melllhenthe.mmentmjon Ilepraolllved~ordernotel.elllhe,"

M""te.'deprao~on""rdejl'e .. 11I! d .. oIIIed, ...... h ... "meoyrrclttm.ofde-

dimarllithn,flJrthord,o::qrtion pra .. ,;n.m.n;I""ofinlor"allt,d1lini" i1l11lll'ito •• I...,dilltutlin:o,boh";or

:~:'::::~'I1i,gUln,lnoliilJto

~,,"m;tj"'oftl1e.~nle.o.gto oryIhOlllll, ..... ling,itohi""'.;illgn"'; di1i'~ly

LIoedll!lentl1ed"um_ln_Fmg"_ofthe"'lI,dogn",edd~1 d,rm.tolilllDt:i,ofnllil.flJnlJJ,ofl1lil. c:allyorbybi'Il'Y''''rapnilindc:UllJro toonoilfIJnlJJ',orfing,.mdfu1i"

lII;,;lI!lantl1,dooumanlBtil1inli:at&o l'rotrI.oD1ofthou~partoftl1,.toma::l1 hiatu,h,mill.;illphrogmiili,h,m .. ilIDthotluilrthrouih.to..-oc ..... II1' ..

• llOlngdllji1mgm.loheml .. lft:hdoiek ~thedIOltmilm,dl!llJ'oIlOdIl'jEGDondl"

hemlll,Mo'llllgnl(onlherrl .. hllltlll lIIIBgelltWleo

~~~=~=i~ .. tomi.,5IIilt

~'of;illThlll(rro'"'ntlltW:>~

dotlJmenml..,Moate.dlorr11e. dBllyI,dogn",eddl"""I~_"''''dogn,,,ed

IDJtedorr11e .. outumdllll11e.,blll .... ""'ed..,otnoIOAle.......,tomrer)!

~:::~:"~~;=;~~~;;;~

11111 ... , dllll11e.gnM',lJ'!'en dllrTh ... _le_,IIenter1,dlorr11e .. noninf8::li",,;illThlll,lII"ullllld noninf8::li"";illThlll,jlJtrofB::Ii'" dlorr11e .... oondll'jdllrTh ... , ""omdt: dlorr11e .. oumm ... dlorr11e .. oyrrclttm ati::liarrholl.orth .... i';iorr11'.

Thi,cm,i,,,,,d""anth,d,,,_ 5!Io:ifiadlatU1ori>"='_ngthan~1

tmlnd_""h ...... ungLlum Mud~gdefnrrrlljr,dlm''IlIj..,,olI1<1TT101

IDJJlred,.,onll'hlo,.~hl.ul'1luUn, 1J'IlWIh,etc,d"lln",edd~I'oI~

1IoBu~ln"._n~I •• 'lull1~1

dallLNiJmul'1luium,n~lli_on

I!Ilg.helll'lllll·,ImIlIImll,.,gu~m,

fmgllel'lllll.,fu ..... ng I'I1II1., grmved

n~I'.tJJlIJniu .. """litiJm .. tannllil

KiJiblychill, Laullllnyd1iiljIJrcIBtaj

lW1omj,lelJqlllthl.ungulum, Ion"

tWln"lIjpeo"g'""".,onyd1ou~.

<IlJChOOyslnJ;i1~<Il!Oh<vlllh"i'

<IlJCh<vJll''',onyoh,Iyt:iG.<Il!Oh<>"hl"',onyd1otm;tlo,onYOhom_~,

<IlJCh<llllll"; .. onyd1'jl1JJ'i',onll'horrtl",""II1nJ;i1iadn~~.(I"pinmyd1ii

Thl • .mel.",ed""enthedoou_9jrrclttm.offeelll'1ldl""',lmllll,.,oed,

tiI1indi::at&odillin"',giddin", Iililln""ddi'i""I~

di""1uililnun.lighth,iidodn"".1Iinmlnglntheheiid,Mllldellellll'que-

nmto,~o

Thl • .me.taJldbe",edllhenYflJ c...trnlledDM'lIIIhout .... ~_

h ... d ...... ntedllM'''jlNenle

di_.i,oowman1ad

Thi,cm'i,,,,,d""anth,doou_1lM2,not.1litad .. unCIJn~l,d,,.,d ....

orP'~'rIIIQ"ulll- tiI1indi::at&othlit~"ul""'di;<Id'" wlirfindi1i,inolulini,louliootion,ul"".

mryMonlfelltDtlono .... ~orym'"'''''"lIedbydlBllete. IlII'grme,O!hI!l'llIlOlern ... ~ .. _jBl;i1 ... 1 melllru._F,",emml*',dl_,,.,gl~ ""oulirdl''''.,ereoljl.dyofunollon,CVA

tIl',glilli"na'i!'di_,p,nli1,ra1 CNJ)"p' ..... findi1i'onNl,ultnEoum.

c:iwllitiJrydi""''i!'liiba1a,.or GT"'ii~ram,_(I""'ii~ram

diobellommmgq,mhy.

DMIIOI'HTHNTST lJICNTIt.

lIBethl • .melllhenth • .mmentmjon c...trnlledDM2,lIIIthneumIOVolllmonlfeo

Moate.thatthepllljenth ... neulD- 1a1 .... 'i!'IlMi1wdillnuldlna",ti1ili1i.

~;~,:=~~ :U~~~d=~ =~::=~~:'=~:"'::'"

the<DrClII,llIjon~"""dorytothe fhjlng..,nervermduoll..,otudyo,fIlIled

dlobete._Th.neumIOVolll .... ~t:aII.., nmolilam'nt1alitoffIJof RlJIitIla'II"ifiadorncm,d"",aratoIy.

lI!,d"",.,th,dooumonlBtil1inli::at&o c...trnllodDM2,lIIhic:h .... 'ou"d""

that~htholrmlogl ... "ndllono.re fhjlnll'ouoh .. MlDJored ..... , ~.Ion

""ndllyto,,",oaulledbydDl>lte. c:hll'1le,~o_,oatmr:t,retjn"edemo,

Thedoounmtatlonmuotlndt:ateth. lllreou.hemm11age,mlmmeurygm',,.,d

"""' ..... iiIi'nohip.Thi'cm'i'mt Hind"'''.lililln''''ddiri''''I~lII11/a'by

utllld""anlill'I"coodil,n.iml1Yoo _~""oo~OEIIIIIIII

""lItO ~_e_, .... orWllyllIIIth dlBllete.

~.:.u: u':!~~~"': ,::: :d~·

fa'tha~hth,*,,'I'ii::lllcmjilon(ai dlobello~ojllt!1~

Th;,cm,;,,,,,d""anth,doou_CmlnJlladDM2I1i111oth,,oompi:&-

Nl!II'Illo,,'<rOth ... tmlnd_thottherel •• dl.- 1 .... '"""dlrithedl_!IJm ... ~n

~"med <DrCl1I,OIjon~_e_,.oondItmCAUSED fhjlnll',~OIIo""eto,not_ ..

MIiIl_o", "'th'diBllata~thlit;'not;noludad;n uumtTIJl1ad ..... ~,Ii_,COOI~;CIItmcme_F<remm!*':dl_,lme oImgeo,dlBlletj,dermmlll!

lIBeonlyllhend ntmjonftjl'm:e. CmlnJlledDM2I1i111renolnmlfe_.

"P'~'roIQ"ulB- thapliti,nth .. "nllld; othot;. c:ou"dIly1l1,d;_lronlllnmifo"'_

toryMliIlifoatatio", "oonlilJtodiBllata',,,diBllotl,renlll looi1,ludad.llIJninuli .. protoinuli ..

dl ...... TheICO--!ldoeonot .. oum •• li!oreaoedGFR,a-,etojllall!lloNI!II'Il_

""",I1I1!101jonohlp,,"youmuotlnolude MM:R>2!l9

~;;~n~:=,Youmu;t~"

~:~~~'d;:=th~;~:<!

<Di!.When ... ",erflledlnthemedl,oI rem,d;_;, .. "m,dtollotypo IbasodonICO--!lilid'~"

1:M2 Ilitlwt<DrClI;c:lition, notatatod .. ... rmtmlled,dlBGno"d'lIrt:aI~

Th;,cm,;,,,,,d""anth,doou_lhmInJlladDM2I1i11wtond-Ollllilloom tm;ndi::atoothIit1l1'lIIlont .... DMI ~;,lition.Mi""~bun;n/Q'rlitio<2gg (orth.typel.mtotmedjondtl1.;t¥d

oIon'IB'IbI~_tI1attl1.dlBllete.

;'"unrmtmll,d·,,"outofrmtml

NOTE:l'Ilorlyrmtmlladorlllorrmtml

~not"'''iDl*dorumen_fa"

unoontmleddl_",oormgtn1l1e

~:~ :~;:::;:':'::~~" ..

lIBedlli1end"ume_omte. Non-_lng",loodM!rtlrulool.d"lln .. ed

d_lo~. 1ly",lonoo"'lII<rotherlmllll'otIJdeo

lIBedlli1en1l1ed"um_ln_llrrIruIlyINllliIClllot'1l,dlagn .. ed'II"oaI~<r

1hItthalB1i'nth .. dyophlg; .. 1Iw~o lly~oii::lllotlJd;"

INIIliblllni,<rd;flioultyi1,,,.IIOIIring

Th;'cm';'tollo""dllhonJllu ..... dorumentedthatth.patlenth .. on _tedPSA.~youo"",notetl1elall

::;tt,:=tI1'-JWmum:

lIG,;lI!lantl1,d"umanlBtil1inli:at&ollllmlill,lD_ifraqUllltlylillin",,;by

atrnli1io,OI!ntr1oolnll",oentriollJlIr, .mo~nghlllttJy,lIIh_g,CXRflnlt1gond

otrnnt:,IftJ",e .. entIBI,hlllertm- <Dtru:tIveI'FT(IIV1,wc<70~

phi',ilIII1ollJllif,lung,obsinJc:tivo

ponlollJllif,p_~,lIIfi'inliJ;

polltlnl,llJlmorwy,""'lIe,.LIl~I!InI,

_,urllm:ernl,unlollJlIr,'"

.. ti::lJIIif",~I,'''m·''llPaw''nt ~ni,Mool";"tlYIl;rom"c:hroni' brnnotltlB .. thl!Jl'Clhyoem.,plnkjlJffer, ... Sllyer-J ..... lI'jI1drnme.DoNOT

:p~::~,':~~!":'u=

an; ",;e 'h ..... 'relllllratnI'jIBlIJl'e ~ itilllll"ant

lIG,;lI!land"um,_in;i::a!&o GEAD ... rallUII

lIII::kII""oI'.toma::l1fki;ID'~hlill'" lalldingto"'i(j:;taotainth'moutl1,,~gamt:aIljomll'llllpolnd"lln",ed'lIrI,,"l~ lI'dIn'byEGll

Thl.oodel.",ed<J'lylllhentl1e dowmantalooi1;ic:ata.a1IJ,orn otIiQ.nophritiG,toJmin .. "",hJitj, ... OOlOllliJeVlfthejllltm!~unde'lJli1gd...",I'(JeeV4S') ... _ng ""'Ilililltaloo

TotaIlo .. oI'ren .. ..,otIon'honr:terl!ed by'IEMItodG'l>l·4mild~,I""GFR

« oo"","in),II1; l""Ic::30'0I!l~mo II1nell'llduOljoo

Thi,cm'i,,,,,d""anth,;,,u_lIG,;lDinlbtoth.,,,,,,,,oI'liIlinjJl'j

::'~~.~~~~~"::':.

E!lBB.l[h"''''l'jllll"m,oodeofnrfal.

=:,h=::ilU:=~;'

.hOIJdlled ...... ntedond.nueopprnjllm:eoode IIhould """""'en

lIG,;lI!lantl1,d"umanlBtil1inli:at&o ~n'll"m'bl";i1ii""MniGl1nlct g_~eed~,g_IIII"'I~el!l!- d"lln",edd~""I~lI'l1/a'byenIilB"',*,,

i1g,otnmooh_lng,entermhlllllo, ... mdl~I'oIl1tWleo

b""'lh'm<lThIlll',",,"I~'odni gam::homormlill'''i_'

hemorm"lle

ArtIIId .. Ol"rlng.fa' Thl.oodel.",ed""enthedoou_Ol"mgol'gostJ1'glornulIIJoilyfa'the

F,,;i1jj1Bimil1l1ion tmin;i::a!&othlittl1'~lant..... i1il111ilnol'c:atI101&, g""""tomy(a·i"PEGji1pl"",lllili'

1IIoI!lyo •• "",mOl'j<Di!

lIG,;lI!lantl1,d"umanlBtil1inli:at&o GeneralzedOA_nglllJ~l*tlIntlI generalzedooteoorth",,~orgeneml- d"lln",edd~,,"I~ ... byllllllllelltUdleo ~,;arttlliti'.ll1i,cm,.twldnotllo

utllld""anth,m,;i::III .. "nji1ti,ato,

'.rthrfllB',""I,hl.ooded7'59_"ot

otmelllhethl!l'tooaIlzed"'generalzed

lIG,;lItlandocum,_onlymm., ., i1intrllW"'II"''''''c:au;il1l

gl"""m."'thmfllt!1er~rm.I'" _ dam8ll.,I.adll1lttl~!IJai iql~rmantdilill""odbyttln<ma1JJIiIlIVD' _~""'''~CEIIIIIIII

lIG,;lItland,cum,_in;i::a!&o QI1;i!i..,,,,,,,,,dbyth,",,wmulll1il1of

goLJt,umteth.lIIII1.mo~.,urt:liCld 1I1'.ddtJ}OtaI',lIIII'Ide;n~lnl_

diosll1't:iG.IJlL!lJ;iIIoth"i,o'llldagra (arth1iti~.kii1,,(ID1a),i~IHad;or(mna).

~~~::d d~,,"I~IIIIMIIIth<lJ!_ted

GSlRiWNlSNOSW/o HMRHG

lIG,;lItlanth,documonlBtil1inli:at&o ~n_ingillililllm.I"'ofotom""h" g_.,gostmdu<li!n~.,gostmhepml- wodel'lJmdlOlJ'olll!dclnlcalyondlorlly

:~~'::i~~~~=::!: orn'~IiIl' .w;i ..

hemo""8Il.orHeedll1l

lIBedlltlenthedocum_ln_ 9jrrclttm.ofheadlld1eorheaddl"",""",,

headliCh.,cep,aI"o, .... cul ... head- d8lln",edd~,,"I~

a::ha,fIiCo..-_lpain..-h,adpoi1.

lIG,;lItlanth,documonlBtil1inli:at&o ~n",,,mcl' .. ofh'ari1i.IiIill""'ddi1i

h'aril1ll, ... dallfn''',IIJ;ite", c:aI~"IlyIlJ;i~

dellfne",mpairedheomg,lIJdltnry ml"~,heredlmrydeafn ... , CDllanitllldaofn'''.''-lD1uirodd,liI'-

n' .. lIIithnodaoc","onofth'aIi,I'iY

ofth.h1lal.....nt

Thi,cm,i,,,,,d""anth,;ocu __ inth,uli1'.lililln"";di'i,,"I~"-by

tmlndt:ateohellllltll1o,Hoodlnll1n. 1IA1 ... ~ood ...... 11lC)

T,mm .. ,lIi .. 0;, .... , jwractlilJl1Jj" lIIle.dmlrllltl!ll!O),lIenlgnhemmun. iji'pottich,mlitulill.intlmJltl&nt hem!l!!JrIII,!IJlfnnOJMjehematun"l,ctrractlilJilJj''''i''''..,i .... ;j

HISHmOFTOIlACCO ~

lIBedlltlenthedocum_ln_lIBtnryofprtrttlll=u",dI8llmlll!dby

.timr,ofttlbliC"u"',;rn-ttlbliCoo tiolo",

u ..... hlllttJyof'lgarette.mo~ng

Thl.oodel."'ed""enthedocu_Hrof"'*"'cm .... tmlndt:ateothatthejElent"'" h",ooloncIillCll,ornh"CDqllata; _'nt~ulllic~Ij\'"'i.I.."ch'm<>-

=d~':n=~:~~.::re =~::~n!.~~;=:=;~

NlE ..... ki!red"curl!d·am.taJldlie do",mentedornooded ... hlllttJyof ",*",cm"".

Thi,cm,i,,,,,d""anth,,,,,_ lIIofblJnc:h.<a1wr tmlnd_thotthelElenttaB hodlul'1lorlrmc:hlol,on"",.,dh .. C<Iqllata'tra.lmonl(aJ'IliOlll~,rBIi.-

:~n':,'::=~:::~~::',,;!

ttmorlltlll;reoent.Pmjenll!lIIhohave li1it:l1"trallimonlorn""umartJJr.. illil1wAAE"noi'OIlld"w-a'·an' .hOlJdlled ...... ntedondO<lded ... hlllttJyoflul'1lorlrmc:hloioon ....

Thl.O<ldel.",ed""entl1edoou_lIollryofbreaot",",,,,,r,mldve .... ,,,,r,

tmlnd_tI1otthelElenttaBhad d"lln",edbyhIOllry

braastClll"Cllr""h .. oom~otod treatment~ulJll'oIttmdl"I"','he

=~~I~d:mom:~=::""'

tunorlltlll;nooant.Pmj,nh;undary'*1l mg-termadjLrmlthe'"fl'l.taJldNOT

=~::':':;~::":E-

=:,~:=1:;:;

,."t:I1ouldbad,wmantod,.""'" ","hIOllryoflJ'eost"""""'"_

Thi,cm'i,,,,,d""anth,,oou_lIIoffllJ_ liI1in,i::at&othlitth,IElonitaBhad

prnotate ........ ,.,dh"'oom~eIl!d treatment~ulJll'oIttmdl"I"','he

=~~i~,:m"":;=::""'

ttmorlltlll;reoent.Polentounde'll,*,g mg-termadjLrmlthe'"fl'l.taJldNOT

=~::,:,:,"~::,=:,~~~~~:n':~-:~n:

oulWilan"NE ..... idara'''''rod· ,."t:I1ouldbad,wmantod,.""'" ","hIOllryoffl1Jotate

Thl.O<ldel.",ed""entl1edoou_lII'I>lrtl!n!lve~dneydl ..... IIIth"""nt:

tmlnd_tI1otthelElenttaB ~meyd ..... ge,.",h .. allIJmlnud!l,

~:~:'~Ihl"'!::;::an ~';;~~=:~i==~~

eroejljonlltl1erLIethottheji1!Ot:IiI1 c:h"'-byGAl<'5,need~gdllt,'!ll.

::':':,:.:Eillraliili, ... h" "-""'I'lan1ol..,

Wh,.,oowmanlBli"''''~i1'i'iiIil' Itghliji,_c:hllidlliladby,l_

hyjBIlf*jeml",ttI.~tI1e"rreot"de LDL ... tr1glyoende

lIBedlll1endooume_omte. _ .. emrofth.eyeleod~tolniilillty

hyfmnetmt*l,lType.,or Ilfllou • ..,oto .. ,qeotooften ... odated

flHij#lta'n .. ,. Ilithllfling,'illfJ1'tlIld~ini::llly

lIBedlll1",thedooum_ln_i1lII..,uoB.lumlltDte,dllV'0Ill!d"IBIl'lllle '_,,",,"miB,potmiumd'~oIoo

p""".iumdofi~'m;,,hyp'''I'miBOC

-"

i1lII~IItDte,lrequently .. _

dotlJmenmlooMome.onhydrmm IIiII1dohydrJilionornl""omium,dililJ1,tlIld

IIiII1hnmlitramill,d,hydrotmlllith Ilyl_ry¥lilu",

hnmlitramiB,.lIItdoplolon, "diJm de~eloo,omlum_n""fluldlo!. """hnm!l!femlll,hypolllmloll'Y'"

.ickooll.

lI!,dlll1""th,dooumonlBtil1inli:llt&o ~n",,,m'.tamofl,,,,~(njpra, .....

bIIblood ..... u ... I"" ..... u.. d"lln",edd~"'I~

lItI!"oIl'M>ltenoloo,hypomn~on ......

otitul ...... hftD1ontim.oc._wlic

lI!,dlll1""dooum,_indi::Bt&o i1lIIthynJidotJita<11ono::1:arilodlJybll

~1"".or;nt·IIIJ'Il1o!l """'llyotme.li!pre • ..,._ ... ,ed .....

~I"" ",noljlMm.dlBG",oedllyhlghTSHond

",uIllyIOllT'1liIT3.TotaIT4

Thi,cm'i'''''dlll1anth'doou_~n",,,m'I' .. of.'n'''tmocm_

tmindi::Bt&oin_",-"""jili:: (jJ,roiji'potti,n,rwdllmllQO,dilV',tlIld

pmg ....... neurlllB.heredltlly d~I'oIly""d/a"byN!MMG

neu~,lntel!ll .. '-'"'jilt:

nau~,mu""I'naul1Jpsth~

P'Iyrw~,pa"'h'llIInau~othy.

atrnjilt:nl!lJm_,Pl!rljilemi

pmg ....... neu~,l'llyneur1l .... ~h'rwm'i'

Thi,cm,i,,,,,dlll1anth,doou_ rr..an"'ofil".lmn'l,paniliofilau~ tmindi::Bt&othlitth'palont .... 1IIl

::,1ItOOrJ.ThI.~oI_.oe"'ndllY

Thl • .mel."'edlll1enthedoou_Eor ..... ilqllctil1dilV"tlIldlJyliract

tmindi::Bt&oim...,mdCOllJman IiIllJ~ilIItm

mpaotedeor olramoloe ... en

pmdu:tm ~.or .... ""'"m'"

a::cuRIJloI,n

lI!,lI/h,nootlJmantaloootJita,

ili"","n~l,ooycto:;rnrtooi •• 'I?jlIiG. ltIlul.lnoam!l!!J .... lng"""ngl1lll

~oliltyordltlbJltyfalllng"'B!p ... rem'*' ili ido'~

Thi,cm,i,,,,,dlll1anth,d,ou_ l'r&oan"'ofintam~h'm'IIt1'itdilgno"'d

tmlnd_lntl!molhemmhokj. d~lcoily

Thl.cmel.",edlll1enthedoou __ ..,lII!tll'1llna(oordlBo!J') ... ong~.

tmlnd_lntmnedl.teoormIY """~"e .. elnfrequenoyor~lIIIV,

.,.,d",""imjlll1jingcmmory IiliQn""ddi'i""I~IIiII1Tm"'i"''''EGG

.,.,d",""imjlll1jinglll!ll'orIi~ ornil!lllki1''',onocto:adi'lJiTIl

_on,lml"mlng~",ute

.....,oryoynd ... e,oormlY~lIUI'-

li::ianoyoynlillm'.U101l1H'liIlii1i''

iltarmoliiil&CalJnory.

lIG,dlltlonth,diliQn''''i'inm i1lIIlB:l""I~Il<'Bfnr""';~1l

defidenoy ...... lo,WIrt.on..... <'4fa' ..... en)duetnl..,deflden~,

a::I1,rhydri::"""'i"lJ"',n",II1,... chllliClllillldllyl""MG~I'''farIilin.klII

=~~,!".;,:iIIIIilli_.,"'Hayom- i1m._dTIBG

lIBedlltlenthedooumentatmln_Jolntd""rntm/iIlIn_ngon~e,

polnlnthell'lde,fnntormetmBn!oI._ d"lln",edd~cal~

Thl.cmel.",edlll1enthedoou_ u..-ertrerrltypolnmt.1ngtheknee tiI1indi::atoothlitth'lIIIlon1l1Ekn... Plt.dilgn'''d'lini::lll~ p~n.patoliofom<llll,ynd",",."

p!lll!llofem<llllpoin

lIBedlltlendooume_omte. Jolntd""mtm_ng;mt:orea

...... "IlIII,hlppoln, ... peNlcllllln d"lln",edd~cal~

Thl • .mel.",edlll1enthedoou_Jolntd""mtm_ng.hOlJder,dlllll-

tiI1indi::atoot:l1ouldori'intpoi1. ,"",'d,*,i'~ly

Thi,cm'i,,,,,dlll1,nth,doou_5kind;;,Id,,con'ioli1iofigmlllhthlll

tiI1indi::atooliCliIlIh,korlllOO,rmill 1IRl, ... h'my,dilllJ1'ilIldclinicaily

IDJJlredalllg_.~nd ..... e,

"lg_.~n,a"1ulredft"'.~n,K\I1"

.,.,d",""hyp,rlwratnoi,fnIIioul";,

i1w1&mponolnl1',LuIz-Mi .. 'h"

.,.,d .... (eI_ ... jI!I!!nn.

oerplgl""un)

lriIIlerLhllArrclJm- Thl • .mel.",edlll1entl1edoou- Stmu.pootomjlJ!!lllonoflOlllertnll

l,nSlJilu, _,nimi,ato,thlllth.jBIiont U1~'d h"lI1l11qlutlili,n(duotntnuniOr 'UlJler)jofonU1"'"dltedlme~the klIIerllmll.WhenthelllljIJtmj..,.ltel.

=!:rt:~~":dlthi"h(lJld

UI'IDMETAIl(1DI5 .00

lIG'dtoinlical&lhItthopili'nti''''~ ParfmnlillcooflllllJrlll<lJlo"',nly

oeenfnrlllllJrattJytellll!

lIBedlltlenyournotelnd_thotthe Ion'ofth.',..h ...... nropocm

lIBedlltlenthedooumentatm NI1,rmal_'id_i"".dilgn""d,lili-

Mcate.all1mnoillpld',tDngertml callyondllyoll1mnoll_ryVlll ....

.. m'rmallipijm""lIJl;;m ..... lI1mn~

=:~=~~~:"m~.

teIm"tpllpkjeml."or'dyollpidemlll' cro..tn21241

Thi,cm,i,,,,,d""anth,d,,,_ llAirMWil1ll"",rElllramil-,.dilgn",d tm'IB'IbI~_that,_orthrltl. d~I'oIly

~ jII!Oent~thel""'rertremil-,~egl

lIoedlll1enthedooum_ln_smru.of",ll1llongtermmtjoo"llulation

1hIt1ha1Bli,nti,ooloni-tonn 1h000000(curranlj

mtjOOlillulilltlharapy,Thaundod!i1l ..m~on(e_g_,h~llryofDVT ... otrnnlo_lIlnlml,njmuotaloolle d,wmanladornood,d

::,::~: ~~:::':'''n:n~.::

.jEllt:ood'.ForeJlll"Cllelherelle .jEllt:ood",fIlrlongtermu",of mtjOOlillu_(ll!iB611,1'l1llarmut" oflllllilioli"(ll!iBfi21and milarm u",ofoternld. (V5ll651. ~'.I"",,,rmnt ro""th,m,.t'jlGCili::ood.

:.~;,i;::~~:I::W:~:ta- :=;~~~:and~r_." ..

:.": .... IrnII.plnel •• ~

lIoedlll1endooume_ ...... ~mllV> ... I""lIiokpain

PIlIn~lhelumblrregmdllV"lII!d di1i'~ly

Thi,cm,i,,,,,d""anth,d'''111111 tatmindi::BtooIUnDIrnolWroot dlmer,lumll,_nervernot dlmer,th'rIIdon ...... rootdmer, ~m;.,."'nilllIdi"l..-p~n,lIIlton ...

::..'::':i,~ItI!~=~':~

1tI.1IIIh~"'"""., ... ..,rteIlreilDly in~ng'mant

~n"'''m'inllamnlltimoflum_ IlIlI'<IlOOlIIIdingropoi1.numlll .. , ... =~lBgno"d'lInbtyordlorlly

lIo,dlll1onlh,dooumontatil1inlbioo llAirMWil1llumblrand~r_." .. ~mblr'ID1l!Gi;.~mllJ'iOOiI Iililln""ddi'i""I~ ... byillllll'oIudi" .1D1l!G1., .... oonil.I'lrd!iO!I.

Mllliinlllll.~n,an"'roolhafB::o,dilill.... edllyl!ql!y

MAUGNEOUNl,NQS lB2!l B LuI'1l,U~DI1J!IIj1l! Thl • .mel.",edll11entl1ed"u_ MIIIgnlitt oftl1e~ng.ondlorlrm

tmjndi::at&olul1jIbnJnohic:oncaroc c:hji1~udi1iti1UIim"",lIdan'CA,.m"coII

lIIIIIiil1lllt""pB;mof111,lul1jlbnJnohi 1I'l1In'lIIlle"IICA,dl'll""edby~1IY ..,dtl1ejlllllent""'notoom;Eted thmugheltherlrm,ho""VjorCTgul ... oe

=:m=~:n:~iti:.:

~ooml*'te,d"unmtDt1onllhould MoatelBl ..... hlmyoflll1gn,mnohl CIII"CIlr,lind.m,d .. V'Ol'.lhara .... po::iIi::croa.fIJrtl1.tuo'oftl1' ~ng.m ~1111.~ knOI01, ~.taJld lie dotlJmented.mrndedoooormgly.

Braost,l'm_ Thi,.m,j,,,,,dll11antl1,doou_Mllliinlitt ofth.e<D1dilill",tlIldby

CoI ... ot8I..,dOthe, tmlnd_oolon,on"""'lIIIIlIgl1lllt ~olBY""-ell!'llltedCEA "eo~ .. mof111e""onondthepm1ent

h .. mtCIJm~ilIIldtralitmant_1Il OIlidicail'1l111,di""",.Mardofi1itivo

treatrnentl.<DrCllete,d ..... entmjon .hOlJdlnd_peroonolttBtoryofm-

D1"""""lI1dood,d .. V1005.Th,,,

.... po::iIi::croa.fIJr'ic:h ..... ofth. e<D1andlftl1l.I'_,ltllhouldbe dotlJmented.mrndedoooormgly.

Thi,cm"lwld <I1yllauo,; if tho 1UJ_;btxl;!>'O'tiJ,"""ulli1iin

...... 1'oI ...... lnd_oooele .. 11'1l eye,~drey,ond'ord"""rulordlm"ll.

hyJ&ten*,n,~I'1lhyp!rten~on d"lln",edd~""I~

..-m~ilJ1onthyp'rto",ion.TI1i'cOOo ,hw;.IIa,,,ninalilYoi'ion ofIte.~g.~~NQTII'jI1<JTj1'T1"" lIIIhunoontmlledhl'l"rtenBl..,

Thl.cmel .... ed""enthedoou_

tmin;i::B!oo,hrm,lninilf&oIiI1.

::~=d:':~lOOi' lotiI&·;iIIg",,;,lini:>lly

poronokjlltDte,_""mnokj,.,d _PlOh"'i'..-;'monlil.~i''''o u","""".",,<ifj';\"ftlOof;i;,,"or doeomt"""'··I"rfII'entIy.

Thl • .mel .... ed""enthedoou_Midloord ... ordomllllelnv<t.1l'1lmltml

tmin;i::B!oomi1rlll_limor, _,inolulini..."t:i',"iuyi1lltm..-

b~I,<mijXlOtoru-I'iillot.Barkl!!~ 1I'1""";iIIg"";lI!'o::rn,liIljj'i""""-

pml ..... ,mltml_lIOI!lIBe,or oth ... lm"ll'lI!Jdleo

!qllllrrllml_

lIBed""""dooume_lItOte.!YI" ~i=i~rotoi"""i"IIiIlIh'ma,bota

III'I"rI~_.m."'''ll''l!edll!'_ted LDL(>16[)qj1'1jlllilld_;qlycori;, (>160m""Il.;iIIg"";by~bYlllJ"

lIG';"",.,th,d"umonlitil1inli::itoo ~n"'''m'p~nml~ni .... do,dilill-

nr,'IlI.,o,flllon1Y8lGlo,lI'".,lOld. ""edot'll,oIly

nr,'Ilfoolollll*'l,flllomyD!II',m ... ,I. p~n.nourmlJtnJarpoi1,"rI1oum.lc

RlJtnJarpoi1.

lIG,;"",.,d"um,nIlItmin;i::B!oo _ .. orra-oftho""l,iidilllDinibililJ

".".",*"ne""I"""dn ... ,"III'I'~- Ilfll''''''fIruoIIlyoillecto,dl''ll""ed

.I"""dn... d~I'oIly

9jrrclttm.ofn ....... .mvomltt1l,dIIg ""'d,*,i'~ly

Thi,cm'i, ... ,d"""th';'''_AliIini_onofpnoum""""lwcoinlltm tmin;i::B!ooth,,,,,lonI .. ooiwd

O!fI!Il!=J'lI1eunonloe[rn!um,

=uo]"",lne

lIBelllhenmrumentel..,M""te. n'lillili,..-n';i1ropsthyduotoan un;odyi1l;i""'(a·i"liibote,", SlEl_lhedocumentel..,RlJotlml,"", ttatthe"';i1r1t1 .... ne;i1ql!l!t!y~

~~~~n.:.~~~ ~i::.~~GI)-ll

.h"_The,,,.oIoondlttJ'l.taJldbe <Dledflrst,.,dtl1l.lItaJld ......... be. ""n...,,,,oo

..... , ",de ony .. IIJ"*'u~O'lI'lII*'Iu~o,rI!I'IIII JlIIIlillilJ"""" .... .,'m'rulonop,mllBlll', ""'rmaI""'iilini",..-alll<llll~GFR~ ... _nlll'lllero)

Thi,cm,i,,,,,d""anth,d,,,_ OIlI""ifnJm'~nlJJ"n"pal¥iGlIIh .... omlnd_thotthepalenttaB. rubel.nl!ltl!dttllJ'll"kjeurt1ed"*'''Ile neli1""tnmyln~""".ltI.~oi_.

""n...,c:oOO

lIG,d""lI1th,dooumlllllllil1inli:Bt&o i:MlI1dnlUlJl.vlllllmlillifilotlili,",ioolud-

diillalcnOU1iliill.dillllali'nau~ithy. i1inUlwna",.li1ili1i.llJmi1illll1l.,lim,

dlobellonl!llll.,dlBlletjollolyneu~.- ~ore~ •. erer:lled_"""n,1IJID-

tl'¥ordlBlletj'neu~ITth~I._ln"'ertn ranl,lnllllllllllty"'I'l_lftjlng..,nerve

c:ImoothE"d,ywmuoili>::lJmant c:onliJo:IionollJIIy.dillgn",d,lini::Bly

tho"""' .... liiIi'"'h"(a,i,,"'U~

2'tn dlBllete., dlobetlol'll!lJrnpathjj

do",menml..,Moate. mrnnt: _1",relllJ~ng i1dlormeo,"""vomlll'1l

le~.,n<Jl--i1feotlou.lllell.,lIe,m~., .momm",lIIIthlnfeoljoLOlIlIlrlaJllbelng

blJlllllllclJl..,inlllimlllllil1.inllimmiiIiJry "'Il_,dililJ1,llIlddinicaily blJlllllllclJl"'.ilElnJinloolin .. inlllim-

IIIIItIon,lIeallnfllmnmlon,]elunlllB,

1DJIe",IIIB,oatIII11"",IIIB,oyoiI""

::: ~~II~~·n..,_;nfoo:li'''C<iIi'

OIlSGHRBRCNG -~

lIG,dlltlll1th,dooumlllllllil1inli:Bt&o Gmmi::bnJoohil,lIIIthlllll"ani1i"uih

"""'e_ofotrnnlolm1'hll.or .hortne"ofbre.th ... hyjrDt.iIlOO< 1Il1,

blue_lIIIth"'ute """,rIlalion d"lln",edd~""I~

lIG'IIIh'nthollllldi,~"",ldindi::Btoo G,",",wMIlIld",2D'ILlMlrid,lIIinly

oo'lily ".;ghtorBMI ofm, .. thll1~O

LlBedlltlenthedooum_ln_Sten"I .... ooolJomofOll'lltldortery

CIIRlIijmmo:iG.oton"i,ofoarotij IlillwtGIPA,,..;ilJm,.dillgno,,,d,lini::Bly

.... ry(l;'mm.."inwmoll,or'orotij III11IDrbyimiUniollJda

oodLOm,IIo1thflJllll!ntlonoflnfBrot

LlBetl1l • .mellihenthe.mmentmjon Non-IIIl"m'Jolnt..,lr1'«tOl'1lllJlllllr

"""IIfthMI,.roo~ani::orthiI' OIIromity.dillgn""d'lirilllll~

1Ifth~,i'intinllllmmiilion,or meullllltlBmoftl1elo_lIortoftheleg

Ed""""""d.

Th;,cm,;,,,,,dro;m;,lItai.po::ifiad Parfmnlill"or.II'Cifi:: ... 'II' ..... pre-o!BD1lVee"."lnal..,ttatdo"mt emmlnmm

h .... more.pedfloood., •. g_rennI

fllu:iimotW;";nijlli!i,ntllilhkii1,,

d;""'.,boforeum,rg<initiJrgIIJ.

lIG,dlltlond"um,_oIatoo:dolir- I~m-",,,m'c:hlilli.;nlllllnllil""" ~m._e .. ,hyJue."onlllveomte, Mud~g del~um,d"""ln ... , iTyporeloB. or ..... d .... "" .... mloomo,oeml .l'lnolll!otme.loB.of"' .. do"'n ... , ..... ..... dwm .. 'octml1'lonco "'m.,.oni ..... d""n .. 'octml1'lonco

lIG,dlltlond"um,_;ndi::Btoo ~n",,,m,gon,,,,,,,,,,;ilJm'.dillgno"d

lii,,",oull1,rmllltolql'rlitu",funo- di1;'~ly

tmolOCllvltyde"" .... oroth ... generlll

_ ..

Th;,cm,;,,,,,dllhonth,d,,u-

=~!,~~~i :~=~:

.hOlJdlnd_..,eofthefolOllo1l'1l· honoywdllung,lmu1,;,liIIo;·.1lJ1 nDith; .. ;,.,~,mc:oli'noflll1i.oclung dl""" ... thmfut!1erl!llionmm When,., .. I,*"tI1etypeoflll1gd~e .. e

~h~::=:~:d=~

lII1idi;'''';",lulini~ni,~,m'iiIi'n IlJlm'iltilili',otc

Th;'cm';'''''dllhonth'd''u_l'Iiin .... bonign..,''art-l;koiRlllth.

tmlndloBteo""orrhel,_... d"lln",edd~""I~oclly~oy

oelrlTh",._,lIMoc .. rru,.

4400 ltli "",,,larD; ...... Th;,cm,;,,,,,dllhonth,d,,u_Athoroo::l.IlJt'iG;n¥IJl¥i1ijlllijilOlliiartorioo

tmlndloBteol"djileml""""lar .... lngm.,.liml!jonorllll'grene.

dl""".,a.orn'It'ooynd ... e.lnterm~- d"lln",edd~""I~lIIthon~e-lmtIoi

tontc:llluj;'iilion, 'motordilll1ll1ion. i1dOlOCllylilljj'illlH

lI1i;"'lIII'm'di:a. '.jllliphorai

1Ite""'d"""e.~ardloe .. e.omoil

.... eld!""'e._nol oeld~e .. e.

p'nli1'raloo;luo;"'d; ,¥iD .... -

tt:d~""'e.II'1lI"derntj'.lntennlt!eno pe",.,m"'lItI!I101d~e .. e.orlBllll.

==!:~m":~iw

~dll!mlJ.loconotl1 ... dl ..... therel.

I'Iiini1l11lll.iog.hll1d.fiJ't.fi1l,reorro" d"lln",edd~""I~

lIBell/henmrumenml..,M""te. p~~mtin;,pul"'i1th'n"k,or!W

=,=~dthtl1';~=h"on

lIG,lI/h,nmrumontal..,i1d;""to, Abnindi;'rdordu.fiJd~;n.;Idl~liIlco

_Imlom,ortedollderntl,ocldln- oh"'-Ilyrealngtrermr.dgldtjrond

pmhl,l'Ir1cInoonl.m •• holdngpoloyor retll"dedrmvemenTk:m"dlratlonlreflere ••

=:,=~:m~;~'

_lmlon,flYIIII"IIdojlllllld .... grlll oynd .... ,;nmry_lmlom,jIII- 1iIyo;·1iIl;1aro.ocParllium',Ii ..... ,. oyndrooJO,ortren..-.

lI!ed,,"en"'edelD1~"'of"'e"nd- Non",,,m,pleumifluld~luI'1lO8'o'lly, =.ffu'ion·lllithwtfu1l1"lililln""ddi'i""I~(I""'illllll'oIudi"

PNEUM~IA. QRWoII5MNOO

Thi,cm,i,,,,,d,,"anth,doou_ IlIr:terlBlpneunml.,ou"dlr/arm",,,1

tmlnd_lI1l!1Jmonla,lunglnllom- fIed<Jllon~m,dl"llnolll!ddlnl"'lyondmr"

IIIIItIon; 1DJII!,~IMI!mI.doulE,"r iIIIg'oiuly

"i>1i:Plau~n .... onii,(I"l'naumonill d,o::rIbad";IiOuta • .oJIIII1'Ic:h,banign. bll.terai,lraIn.",,1!Ilml,otrumlD1lled

C<Ill' ..... """"'ing, d,l""d "."Iutm.d<l.llI',..,id'ni:;, .... r,nad1 f1Jmlnlltt,lIJngokj.lJUI1utmmnu •• hemorm"llt:,lnoll*n!.lnfmtle.lnfe<>tilJ',inliltnl1im.iu .... ,immnittani Iotant.looa,miillitDry;.-,m <Jllon~ed.ovenllhelmlng,l>'h~

pmg ....... ,lBeudotlllor,purIJlent,

.. tiWad,.""nd~"ni~,...,.,

"Rlu ...... tamin~,tnJ'.U1""IvOO. ~:IIo1ttaJtllTj'OU._<JJlon-

~B I :~~~!~~I. :i~.:.~!::~~~:- =~:I~';:::=~ .. ~

I iii.~;;;;-""'--.' polynr,'lllgl .. rl'lll'"1Y8lGl.rhelJmotj,"- ",loredllo1thterqrnliortl!lltl',dIOlJ'olll!d ~dooIJmentmj"'aI!"_tI1'lID*"! d~I'oIlylllthelevatedE~

h .. jjant""lartariliG,tti,.houkj~til

b,cm,dl4tiii·

oth ... "'onon"n!l,d"lln",edd~I'oIly ."m,,, "~m' ":, :::;

:~:.,,~"_m"

:i~':''''~!:::':~:~:: :=~"ofP"-'~=i""OUI.

OIIdI",",,"IIr<E"'"""'lI"'ol"ratlvel~

lI!,onlyllhanyoordOOJ_on Moote.youoredolngatllllllYond phyoi'~Ellllllllinil"'f<rapiilianth .. - i1iitJJ'Ili::lllp""du-a

Parfmnan"ofH&PlliortotJJrp lJ'Il"du ..

_ .. omroftho""l,idilltoiniiliililJ Ilf'lOU • ..,do .. ,q,,"'dLl!lllQng d"lln",edd~ool~

Thi,cm,i,,,,,d""anth,d'''lIIII1i- NI1,rmlllc:ardiliOlIJm:tionlllh ... SOB.

tmlnd_l>'horyOll'dI""""'lEth~ !J'ondlE"~emleli!m .... ,ord~oI

IOlojlllttl'OII'dlonr,"lljll!l1~lOlojllltlt: oyrrclttm •• lnoludngldolEthlo.dllllll!d

nr,"Il'artiolhypartnJpIly.nr,"Il'ard'jIl!I1y ... lri::Iioa.oen.mc:tivoll1dhyp'~i' d,o:;ribadi"oengaoli .... oen.motivo. oI~i".dilgn"'dby""',.anjj'inm _loI.hyp!rtrn;tl,nonoiIRtnJOIjIl!.ld- .motherllllllllelltUdeo q,O!I1lo,~_,obRtru:llve,lIImory.

ra.molioa"'IIJrlldi,.oen.motivonr,"ll

Cllldili'.m""'-;"i'.I""d~1EIIl'

... ldl_I,CllldI<ml!llo!y_lflnJrceot

OII'dlom!lljll!l1y~kn",,"(e_gOlF)

ftj"houlO.loob,dooumonilldll1d

-.

lIG,lIIhanihaool1Jmanliiooi1di::aia. otrnnlogIBlJI ... "I,.lmt*glouoom ..... ~anan",glouCOOlll,NOTE:DONOT U5Ethil oed, ~yw-nola ..,.oo~

'GI ........ ·,IIIht:h~ooded3B5!l

G1roni::irora ... i1intnll:l.lor;noo'ur" ,,"".II'1l~'nerved"'"IIIl",leomg!ll IitJJ~impoimantdilgno"dbytoo'matry III11IDr~hth~..,.oepi::""'"

Thl • .mel.",ed""enthedoou- ~""ooodfluldlllthlnthelung.leodll'1l!ll

_onlml,ote.oheotrmgeotjon IXlu,,"ondSOO,dl"lJ'olll!dollnlollllyondlor

pulmll1lf)'lDll,otm.jIlJlmonlllJ ilyimllD'otuda

hl\XlOIiIi',hyp'oIiti::lU1i.otrnnicluni hyfnmoI.,lung<D'1leotm,jIII! .... ~ng,_~dI"""""!I'd .... ,

~niodam .. ta"'*'~IU1i"lU1i

oni'rgam,nt

lIG,dlltlondooum,_indi::Btao 1InJ,*"oyrllt'm'._i •• ~ht mlddlelolleoyndrnme,jrlRIjn _ _ ctaBl',jllltloioteleCl!lOl!,<m"Clre •

• ioo_i'.jJJmonlllJiilal&::tllsi,

~:::'~~""'WI"'"

QIqllata"IIIIfIi~IXlII .... 'otip'rlOO ofth'lU1i.lillfln""ddi1i'~~lI1d1a'lly hqelltWlelllllm,h,,"VI

LlBedlltlendooume_lnd_ h'jjm:I1olelltl!rnl ...... ,Hype~o protail"Olli .. "oh~',",~'mi ..

Cood~ooctoncmr1ll!dllyell!'lllll!d oh"leIne~(>~OOI

Thi,cm'i,,,,,d""anth,d''' __ ingfnmractlJmandlDran'''.IiIlfl-

tmlnd_thotthelElentl'lll! ""edct.I'oIlyondla'llyemo~ge

rect8lbleed~g,II'IIII~l!I!dng,re""l OIIJdleo

h'm'rIf1I1fl",II1~h'nmhllll',BRBI'R (bIiihtrlldbl"dparraoturrOorh,m..-mOil'ofon",

lII;,dlllh,nth,d,oum,nlll1imindi::at&o

• """""nttttl·multbe.ped~ ",,1""eoflnVlllul..,oIde;reo.I,n, ,-,wrrontmalin,h,liIo.roamnt

~:,:=::::~.i;!'=

m.iJIIonoimel.....,'II •. 1I!OIIfI!Itt lIIII1'jIIILO .. m'I.....,'li •. n>::UTlIlI otujXl1Juomallill,h,liII.,-,ourIlllt IIIlltmeddejll! .. lon.rewrrmt~ de;reo~on,"""""ntmant:d ...... 11I! l!Il'P'Y'h''''Id';no;''djocllDJrront melan'hoi:d ...... m""""ut._ III!nt:lI!Ilardngtheleveiofoell!l1ty_

~n",,,m'd nldapra,tU1

ldelJ'l' .. edrmod,I, .. oflnll!relt.oImg • ~""lI!IIte,.I...,dllltlltllra!.lIeh"'or c:h1ll1l,.do::no ... i1on''llY.guin.iniilililJ

~~~:=·r~,:i~li~:'W.lhm)"'tI1

Thl • .mel .... edlll1enthed"u- ~ammatj..,of"'li1l11lu.08IJlII!dby

lIIIlnIliIion_r&fkIIc,ooli1lO1i'." _,folmBc:hflJidlalldingro",ili:

"'pI1li1l'~r&fkIIc"'tI1 .. 'phlgili'. _i1th'moutl1.'~IjIEtri::IIIJj'mil1ll

pnlndlllllnolll!ddlnbtyandiorbyEGil

Thl • .mel .... edlll1enthed"u __ veemrofth.eye,e>:<iJdll'1lmyopi.

tmlnd_am~a,retnr:tm .mpreoll!llpla,dl"ll""edot.l,oIly

OIl1Jr.rafno::Ii..,litmJ".rafrB::li ..

lI!edth~oodelllh""thed'wmentall.., _..,ermrofth.ell'ohamcten>edby Moate •• lIIIlJIlatj"" on"'lter1,oIoomealeadll'1ltod_ iIIIg'.lililln""ddiri,,"l~

lII;,dll!lontl1,dooumonlatil1inli::at&o ~n",,,m''-'n''lI1d1a"uratarlildyslu",

mlllill!d~dneyfunotjon,lddney~", I..,.dlllllnolll!ddlnbty

tm,~dreyln_oy.lddney~1trate

kijn"Ii ..... '.a::uI&~li1"dG .... '.

a::uI& .. n~ dil, .. '.'iltoyndlOOl'."'~

lo!~gdloe ,IIIIIt,,",ll'1ldloe ...

non-fundj ng~drey.llllltlo!~

n'Ii1Ii1i'.fullJlIIr ..... ing.TI1'm·'

di lI1d""".IlIOI'··RlU'blld<-

ft"" IIIt,""h~a!ITj.

Thl • .mel .... edlll1entf1ed"u_ Pmjentlllh"~ond~l. tiI1indi::at&othlittl1'lIIlon1illllli1l

malnmlned"ndllt,'!ll •. TI1I.~oI_.

""n...,,,,oo

Th;,cm,;,,,,,d""anth,d,,,_ ~n",,,m,pulnmory.,..;ilJm';",ludtiI1'lIJIlllPalClllln;',hl\XlWntillltm, i1itm,trll",ofbnliill1,._mliilioo I'fIVJlorll'eothl'1l ... lolued_lngdyopnea,n ... ",I",hllle"'OII'Io,etc ""dyopneaonelll!ltjon,re",lrattJy

d;m...and ""piitlJry;nouffi,;an"

Gmmi::;nflllmmiiIiJryd;"rdorfocm,,, thIl16"""',d;IIIJ1'tlIld~;ni::llly1llith4wt ofthefnl_g:_ng3orrrael,lntl!, rranlng.lffn""oymmetltoltllntlllin PlPIMG'i'ilt_mant.rtlauRlltad rOOul"',,,,,,,mool-rBj'and+IFor+W'

lIoed<J'lylllhenthed,rumenmloo Moote.thm:thep;tjentll"'enIl!dfa' arwtinogyn,c:ol<vool_iilion Th;,cm';'mttollo""dfocpiili,ntIl lIIth.kmllnllY""'I,gt:al",m~on

lIoedtnlnd_ttatthep;tjentl."en focaroutino(a,i .. pmontioo)"r<ioo

orntini~i"'ntil1ionraliiilinililllnl""" ertremll .. ,liDgn"'ed'II ..... ~

:.:.:::::,:,'::~!i::.'

Th;,cm,;,,,,,d""anth'lIIIlont p"",ntIlfoca"",miPliIltmOor,

lIo,th;.cm,lIIhantholJliionth .. n, "",,",m,ornywnp,rfornini' "'*""""VIorllttl'lfn'ooru~~ood

Parfmnanooof",*",,,,,,,,,o:;roan;'1l, i1~udi1ioolon",oolll,'h'c:kingiiIiJ'lfn' "",u~lItlod, ... llIInllllenem"-

lIoed .... the"""""lng .... m'gmji1y Perfmnonoeofmomm'gmmfa'_

OI!IttI!ro,lnterpretjngmdioqllot""en """ ..... "e ... ng

thopiili,nt;,,,onfoca,,,,omi

Th;,cm,;,,,,,d""anth,doou_50oonIilJRlllliinon:y;rMMlliylqlh

tmlndt:ateom_l.tolymji1 rOO",dllV',III!d"lJIbl,1I'Y

n,d" ... glom._hnode ... glorn .;lo;.not.po:;iIiodj,Whonkrnlln,tho pnRIIJ'anoo'.ito".histIJryoftho pnRIIJ'on"".hOlJdoloobeOlded

Thl.oodel.",ed""entl1edoou_SeoonlilJlIIIIIIgnll'CYlnv<M'1ll>lne

tmlndt:ateom_l.tothebone(ol dogn"'ed .... ~~

... tronomlllllJlll,WhonlillOlll1,tho pnRIIJ'anoo'.ito".histIJryoftho pnRIIJ'on"".hOlJdoloobeOlded

SEC(».IDMAUGNEO -

M_em .... Thl.oodel.",ed""entl1edoou_SeoonlilJlIIIIIIgnll'CYlnv<M'1llr'*'or

andAwtoLoulwm;a tiI1;ndi::atoom_;.lothotrrain .~"'d;liIl,"",od"'bql.,. ondla'.t*101oord.WhenknOlll1,tI1e pnRIIJ'anoo'.ito".histIJryoftho pnRIIJ'anoo'.hwd~"tr'Old'd

~ILE[(MENllA loo'ofillllll'ctu~func:li<l'O;",ro<*j.i'

lJIC(J,IP .... lngtolntl!lferen"'of;oIlyfunOljon

~~~,=::""":" .... :~ .o.oa .. IIita; ,Iitirict,;ilin",,; 'Iiri""~ ootmr:IlIrlg""'I'IJ,leorOll!Bnr:t

Thl • .mel .... ed""entl1edoou_ 1le"" ... ~l>lne""" .... de"'lIyliJeto

tmlnd_oll!lqlorn.I., "",lie <*jlllledlllllno .. ddlnbtyIr/DElrA"on

"'""IXIl"';,"Ill"I:-m,"~IiIJ"'1 III11IDrinlill,o!IJ;i"

"'""IXIl"';'

~"medH_ lIBed""",tI1edooum_ln_ll"""eondlorllyoMotIonofSAnode

MfllIh_ c:hlJni::t:inuolrBdyoord .. t:ino-itrill lalldingronoo-<i1uorllJllm.lndycordi (SAj1ndycmd1.""",orllo1thMPllrmI- d"lln"'ed .... ECG ... rt1ythmmonltnr ytJ111111B::Il!oordIijNCTE:h:ut&.il'lJ'

bmd!l3'dI.~427B9

Thl • .mel .... ed""entl1edoou_ND""'*'goftl1elllllnol'onal .... lngtoth. tmin;i::at&oluldlor'llinalotan"i'''' "'m ... "iooofth.'~l1Ilmlilldn'''''' ~mllo!",mIlten"l. ....lngto.,ondmroll100nol .. nlllltlon,

Iililln"";di'i,,"I~lII11/a"byimllll'·tuli"

l'IiI:'milwrpB::omont.;iagn"';'lini::al~ ....... llIIIIIllnglllJdy

lII;,;""ontl1,dooumonlatil1inli:atoo 5wo1li1iin.~indwingliito.;iag

"","1t.gln.tnIl,Mud~gdl"'" ""edot.l,oIly

Thl • .me.taJldbe ... edllhentl1e loo.of",n"louone"liJetolnodl!lJJlita

d''''''ntliIionmi'Iita'.,.,~, H,,;nOllltotl1'IrlIi1.;iagno,,;,lini::aly

f,MthMun;odyi1iOllUtlO),c:oIIliPIl'.

un"",dou,"e .. ,~allI!tIr:k,

VIlilal~e, .... om_1I!tIr:k,

blliJ:lwt,fliinti1i.!bIIon.'!I1;IOOI, •

...::I.Iorh!ll' cta- ..... ,nm.-

~1IIlIIl1ll1y,n yn"I",_

phen.....,on, -oyn"'I", ... CMVII

roIIOI,Cllf"dia::oyn"lI',h,ortoyn"'PII ...... '...,oIJiolionoyn"lI'

lII;,;""ontl1,dooumonlatil1inli:atoo ~tIIfIi::ionttoor.o::rotmlllithoymjl1JJ,",of

dryeye oyndrnme,nutH!n!teIn eyel_n,~eotlon,d"ll""edd~I'oI~

~oumdent_lII!f:II!tIon,li!ft:Ient III11IDr .... 5<:tIrm .... teot

Ia::lim~fUj.to .. ftndoli'i'"CI' ...

dry"".

lII;,;""ontl1,dooumonlatil1inli:atoo QJrronttolB::cou"r,;illlJ1'","bytEtory ltatthepatlentl •• """nt.moker.

PuthlllttJyof""o~ng~"ded",

V15ag(porD1~hi.mryoftolB::couoo)

R''Ilirata-D'pan=".,h.",nnmy

Thi,cm,i,,,,,d""anth,d,,,_ ~1rid1"otmry~UYical~ingof

tmlnd_thm:th.palent""'" trIrtm)

tnr:henlltmr/ln,*"",.ThI.I.oI_" ""n...,,,,OO

lIB.d""endnoum._lnd_ lniI1.mntio::tomi'_,..-TIA

SlJlilenlrlef ... tmn.lentfn,oIlr'*'neurn dafi::iI,losIi1i 1""1hI124h,, dilg"",d di1i'~ly lbntinnofl"",rElllramilJ,dillll""d di1l,oIly

Gilrnni,UI,,,ofth, ~"",-lletlJ~ru.

lI!,d""onth,dnoumonlBtil1inli::at&o An"""""D1JU'.'"IlidlyimllilitDl

KemtDlr:mthnm"nrllllttlngtMk u ..... thm:ulllJoIly ...... "".un-ertn.d ..... ofth.lIIIi1thm:omgn_1IiItaJt

-

lI!,d""ondnoum,_"""UTl Galdili""c:hIictIIizIldllilh'Yrr1;tnm,

ofulinoryfraqUl"':",,"uli .. hOlllltuM. d"lln"'.dd~"'I~lI'l1I<rpn_UA

DaoumI!lllRIDnR .... """"nII farClldllll1

=rc=atI1" I lllE""i,u","lIIhanthooo::un,ma-

M~ilJ1ont""""of1l1'~il.rn dililJ"","bybilpoy

U.eth~oodelllhenthed"umen_ DelJl! ..... dmermteIB_ In_'delJl!O.lon·orli!pre.lllvedloorti!rol ... med,moy"""' .... e·lIIlilllm. Illithnofurtl1",,,<Ji!l1D1. ofdoi>'"''''" m",.rnl,,,, ofintoroot,

c:I1li1lioi1I11lPOI1o"I""IldiollJrbIIt:o beh ... or'hll'1le,d ....... i1energy, gul~, InoUlltytn oonoentmteilJtnotMOO

An,,n.PeottJ101aO U.elllmahlllttJyofmyotD"dlal_on HIOMI ..... dentIlyQ....." • ..,1J(G

M;o::IIflJial_on i,lilwmantod orc:l1....::toriGlciibram~ .... lIIl1iln

~w DEFINEDCIRE

~.::~~:::~m'~~:=ou. :~.:.<ifi=~~'~:tIovIEOUI ...

.... menmlndt:ateth~oodellhoulOmrelybe u"'.~i' nutth, oom;ct,,',liJrGI'II.lho <XmCi:"';"ofCIJ'",liJrGI'IIIli,4I!4WI

ltiG";oi.,,,;IIIh,ntholi>::lJmontaloo Awtoinfoctionorilfllimmilooof

Ind""'" ~"",gltl!, IDJIe ~oryngltl!, .ore ~1I'jM, d"lln .. e; 'I~"'I~ thrmt,"en~oryngltl!,oatIII11"lI'1llna

fliu,,,,hyp'~lIIlI1liti'.pI1'im<IW'

lIhIlrIlil •.

PNEUM(».IIA, OffiANISMN~

lIiBoodel.u"dlllhentheli>::lJmentaloo Bocter101l1'eumonla''''''',,"byan<JI-

inli","" lI'oumonill.luni inflllnmltion; ",,<iIi';'rgIII1i'm.;illin"";'liriOlll~

~o:,~~~n:'::~:,~::'a~:e=eu- onlilorbylm"lle 0tIJ~

I'J1III1'1c:h,bonign.lilatorJil,lni1.oorlllllil. 'irclJ ... 'rIlo;.ClJng' ..... 'reopni d....,.,d""olutlon,doIJ~e,""ldeml',le'olr, fl"""fulll1lnont,Mgo;o,grmu_.

~::~~~':ii~~"..::°i:~~::

mllJ!l!ll~ .... l>lm,orglll1lzeO,_elmIng,I>'h~lJ'Ilg""'''',poeud,*","" puulont,ro_,tlGCOO;ory,"nl'."Iii'. tJJ~,"'"nil1ll.truo,un ... <Wo; :~IIr"IthOutony08lJ_Orglll1l""

lIiB oodel. u"dlllhenlJ'onchltl! I. the only

::=~'~:'~~~:'!;=fmn

of thedl" """It'olml'lrtmttonom_ fIlrmoftl1ed~e .. el.lJ" __

Infeotjon ... ilfIlimmatmoflJ'onch ... c:hano::tori!';by~hanlilDrGlCA nomlll~inliltrat&l;illllno"'~ini::llly

'.'"

PIlMCONGESTI ~~=

lIiBoodel.u"dlllhentheli>::lJmenta- In"",",edfUdllllth~thelunll'leadngtll

lonimi,ato,c:hootooniootion,pulnmory <XlJih.rnSOB.lililln"";di1i"'l~

"niootion,pulamoryhftD;tal •• hYlllolati' anlil ... byiIIIi,otWi" IUI'1l"hrml,lunghftD;tIlJIl',lul'1lomgeo

lon,p ... i .. lung,l'oflIi1~di"aso/syn

dlmle,lungedelllll,termll1lllung ... lung

onlPll,mont

~~Inof,=n~,n:::=~:

Inaulltyll~u",udne,d"lln .. ed ~ini::lllyorbylib""u"

DEIN,o;r(J'HYTOOIStFNAlL

U","IIhantho;<>::UIIOntJilionmi,m,d,,m"",~~.ofn",funlJJ·ofn",tnen" funlJJ,,"finljll1l~ffu1i"

lIiB "d. I. u"dlllhenth.dooIJmental", In_ry..m~onoh"'-""

Ind"""'thatth.jllltBtth .. ..,lynr,'BIglII ... neok,.houlOerondtlpjU1ombe .. "

~iiirf1aumilc:a.~dooIJmanlil'" ~m;lIIithmm;xnlortalili"dillllm","

oI".tate.thepotjenth",gmtoelilltenl., dlnt:alyllo1the_dESR

thi,t:lwId"',IIo,,;oo(441i5j

FUI1l~infaction'fth'nllil.;ilgn""; :~~or""~~""orqllng .m

llli;.m,i;",;lIIhanth,;,oumanli- M~U1li1lt'IiIl''''fth'''lon;ilin'''';

~onln_.",*",,,"",,,,orm.ont ~~oll'Y+I-_dCEA

neol*"mofthe",lonondth'jllltBtth",not

::w:-':,:m::!:~:~th'

~ete,linm!ntatm.houIOM,"",pe....,oI hlottJyof_ ........ ,ond"ded .. Vl005

:e'::~m:.":"~:h':~e

dooumenteOond"'d""",ord~g~_

Lmg,~erlllGellt1ve Tmct,&otherS"""

-

lIiB "d. I. u"dlllhenth.dooIJmental", Ind"""'III1gn,rnnotl ........ "'molV1ont n~liIJIIofthokl1jj/1lrnnctill1;th' poIonthll'nof"'m~oIOOtrolitmant~'""" atered_gthed~e .. e_Afterdeflnlt1ve troitmonti;"mploto,dooumonlBtil1.1w1d

~~= :n~",~~-;:~to~o~~U~::'':i

",edll'''''"''fa"thelolle.ofth.~ngondW thi.i,kmIIn.itt:l1ouldb,dooumontOOlI1;

MoIV1ont,on",ofthelung'lI1dia" lnI1d1iindwing.qum,,,.IiJjOltlGA, tmIIIl0011 1iIl1VD,11IIll,ooIlGr\liIIin",,; ~~oll'Ythr<llJghe1ttorb""""""VIor CTguldon,,"

Ihoot._. llli;crooi,,,,,;lIIhan1l1,ID::unonIlIIi<l'l AI:Iioom~ignlillt'IiIl""of_m

COOrectii]liIl;oth" in;i::ato'_,,""'''''lIIIIIiinlilltnoo ;illlJ1'","~1i'psJ-MIiIIIIql,"",coulO

~"""of1l1e1J'eoot"'dthepmmth .. mt llenl!(lllttol

<mClleteOtreatmentdmedaterajt:mjngthe ;i,,",,,.AfI,,;eflnitivolroiilmonti.C<Iqioto. ;"um,_.houlOi1i",",po""'~hiiltrlyof1J'eoot~lI1d<Di!O"'V1D:3.Pa-

~£M on longtmnlQNontthemlJj"ntlnue

Ioboco;,; .. ifthoyh ... 1ho1flll!J11i1l'Y.

=:::!th:'!"'~'~~I:!'

dooumentedll1d<Dll!O"",crdlnlt/.

_,Gan,,,iJ1j ltE";oi.,,,;lIIhonthodoolJmanli- Socoo;orym~iIJ1Ii1lCl'iMJ1iing1ympl1

AoufaLou_ tionimi,m,_,tolfllllil..oo" nodoo.lilllln""; .... LNbqloy orgmd.(t,'mpl1mdeorgmddtel.mt ",edlledl_wtmIf1011111,thepnlllllY'on"" :,~:,~i:-'ofthoprimory...,'''t:I1OUIO

_,Gan,,,iJ1j ltE";oi.",;lIIhonthodoolJmanlil,,, Socoo;orym~iIJ1Ii1lCl'iMJ1iing1l1iin ...

AouteLeu_ Ind""'" m_tn1l1e Ir'*'ondm, .... nedlllG"oedtr,obloll'Y "'lnd .... _WhenknOllll1,th·lJfmll'j'on"" :,~:,~i:-'ofthoprimory...,'''t:I1OUIO

M~U1li1lt..,om""onthoflio'. ;illlJ1'","~1i'1I'Y

_oc.no"iJ1j ltiG"d.i.uo,dlllh,nth.li>::lJmon1aloo Socoodorym~ilJ1li1l"iMJliinglm'

AouteLeu_ Ind""",m_tnthel>lro(lj ... bone dllIIJ1o",,,~olBY mOll'lllll.Whenkn""",the;rmoryom .... :,~:O~i:-'ofth.primory...,O""'OUkl

U"'"honth.d<>::UllOntJilionmiollta, oderan""'dB,annkhlte-Cmodo.."li'nme, "lonlDYP,.~~IDYP,,"jlJt"lIlDYP "wm~I""'oaIp'I!Il,h""iilioflolu .. ~ortaml~od,rammJuop,Iyp,

N uol,oonin ,,1,n,dilllJ1'''' "o'*""""VIondlorradologloll!Jdleo

U"'"honth.d<>::UllOntJilionmiollta, Ilemtn""onthOOlll ... b!l!!1ll'1lttunknl!'l\J'

Anonolill","w"rapij~IJUIIriI'1l·~n rumorttatLOultyooOU,"on IIIJn ",...,.ed ..... ofth •• ~nthm:omgo _lIiIItluttrom:mont

U ... "hond<>::UllOntJilionimiollta,hlIX>thyrnld~m, ... pollt-oulJlloolh!llothyrnld~m

lDIIIthyrnid_ohllfidorizOObylOlll enl!lJlYlItate,dell"' .. lon,,,,,,ok,,, ..

ed ..... ,ooo""'iilion,dlllJl"" .. byh~ lSHliIldLOUItyIOllT'1liIT3,TotaIT4

Gcndlionohono::laJil,dbyol_ oh'I'otnJll>~D)

U ... "hend ...... ntJilionlltate.typell h!lle~o;mtl*"ml.,mnthOOlll,lIem d;;, .. ,

Hypen"'dem~ohllUCll!l1zeOby elevateOllll(>'60mgMll.melevateO ::~:'(>16[)qj1'1jll,lillJln""dby

l'I11ondOOJlIIIIlIB1iononiyinli ..... h!ll'~idoni .. thi.i'tho ...... ctcOOo,

Hiihlipij_ohono::l:aJil,dby_md lDlortqjljCOlid.

U"'"honth.d<>::UllOntJilionmiollta, olramoll,,ld',oon(J!nlmlolmllT101 lipid m_"",orolramol oholeoternl m_,,",(Notathlitmotall,l;;mmum:

IIomonlm,d,lhotorm'11!1D1ipij,mi.'or 'dydpl_o".me.tn2n4j

AIIlOO'/l~lilidm_m,dililJ"'" :~ondbyolmllT1"IBIlO'"tnlY

U ... "hend ...... ntJilionlmloJtte.gout, umtetheJJou1""odB,"no""ldd_ .. I.,

Condtlono"""dlrlthe 1010001 uJt:addOl'jllDI.,mllYli!podt~lolntlJ (lI111Ji1iGj,~dnoyjotDnoj,lJIIll*Idd"

:"'"...:! ~::~d oliri"'l~ IIiI1WJithwt

lJiJJood.l.u"dlllhenth.dollJmenmloo Ind_.lI'ITjItiiIionllo1thtM>lmtremlo dolldlll1il1l11ithh!llonlltnmi .. ,iiltd,pIotion,.wumdopiotion,,,diJmdolioi,Jt:Y; flukllo .. lllithhl'l'lnlltll!mlll,l'Mn!molltty ,,,io.coII

lDIIIeleJ:tmIy!e.tm:e,freI1uentlyo."ol Jttedllo1thli!hydmllonondbll"dum, dilllJ1,"'"IBIl'IBl<IJYIIlJ ..

U"'lIhonthodo::unonlBtil1indiclita, h~otm'mi .. jXl1lEt:Undoplotion,!ll1Bo JJlJmdefidenoy,hyJDmI ......... tM>lkBIemlo

U"'''hentl1.dIIgn .. I.I.~ndeft:lercy lDIIIRBCleveI(H",<16fnrmen;H",

onemlll,lMtt'I.nem~,.mloJt¥ddo..,emlo <'4fnr........njd"etn~nd_oy,

:~""'~~~:~':ni.,FiiWr .. d;;, .. " :'''::::d~~CY,IOIII-

U","IIhanth.li>::un.ntliIion • .,.IiIl,mill N<I1lll'Cifi:;loIIIIlGI .... I(Hgb<16fDr

'ryth~ani.,orl""h'_ man;HI#l<14fDrlllllmani,liagn"",

IrIlBIlorattJyWllJe.

ltE",.i.""II/h,nth.oowman1aloo Ind_.ohrml,lrmlnfeotjon,otrnni::

Intnr:mnlal~otm,'hrml'lrmtmum. miIW_liIldlllfBrloo.1aIo,_' jIIIIBI1'i' orn_lIJCIu;il or'OIIIIlIlIi .. ~1.aI!oLOed 111m a.jEllledtypeoi d~orderdo"nO!h"'.'l"dlt:entry.

1'irIIi,..,n',orn IUlIinutoo~Di_ ..

LD .. oIinlollo::tullllJm;li,,,du.ID,;; ageleadlng~re",,"oIdltyfunOljoo 'illlJ1'","~ini::aly

N<I1lll'Cifi:;psyctilitric"n'iIiI1moy Indwe_,IIIfBrl°IO..,dllRYohotlc lItate,dlagmlll!dcllnl,ally

UlII!dllhentl1eli>::unentlilionftjl,are.ttat CUrrenttnillC"u .... ,dagn .. edlrl

th,poIonI:il."rIOnt.nDIor,PaolhistDry himry

oIiDD1i1ii,cm" .. VI5B1llll'roonai hlRtnryolttllllr:mLOej

U",lII1endocu_onlnd""",Alzhem- llIm!ntIaoharacre_"h'clalmmt

er'd~e .. e,a~I'lrmdegl!l'Ol!lljon,or Inml!llD'j,tI1l~gandbeha~or,dlag-

AIlhoim,,'otpodom'nii' n""clini::alyornbymi1i-manllllotJito

ElllllllinaiionOmininum"i

U .. lII1an'oculllllllalioninli""" I'arkin"nilm,IIfIIIi,,~,relcorili'lIIthi::

I'arkin"n~m,.hllllt1lpoloyorp!l!lll"~, trem~lngp!l!lll"~,p!I!lIl"l."",rIo!demtl' I'arkin"n'otremoc,l'IIIoin"nil1,llY'i"lioo poIi'onigral.,njreRll,prilllJI'irIIi'oOOl.m,jIIIUIyol •• gltll'!!, ... _IIOO~

d~e .. e,oynli'nme, ... tremor.

Abrai1ditilrdorduolDd'IIiII*"imbalIiIlCllchano::loril"lrIrooli1itremoc, ""dlly..,dremrdedm_oordna~on.tell""',dagn .. ed di1I,,"I~

lIiB "del. uoed II/hen the ootlJmenm~oo inlicalo,ilIlRIiIiBIhyportnJpt;cpreiro .. i", nouili',horoditarynoulOpsttJy,inllRliliBl hllle~I'nell'llpo!l1~IIIJ~~el'll!lJrnjllltI1y,iD'inl!ll'lljllltlTy,pe"~erall'll!lJrnjllltlTy, ~icnou~attJy,P'n~'rallJlli""ivo nOU1Jlllth~llllyrwriliGor~onOU1Jti;

N .... jElli::lo"oIoenoalion ......... manl'uololOi'lIIthi:: ...... dllmag. 'illlJ1''''"~ini::alylilllVDrIrlNGSJEMIl

UlII!dllhentl1eli>::unentlilionftjl,are. dlBlletj,neuralGla,dl_nl!lJrnjllltlTy, ,iIIIlolicnouriliG,diaboli::;DynwrejllltlTyor 'ilillolicnou~hthi.i',ln'Id"lDoh" .. tI1l.rmeYflJlIIJotd ...... nttl1eCIIJIIIII _n';'lple.ll-,nl!ll'lljllltlTy2'lodallete., 'ilillolicnou~attJy)

llMornneurologlcalnmlfe_. Indwlngnumln! .. ,~ngllng,1un11'1l ","tiItm',iaolnJlli'"'i',on;cIj, _rcIiI1,aufDranicinoiallilityocp," tlveflmlngoonerve<mduOljonO!!Jd~ dllV'olll!ddlnbty

U","IIhan,o::un'ntliIion'rtJ_ iW<XIII.llithnofurthorinfDrIIII1ion

In"""'.inillniD"l..-pro ..... cau'ini ,plcno""'_',IOIIdinilo'li,,1II Iml"*mentdagn .. edlrltooometly androro~lmo~l,emm

U",""han;<>::UIIOntJilionimi,IIta,c:a1i- ~WIi""onoflan'I,IiJji1i1Dimpaia;

rlr!,m.ohll'1leo,lnttJ"""",ntll!l'l!, ... leno vlBl"',dllV'0 ... dlnIOlty

ojlldty"""outllJrth ... de .... jljon

U ... "hend......,ntJilionlltDte.hl'l"rrre-R_errn'oftl1eeyele8dlngtolnIrDpiII,hyp'~ .. orfin;il#lWdn'" obIIftofo::lJ,ond"",bjo:;Isofton .. - _"ithlilli1i.lillin"";'Ii'iOlll~

U",""han;<>::UII,ntJilionimi,lIta,myopill R_,mJroftl1'eyelalldingro

n .... lglTtedneo.,or.hortllghlEdne .. InaHlityllfllou.onlDnlIIIO.yollleotll

dllV'0 ... dlnbty

lti,,,,;.;;,,,;II/h,nthowwman1lll..,

:od~:.:,~ret!...m:,~:,:';!""

IiO",mm,;otmorliO<Xlllm,;otmdimor

U ... "hend<>::UllentJilionlml,,,,,,."lI"iIIly- R_I!IIll,oftl1eeyele8dlngto

,piII'ori1t11ffi::ionta::cmm,;iiIi,n inlililityrofll,,,ond' .. ~'ob;;,,,ro liIli1i.lililln"";'Ii'i'~~

R_.mJroftl1,eye,OJIOludini rr1R'1.ondll"~!l,dlBgnooed dlnbty

lti,,,,;.;;,,,;II/h,nthowwman1lll.., Indl_.h'clOCll!d"""men,lmjB:ted .... lIIIllI,olI1<rmoioerulllll1proliJotIon, .... ln ,or,or"rulllll1lilX:U11ulotm.

U"'""hantl1.lil::un,ntJilionmi,lIta, hOlllinil"".;OIIfn",.ouliloryd,IIfn,,,

Im .... red_ng,oultttJyh'clerceptm, hl!ll!dlmrydellfneo., rmgerlmldellfne .. , " IiO'U;-o;; ........ 1IIith no;",Mptm of tho oII,l<wof1l1'impoimant

N .... po:;iIi::bo'ofhollMng.;ilgn"'; dini::lllyorllyou;o,1IY

ltiG ,,;.,houklonlyb,""'" ~1I1'm';ic:ol re::omin;i::atooliOOIII,rall1lhyporton ~on,~I1lhyp!rtenolon"lIIIIIIgnlitt hlllertenolon.ThI.oode.hOlJd_1le ....,in.~~anofli""tling.~i'NOT oyn'Il'Il,,,lIIithurcmlnJlloohyportom:ion.

valY'I_~(njp""U-O"'"~l1lin eye,kijno~.rn"""iO¥is::l.lor;_,. dllV'0 ... dlnbty

Do::unon1lIIonmLOtinlic:ol&baniin ... IB'Igneolll!ntlolhypertenolon.WdotlJ men_"'~M_.hyp!rten~on,.ee 4Il19.1IotlII.

HlN(SBP>14D,DIlP>9Don200::a*,n~"'th<lJtllTjend<Jllon(eye,~dn~ ",ord_tlJlorld""'"lle,dlBgnooed dini::llly

N ... o .. etongln.(cIIdlooCPjorll'1llm

lllithilt:llll .. i1fro,uOlt:Y0'in it)\

;ilV""'"dini::lllyIllithTin onon

ECG..,dhypo~neol • ..,eohooard~mm

lIiBoodel.uoedll/henthedooumenml.., IndoateolntermedIllteOlmory.lI'd .... , impon;il1l<Xl1JnlllJoynlillm'.iqlanlini myo:;IIf1Jilllilflll:lion.inponliniinlll1:l oouteoornnlllJoyndrnme,..."orylnouffi'ianCl'.,m"'"',unotali.liI1lin .... intonn';i ... ".....,.

'O;'gin.P'oIOOrI{I; MyooardlBll_on

U .. ""an;"ulllllllB1ion"""'iim on"n.jBlllrlB,lIeIlerden • .,mrnme Ukrlff'ooyndl!Jlle,5ohoufenote'kmrIItoIr, anjjn"",mm"""i.,.mm~iill,orollllll'

N .... po:;iIi::--"1IIli'~'IifIiII'c:hootpoin dllV'0 ... dlnbty

"""".,

lIiB"del,u"dlllhenthedoolJmenml.., inli"""milnllwl .. d;"rdor,blllloonil1l iGtaM..-loiillat,BorklII"pnJllIIl".niIniI _rmap!ll!,orfl<wYmItmlVlllII!

Anydmer ... dllm"ll.IIWIlI~ngmltml _.iltiJdil1loia""i'.IllIlU'llitlilionor i>UlPSOdi"ll,"",ooby"h',lI1ii<vam orotl1erm"llelltlJdleo

C<r!l' .... H'IIftFllilura lllEcWO;,,,,,d""anthodOOJmanlllion indi::ita'!liIBJ",,"i""lllpsttJy,ijj,psiI1;' tD'dlorT1Rlll1h~ldlolllll1l,,,.,,.,,tD'dlolhyI"rtmli1~my=rdq,mhydeotJ1l1ed .. <XI11'otivo,CIln_,fimililll,llPartmlilic nonw.tructM,ijj'psiI1;',ilIillrilioa. olBtru:tlve,!Dn!IY,re_or.1"fIIdo rm_myotD'd~.,~I.,omi>rrJRB1hy(Jidqmtti:;"""i'm'i",,,~tDJrw

====::~~~,th;,

U ... "hentl1.d ...... ntmjonftjl''''''.1r>-

:=:=~~ooj..:;;.~n':::"

ortedo_,IrItj'VIliIl!,onrtlo_ Inouflld~IrItI'_oIllltnJr:tm,oIItt: _oIlmtil,..-..,rti,murIllJr,

llIBorderordlllllllle In_1 onrDO_, mm.;'orirouffi::iGn'YraiU'llillltil1, dilllJ1'","",ocho,liIli~""""-otI1" Imll(ll!lItIJlieo

AIIl<lTll~,ordio::furctm"h,,,,5(JI GPlI1dlllli!il ... I'd'm .... ""'"in .. oymptilmB,lrdJdll'1lldq,mhI',IIm:ed, relltllr:tlve,rmlltll",,""ondhyJ&trnrtt: ati'I'jj",dililJ1'",""'''ho,lI1i~ram IiIldothGrimlill°.tudioo

U"'""h'"th.d<>::UllOntJilionmi'Iita'oo~ irIflJIhnill.,ordill'dytItlyll1mi''''orIiliO

=.'::h:d~~'::e~:::~d

1iPPll!lB1&~,

N<I1lIl'Cifi:;Im-'-'''rllJllmdililJ1''''" III'EIIG..-rhytl1mmonna-

C<r!l' .... H'IIftFllilura U"'""h,"d<>::UllOntJilion,.,.llomtoim~ 'YllItllm,.QFoch,ortfliiua.

Girdn~,,",plmEiltiJ;'S(JI.,"'m .. or~dilillnll","by'liriOlllfin;i1i'lI1; +i'VConCXR ... emom"YII!'IeolIOllEf lo:SO~ondl''n<lTT101EF'''thd_'

"'"-

ltE";,i.,,,;IIIh,nthowwmonlition_,lI1y'""im'i~~lIiIt<lut""'

~!=~~'::~~I~~:"!-~U'"

,,;,,40~-40211.

EnIify'""'ort.;ilgn"";'liriOlll~ocby Imllll'lIUdeo

SU;;..,tiMofor1nintBltfo::llltirain noUlJdoli,lt,llEIinglo .. thIill24"" dllV'olll!ddlnbty cand~onlllherefDttym!lll!l101~del''_

intho_oflilJrta_ironimlllill h"".,qllffi'Dr~Il'_.liogno"," '-'1r>tyrrbyonllollllMnBGellUdleo

Ind_.thatthejllltmlh .. ..,lIIldormoi lilJrti::or",condnilllJjllmil1llll1oullllm thllth .. nutrupture;.rnh .. mt"'on

.. "

MI1,,,,,,I'''''i'invOOiI1lP,,,,h,rlII

orre .... ll!8dngtn_.,u_onor g"'1lren.,dl"lJ'o"'''nIOllilyllllt!1on~elrB::ti~indalorbyll1i~ram

ltEoodoi.u"dlllh,ntholi>::lJmontaloo i'ro","wofilllln""""'",,'id,diliQ-

Ind""'" Intemol henmtdd. ",oed,lInbty

U ... "henth.d ...... ntmjonftjl'm:e. N .... jEIIt:_ofbll~"djll! .. u ..

10000_jII!OlIIJre,blllpre'lIIJre,lItI!I101 dilllJ1'tlIld~ini::llly

h!llotonoion,hl\XltOrOm.oonolilution" h!llotonolon,"'l1!ID!l"Illlojll!"u"

Utllld"hond<>::UllOntmjonimi,m:e''''liratnryinfoolion.lH, ~rlII"",irBl<lJinf8::lioo

N .... jlGCili::a::uto'lililinf8::liooofl4lpor rejlllfitlJry1rict,in_in"'lI1dthr<Bt m''''''ll"l!edbyrunl'¥",oe,oorethr<Bt he_lI1dll~feelng,dl'llm'" ~ini::llly

Utllld"hond<>::UllOntmjon_,bllm,hil •. lhoIG1}-9......,. ... u'"" ",uto lIoo,hil. UI.mt.pedfled

Awtoinfooli,n/ilIIlimllll1il1ofblJnm ... ofI&nl,liJji1itoPrOOJrnooouihIl1Oi'a" IIIlJIlJmjll!duOljond'llnweddi1I""I~

U ... "henth.d ...... ntmjonftjl'm:e. oIll!1lll'''*'~.,Bo-.dl.'"'.,fetrl! ....... "" __ .~loryicrtiniti ...... '1IIlta" ~:~~:"""m .. thin<lTh ... ,Or"'mmi'

N .... jEIIt: ... rglolnflllmmotjonof ",oe,ll!8dngtnonee!ll1l,oongeoloo .rumy.fiI:llyn"".liliQn""d'liri""l~ anlVDrbyrtli""oopo

U"'"henth • .mmentmjonftjl,m:e. 'h .... 'brnnotltl.,perllrnnohlllBoroen .. IIoomiti,.butthotyp,ofbnmc:tili,i.not

~":o~~u::;'o~~m=!'::d:

(o,g" mrai,oooinJ,"" lIoo,hitioj

U"'"henth • .mmentmjonftjl,m:e. ~i'."ntrio::i11ir,conIIil<DJIIir,mrai' diffu" ..... nti~,hypor1nJpti',into~ulllr. IUI1l,ollRtru:tlve,lB'loIIJIir,,,",,,I,_ poIB::i11ir,p,oIIJraI,pulllD'lll";,,nlo,tJJiI!*lJraI,tnlotm.U1il.torlll,unl'IIJIIIr .... ..... 1""IIIr.mli1_ ... I1ype"u:ent~ng Mooleod"oyndrnm.,otrnnloblJnohltIBlIIIt!1 'm~m .. ,*,kpuffor,orSWyor-..Bm"

:'~~,~=~=::~":.u ..

todooument.mrmemrmo"lIIlI .. tnry fliilU-O"Killl"ilIlIlI

DmIIIGeto""'olfml1uentlydll!lJ'o'" by.m<*il1lhimr,.IIIh""'ini,GlIR fimi'iandoooinJrnol'FT(FBPliFVG <"-

:::::;; .. "

U ... "hend ...... ntmjonlml''''''. BrDc:k~.,.,drooJO,IitaI'ctJiIi',liihtmdl. 1,lIooyrnnmll, Ill_rna IitalodJiii, !III1IBIatele""'''','''rrcre .. mlltl!le''''''~, iUnonorym:eleomsl',<DrClleteoteleOl!ld! 1I"'"",c:cIl'lnloocrallillll1ionlltal,ctJiIj,

---

cam_ ... porll ....... p!II!of.~on oftl1'lung,dilllJ1'","~ini::lllylilllVDr ",inlill,.wdiOOlbnJ",h"~

l'Ilrtru'ionofth'URl"poftoftho _intD1I1,1I1,,,,,,thlJu!#1."'-or IIleokne .. lnthedIOltmllm,dl"lJ""'" III'EGDlI'dInrmagelltlJdleo

A'lintlinmiilionofth'_lI1dintellth!re!IJ~ng~dlorr11e.,"""VIlm~g ond"""'1l,"""lnfeotlou.lKI1<uplD1g "'gotioa.lililln""ddi1i""l~

ltEoodoi.",dlllh,ntholi>::lJmantaloo Ind"""'tI1attl1ellD*"!h .. lI!OIlIIbleedi1g, """~eedll'1l,II!OIlII"'!n""",,ge,1I'IIII honmhllll·.BRBI'R(lqhtrOOHoo'lI'< re::tu~"hOllllThlg'ofll1".

BI";i1ifrDmre::tumlll11/a"lI1""dilg "'oed'lInbtyordln' .... end .. "PI"lm"IlelltlJdl ..

U ... "hend ...... ntmjonlml''''''.renol

flijlu-aor""utaran"fliIu""Ghrooi,lIGn~ 1>1,4miflj~ ... d, ..... 'inuli",'utput F~u. j'n....- .. "m'd, itmuolbooapi:illy IdO o::/h~.lililln""d '1i'i""I~ ... ",

_ lollfhjlnlll

N""IEIfIo,*,"dll'1llnv<t.1I'1lGItmct,d~ "Il""eddi1I'oIly"'d/a"byem'~" orradj,I'li::III.rud"

lIiBood.l.uoedonlylllhentl1.d ..... enm- Chrml,renaldyollJnotjonohmr:tl!l1zed

tionimj,m'5tiQ.I!h1Jni::KidnoylJi;,'" byll<l1lll1ingc:rlll1i1ina>1.5,orl>'O-

ANDttorel.adorumentedGFR>90Illlt!1 telnll1o,<rhem!l!!JrIa,ormt:mollumin

tmI,l*jnoydlimliQ. urill,or' .... inth.uin.'n~,fi1dil1l' onjlllttmgy/lioPRY,ormdloIOV'fi1dil1l' (M'orMRIIGT;i"._,poploryn, ",,~~ondll1nelJ'llduoll"'(leeolmel, <110n0::t0ril,dbyGFR>gO-(G'R)= 114D-liQOof!B1iOnll(ll,dyllOiihtof IElent~KGI~nl"'~mg/d.J(r.'1 ~~':e~byl.2~~IIIIII' ond byl.05if

lliB"del.uoedonlylllhentl1.d ..... enM~onlml'm:e.smg.la.rn .. 'lCJmey

1Ji;, .. '~th,roi;.d"umontodGFR frnmBD-Ilg

lliB"d.l.uoedonlylllhentl1.d ..... enM~onlml'm:e.smg •• Ch..,I'Kki1ey

1Ji;, .. '~th,roi;.d"umontodGFR frnm~D-lig

Ch..,I,renaldyollJnollonohmr:ter1zed byGFRof3D-5!l

ltiG"d.i.",donlylllhonth.d<>::UII,ma- SIm,a''"'i,l ocuri1,prDductm~"

:e=~:':"~IV.~O:~=~FR om.e),""omcte''""~Gllofl5-~9

frDml5-29

neemgd""'l.octmn.~_ TomJlo"ofrenoifunoll..,_''"" lri_dO"(>1.4mIJ/dl,IoIIGFR l<gDmllnirO.liIldloll«~D::c.f1r)1no uri1';miJolion

TtI."'d.~u .. donlylllhentl1 • .mmenm~onlml''''''.ESIIl,endllllilen."hr1l1!, to",*,~noli1riti."GKDoIBg'V~tho potiontilum''lJinidillyoi,(s"V4lil)oc !lIIIIlI*1ltmn.~_n

CHR(».IICI(JI)NEYDISN~

U"""entl1edOOlJnmmtlonlnd,,,,,,. N .... ...,moohrnnl' .. n .. dyofunOljon

'hrm,kijnoyli_.,c:hlJni::ron~fliilu ... ohono::lo .. ,dlriinpailOdlRl

'h .... 'IdOneyd""".orohrnnl'ureml"Notothllt'hlOOi'~dnoydi""'''''''i ","uIOMudead"llnORtj'lItIItI!IIm!oftl1.

lltaGeofldOneyd"""elllh......,' ..... 11E

UlII!dllhentl1 • .mmentmjonftjl,""" N .... ...,mormoililldloruretemld1O-

imlli"d~li1"furclil1.~dnoyina::li'" func:tion,dililJ1,tlIlddinic:dy

~dreylneflt:lercy,IdOney~ltm.te,IdOney

dil, .. ,.""uto~dnoydi" .. ,.""utolOl1ll

d~e .. e,.aIt'1I'dreme,lIIIItlo,*,gd~e .. e,

1IIIIt .... ll1ldi" ... ,non-furclil1ingkijn". IIIIItIo,*,gneli1'I.,rullJl",""'II~g,Tl"ln~

d~e""""'li'nme,pyebveno ... _"",or

IIIIItn'Ii1'"psth~

UtlIldllhondo::unontmjon,.,.UTI GiJnlilion'hono::loli!'d,.;th~'

ofuMl1If)'fIOGuorcy;dywMa,h,mafuli" dllV'olll!ddlnbtylilldlor .... ~lI!lIA

Ttt!ood.l.u .. dlllhenth.dorumento- BI"d~theu'''',dllV'olll!ddlnbtyor

~onlml''''''.temaI!JrIII,~''''"lnuri1e, 1ri1lA1+~",," ... +RBq

T<IIIII .... i~Di" ... (I;'m;ctdl1Jild',_ 1iIl·lllininioto"~."'niinh'matulill. Idq,at!1I'hl!llllltU,a,~rmlrtenttemaI!JrIII oulfnn_ehematu1.(cmeotdrull'd","Il'

"'..,i .... dj

N .... po:;ifi::_oftho.~nlollding IDIIBrmth,oryttom .. "",lIil1l.dilgn""d

.... ""en dlnbtylilldlorlrilm"ll'O!!Jdleo

In_onofthe~le"'ll1lto 'ryth'm .. ""'I~i,ilI:tin""dilillmtllld dini::aly

ltiG"'oi.",'II!h,ntholi>::lJmon1aloo ~di"njorcoot:istingofalJU\llththlit

Ind""'" ""'"_'e ..... ,ooqlke' _1m1~d"lln"'e'd~I"'I~

oIllGmnr~di.'"'.,oIllGmnr~,ooqu~,

fit:l1 tiin,K¥rIo'o ""drcmo,ll!\III1IOnmJt"

fDlli::IJori'in,utomjlll101rin'.Lutz-

MI .. 'heroymrnm.(eI"""'~I"rf<nn. III!Ijigln"umj

UlII!dllhentl1.' ...... ntmjonftjl''''''. Pre,""" .... ~g""""ulll.llll~"""'"

octiniclwratD.i',NI, .. nilo_ ...... nilo "'''lHIIIXl'u,""illlJ1,tlIld<inic:dylind

h!ll,,,,,raro.i .... nilokoratmlll,lwratD'i' ",.~nbql'Y

""'1I~,"lorkelllln!~,"nIIeIlM,W!II1J'"

""'1I~, ... "nlelllM

U",""en'"u_onlltDteOlnlJ'llllll1nal,l'aInful",ndtlonoftl1egreattn.ln""lrf1 onP1'<J'ftl1D .... ooylIi',ll1iuiliramlitu • ..- th,mdg"""'in1D1I1'iD1oooith"'i'o ing""'l1ln~1 08Ut:iniilllllmmlitionlll11!..-ilfI,,;lim.

dilllJ1olll!ddlnt:aly

lonimi,Iito,a::hlJmiaul1luiun.",qu;-O, md,i

=~~;,:::t~~LI~~~':~:", ,"II"oaI~

nlllldi_'n"ii·haln~I'.friljlitas ul1luium,IriQI'n~~.fulTllllril1ln~I •• grmve'I'IIIII., ouiIJl1luoi hl!lllllttmo,h<m nal,lIoIlonyrnlo,leulmyd1lo(IIJnomtDl ~1rB1BI,lIlJlwplithillU1iliJm.miifudin" ",,"..-groow',ooychtuIIiG.<Il'h,'yotm~,ony<:lqryJi1"'I.,onyrnogl'jlD!l., on!d1olyol',onyoho"""lIIa,OO'jCtoltmji11o onP1'miid .. i •• onyrn'm~a::ia"nyctql 1IJ"',ooych<lTh"';',IitnJji1i"nllll".._.

R1eummnldArthrlll! .mlnllOJllllllttJy Qm,ctivoli"",

UlII!dllhentl1.' ...... ntmjonftjl''''''. N .... jEIIt:.~n'~order,Mu'~g

'enn"""~,.~n'~e"'e,lB1n ... _, In_on,dl_on,lnfeotlon,

"'~n .... ' i"""",irIitlilion.otc,dilill,"",od,*,i'~ly

IinlViJrbybi'll'Y

lIiB ",.1. u,,'lI!henth.dooumenta~onlltDteOrteumatnldll1l1r111!,meurnatt: orttlliti',dm"'llliyaf1l1MI •• moum_ IIJrtiCIJIE,pM....,Plli"' .... or1I1riti •• IJllIlfem~1I! drlll!, ... mrnlt*: 11111;* ~tI1ed"u_onlnd"""'ontyorthrflj. ",7159

Chrml'lnfllmnattJydmerfnr ..... tI1""B""",d"ll""edd~I'oIlyIllth4 outof1l1'~I""I1l:liffoctini~"m''" i'irn..m<mingmrrn"','jlllmotri::ol jolntpaln,PlPh.1!J'j<*tt_ment rheummnldrmul .. ,e""loooo.- ..... Iind+IF..-+GGP

U..o"hantho;<>::UIIOntJilionmi,m, OAmllini~mbir.n1I'<'-''''rlII ...... lumll",,,,ond~o~ •. lum,,,,, ...... ;rnlyIo!I., dllV'o"'dlnbtyorlrllm"ll.O!!Jdleo or.omI",onlt,1ool'

U ... "hend ..... entJilion.oyolumbllgoor 10"_"

I'aInlnth.~mlErll!lllond"lln .. ed dlnbty

ltI."'d.~u"dlllhenthedorumentDII'" indi.".,'Cotu1i'~;i" .... GotuI1l'~"" ;1OOI,.I.d1iau .. ·",ruia:pntnourlilii. _,,,,urlllGlo,,,I;tj, IIlin. InfeOljonai o::iII1iOllOCo:ill1i::ll

Irrlmtlonot_ ........ leodlngtopBIn

IiIld1i1llil1l IIIi"'''''ill1i1i;'''"

l"""r .... mil lililln"";di'iOllI~

ltI.",d.~u"dlllhenthedorument&tionimi,m'~mborn'''''l1Jot;i"njor. lumll,...,.lnorwruot;;;,rdor.tImiJ;i, n"""rmtliB ... er.lum""''''rlIImdlrulll' ",onterlor,rumlmdt:IJ~ •. legmdloulltl! lumlllif.lum""'",rlIIm;iouiIiG.th,,,,,i, mdrulll.llllthvIBoerlilpolnorW!l!elralbody Implngl!ll'O!M

N .... po::iIi::ilIIlimm.I"'ofkmbinl"'raI norwl~I,IiJji1itolllin.numllno",oc ::6:I"Il"''''oIInl'oIlyondkr''

U..o"hantho;<>::UIIOntJilionmi,m,my- N .... po::iIi::painin"'Ni1imu"I'.

~iill.fillmryalgi .. lllj'lJtiIi'.myofadiilpain. ;ilV',..odini::Bly

fllmnyaB~.,mu"le;U1.nell'llmu"ul", ."ormeumal,mu"ulorpoln

Palnlnlllll,ll!Il.hond.fnot,flnlJ!R"'_ I'aIn In 1IIIl. leg. hond.fnot,flnlJ!R'" 1D".dililJ1,..odinic:ally

ltiG";o,houklb,,,,;lIIhontho LD",ot<mo::il/""",;uolDillld'qUlto

;<>::monllltil1inli::Btoooyn"lIOtorith<lilU1 ~(njfkllllDtholnin.dililJ1'..o

derl!tl108lloel ..... !lIBe,u ....... d .... ""., dlnbty

.... o-wlllolmmd!.VIlilal""~e,""<mlttr _.~idwut.fiilIini.G"""r .. oynli1Jm' •

.... oul..-hl\IIIrIlactDr .•• ulUllDrinotal!llJ.

n .... ""~e,""<mlttrphen .... non.pre

oyn"'pe .... CNBJlIIIrefI"'.tD'dIBo.,.,~ h...-t_'or .... "onolliction.,.,~

ltiG";oi.",;IIIh,nthodoruman1al,,, Sym;mm.otfoolinglill)\imll~IiIlc:a;

inli."."liuin"'.iij;in"'.;;;,qlilillium ;ilV',..odini::Bly

lI~eodeme ... ""'lIII1Inglntheheod,MIII

;oDol!arquomantorYOrtii'

U .. ttI.",d.~tI1.medoalre"rdM_.

=i .. FU:=~.'pIlOlllllllil--.

U ... "hentl1 • .mmentDllon ml,m. AII1<rmoi pettemof_g,d"lln .. ed

_llI*,goltolliorm~goltdIO!!JrIm'" dlnbty

ponIJIicillil .• d.ugait,·paoIi'gait, ... i

ioriniillilocimblilll1'"

U .. tti'e:c; • ......,1I1';"umonlBtil1inli Ac::lJmulll1il1offlJi;."'lIII~i1tho "m"'""IIIt:II._~oo'm .. ilfoctilJ, I""'r .... mil .. "";do!lon;ont .....

e; ...... ~ttjng'"em ..... '"em. dllV'o"'dlnbty

U"'"hentl1 • .mmentmjonftjl,""" h_d1e,";tIIIIgl •. "",,"larh ... arne, lJiJ;,orlB::i~pain ... h,liJjpoi1.

Symptml!ofhead,.;, .... headd~oom fDrt.lililln"";diri""l~

U .. llhon;,,,lIIIIlIa1ioninli,,,,",, .,itliIi'no.jJJ ... inth."""' .... JIlu ..... """medtl1attl1ejlllllent"",an_"ne,, of1l1,ir_m:.

1'ro"""'ofpal~taloo.;ilV""'" dini::llly

lti,e:c;.ilu,,;lIIhonthooowmontaloo SymjltmJof"uih.;ilgn",;,lini::llly

indi""",,e:cul#1.IIIIlI1l'~oyne:cIl''''tu;.ivo

U ... lllhentl1 • .mmentmjon M_.ttat tI1ejllltBtth .. dyoph~,tmuble_owing.";itli::lJlfin ....... IOIIi1i

1lItItIJty_OIIo1ng.dllV'0 ... dlnbty orlr/mdlologlOllilltlJdl ..

lti,e:c;.il"'ilJ1,;lIIhonthod,,,montaloni1;i'Iito'II1.IIl<llll~(IlI";llilxIatrI

~~::::~;d~~~!~ddagn"'I'

"'1iJj' ... ibrnrm~llIdi'l<wfi"'.'iin~ni IUl'1llnfllmte.orlll1gooln

:r'~:::::I~~:D:!::_-='

urojlGCililojintl1,m,d::III,."".di_ i,",,,mootobo1!ll,1I boo,; 'nlW-9 gLfOelm

1lM~lIIhI1outoomplmtlon,mt_d .. unomtmlled.dI!lIJ1o ... oIInIOlliIy

lliboto,lIithout ltEi

QIqlliCilioo

llibote.lIIt!1out lIiBood •• houlObeu"dlllhenyouh.", ContmiledllMl1101th<lJt<Dl'CllI,atjon

QIqlIlCilioo d",,"nmtedllMlorjuvenlledibote.l.

;,,,,"IlI0I110;.

U .. oo~lII1md"um_lnd_tI1e ContmiledllM~IIo1threnalman_-

jIIIIIentha.renai dl" .. e1l1at~ "",ndllY ~o",08IJ"'lr/tI1.dlal>'!te.(rena1

to;i_ .... diiboti::ron~;i" ,Th' m""ifootaIoniltiJ;,d"'umi1urill

IGD--Il;""not .. tuIIO.08IJ liiIi'noh". ;rotoi1urill,;,,,"",,;(Jfl,Gr,otI:)

:;~U~U!~:d~::":~:~~~e- DIaIletl'Neuql~MMJ1>2!l9

U";"""'th,li>:;Jm,ntiIil'lin;i ..... thot GiJn~I';DM2,""i<11h .. CIIIJ"''''

Qji1thB1molo""... o;iTth'*'"*#:BI"'nd~onoore."""dlrytn, flnlt1g •• "", .. M""ullr"em.,~~on

lt1.pedfleO orCIIIJ"'lrId __ lhI!m,um£MDllon <11OOIl",retj~!l!t!y,'~~01

MiI1ifa_, muol~;i""'tha"",,~_on~.llli"oo, ';OIIIII,~tnw'hImlrrhli"ni::nJOO'lI-

i'notl.Ooo""",oo",,'''';iIiI1~CIl rytJIE,II1;~mn .. ,,;illlJ1''''~ini::llly

el!IlItlIl .• ,."",orbljlljjlllth_'.lIft1m oodlorlrl~ITth ..... "'pt:emm

the<mdltm ..... """'edlrlth.dl_,l.Oe thi''';'MDth,.mafiJrth'~

""CIln;iIi<l'li"llliBllali::retjnoplithy)

U",h";.""""th,;"umonlBtil1 GiJn~I';DM2,lIithnourol'ii::lllllll1i

NeIJ~I,or()ther Ind"""'thatth.jllltBtth".l'II!IJrn~I'oI felltatl",.2"DMMud~gnumllne ..

S!>ldfleOMiI1Ife_.oom;a:atmofthelrdlBllete •. ll1ed"uml!ll-~nglng,bumlng"nootjono,g~

tlitionmu;tinli"'"'thlttha~i'litionil "'i'"re::tlI.dysfllu;lion,lIIIIoo,mic

.....,;orytnth'di_.lll.rw~i'~ InOl!llillVor;nltlve~dll'1l"'nerve

oom;a:atmmulllbe • ...,medood"'d .. <mdu:tmotlJdyorfoll"nmofll_

"",oratoIy. tooloffiJot

tionimi'iiIo'thltdlt:lJllitiJrydi"" ...... """"doryto ... ClllJoed"d_.mellitLo For""'m~.,dl_lI'1llo_,googrene 2";i_,p,Mji1,raldraJlitiJrydi"''''2'' ;iBIliilo" ... ;i_'ni""oojj'pIith~

.... "I..-fi1;ing'iltiJ;il'1l~iU;i::atiI1, ul"''',OIIngrme,athernm-n'''ILe l""'h .... """"I"'d~e .. e,l!II!OtIIedyo func:tion,CVA.G.'D)orlll'itioofin;i"Il' onNl,UI1nE'II1;,GTlI1i~rorn,_ oroo"og'"

ltE";.i,,,,;IIIh,nth.li>::lJmontal,,, GiJn~I';DM2,.;th'thorCDqlli'Iiti' ...

NolJ~i,or()thar inli ..... thlltth ... il.;iBIloti'CDqllical", CIIIJ"';"th.liiboto"""' .. ..,

S!>ldfleOMiI1Ife_. ~-".,.<mdll"'CAIflIIl"th.d_o) flnlt1g.,lnfeoII .... ,ete,nototmed ..

thatl.notlnoludedln.more.pedflodlBlle un<mtrnlled

to'CIl~i'lition,,; •. RlrEllllllqllo:liiboti' imoc:hini",;iBIloti,d'rIIII1iIiG

ltE";.i,,,,;IIIh,nli>::lJmontali"".,. Lo .. offluidfnmth,b,;yloiidiI'1lID

Luet!l<11er'oynltnme,lu!to,her'li!hydm- "".kl" .. ,thlrot,foII!_at, ..... ~

~on,del1ydml"' ... lI1h~ml'" ttJlJJI",l'M>lmlllfemlo,ete,dllV'ooed

~ini::lJly

U",""onth,m,;i::lllmmimi,iiIo, Gh ... ctorilo;IrI~!I."",,rij'~lIJdy

'''''ill ""iiht ... BIII of .... thlill ~D

U"'"honth.li>::un,ntalionmi,iiIo, Anoni.;ofinoo ... milollithh,m'ik>-

oo ..... ofohmnl'dl" .. eduetnoh .... ' ~n<13g/d ... hem.tnorlt0::39!1.;or

~dreydl" ... ,ESRDorEPQre~1ItII1t femole<'2g1dl ... 37!1.,du.tnCKD,de

:,":~~:~;~~",!:g finoo ... GFRof<OOor~Ii1"_i'

d"""not ... ume ....... oIre1otjonohlp.ll1e Ume"~ngohronl'oondltm(e.g.,HHl 5!lifi)'houkj~tilb'cOO';.

A'1'milldofi",; ... m~'lIIithh_I' ~n< 1~g/d ... h'm.fiJc:rit0::3g!l.; or femole<'2g1dl ... 37!1.,du.tn m~ignlillCl'

U"'""hanth.;<>::UIIOntJilionmi,Iita'II1'- 'O;'oni.;oIinoo ... m ... lIiII1h'm'il<>-

ml.'f'hrm'dl lln ... (e_g_,RI\, ~n<131J/d"rhem_0::39~;or

SLEondlverd e~.D"um_mull! femole<'2I1'df 37~,duemdl" ....

inli ..... thlttholl1,miai.;u.m,h"";, tu:ha,5LE,RA, Ii...-;i" ...

;;;' .. ' ... ilno .... 1W-9d'''mt .. tJJm'

~'~d: ':..":"! ~.,~:~l'4lmrnnt:

UIII!d"henth.d ...... ntJilionml''''''. on epIBodeofll'Mlluboid ....... I.."

~:::::::::=:.=;~Ib,men<>-

jIIILO ....... nch'liII,'""'nJU.m'IIIIt:h'li. Oil_de;reo.lon,poyrnotj,de;reo.lon m,IIIIt:h,lic;,pro .. i,nllilltlut •• tatamonl regll'dll'4ltheIevelof.everttvormentlonof 1I"'i""'pE';'"

N .... jEllt:li!pre.om (Ii!p",,1II!d mood 1, .. oflntereoT,clmgeIn lIAletfte,.leep ;ioturlB1".IIoh ..... clmi·,d' ..... ' Ine""llY,gLllt,ll'IIIIlliftyto"'""'"""""', :~~:::(lJihts)lIiII1d'I"ionandIDr

IEGURRDEPA es

PSYOKlS-UN5P

U"'""hanth.;<>::UIIOntJilionmi,lita,a N .... jEllledrecurrentdepro .. lon

"","rrenttthl'lIIJlI!be.ped~epIBode (d'proo .. ;m";,I, .. ofintaroot"hlll1l'

oflnvolLJtjonalde;reo~on,retlJrrent In!lAletfte,~eepdlmJrIlon",tmovtr

m,IIIIt:h,lia,rotlJrIlIltd,proo'lvofl'YClu;;;. <11ango,;,,, ... 'in"""ll~lJJilt,i1I~ity

:::'I=~~I=~~~=rrent ~,:,=~;=~!~u""'llMth

fIIU"melllnch,lb,recurrentlltql,rnLO m,IIIIt:h,lia,rotlJrIlIltllllitJita;;.,,,,,tU1. ""'"rrentpgyd1ott:d."re.om,........"" mont:li!pre ..... type"'II'h' ... (defl"'''d1 orre::uront......,'h'Ii::;.'''' .. iI1l1ithout .lItatI!III!ntregamlngth.B'elof....."rfty_

U .. llhan;',"lIIIIlIa1ion..,.~ nOU1Jt:i"noumti::otIita.ibram~"'_ prohenolon,."proheno"""",flRY"lqenlo on~ety,anD!tjrIltate,poyrnonl!lJ"Otj,~ liIIlhycli::anliolJorllflliolJlim"

Gcnlilion,hano::lolil,;byaplitlllmof fro,uontllOrryan;iflliolJlIIllut .... raI dlfferent.."n_,dIOil""" dlnbty

U"'""hanth.;<>::UIIOntJilionotlita, ~i'miWl .. drylllDJl .. raulIlW_ macullrdegl!l'Ol!lljon

Doo::roIIo';litJJ~iWilJ ... conIniI"liGi'" 1",;u'tollllinglilifl","';di1i'~ly

U .. llhentl1ed'''"nmmtlonlnd,,,,", ,hrm'glau"'IIIII,'h"cllegflllmlo,or 'fIII1l11il·illlu"m .. NCTE:DONOTUSl

:~"!e,~:~r3~:· ..... 'riy 'Gj ......... ,

Ch"'I'ln","",eln~cul ... pre"lJ"e ,,""~ng_ ....... damOile,leadll'4lto "liGualinjlliirmontdilllJ1'","ilyton<me!ryll1d1a"."ITth...,,,,,pI,emm

ofeyelrrftmjon,lnjeOljon,dl!llJ'o ..... nl- 08I~,",d/a"by5ml.....ntelt

Utllld"hanth.d<>::UllOntJilionmi,lIta,b, lvryc:oJdi",...,dilooduoIDHlN

nijJ1hyportonoivor-tdi ,hypor1&ntivo indwingtD'diomogoly,OII"iIfrlolBlll',

hl!lltd"""eorlurtdl ""ndll'jto tD'dtwu:lJlord~e .. ellllt!1outCIF,

hlllertenoion

lIiB "d. I. u"dlllhenth.dooIJmenmloo inli""",,thotth.pIItionth .. Ill1hStBgoV GKDliIld,-","t:ion.NOTE:GOOoointho 4ll3X" .... .,.'"' •• '''jljontotl1erLIe thlitth'~mu.td"umant.,",,~ _m:I'i~_tIIoli .... "

Hyportonoivo~li1"dil .... 'IIIIt!1'hrooi' ~dnoyd"'"liII',tJJm,,"'umillJn. ;rotIt1u"',hellllltll1o,,,omerLIone~"~', olI1OO1101 ,reoll'lne orrmollDllure, mora::i:oril,dbyGFA<15 • .-jing dilllyii,oc1nl1'1lllillmloo

U,,""andooulllll1lB1ioninli"""""r<I1If)" othe""d"",,~ororterlomn~.If,IDJIlJ

h ...... mtedthattl1.patB1th .. bothn_ IiIldroo-n.I .... ' .... --butyouh."'not inIiOll1OOlIIhic:htyp'of .... 'li.liff8::tooj. ~Y<Ud"um_ln_on~'CAIl" tI1enth.",rreotd"lln",I.I.4'4ll'

Mh,,,,,,I'''''i,ofcml1oryBrtorioo de_by .... It1ve.treo.teltor .... ~1I! tD'd1Bo,oth1lo1ttaJt.jEIIt:attJ1of

lIIhothorn_orgrart .. , iliIMJivOO

in.pIItiontllithirlltt '

Utllld"hand<>::UllOntJilion_,.1riIIIfiirl- RlijidiTo!JJlorh_litdillllno .. dby

1.loo,lloouroto"'od<>::UII,ntlilld",d. EIIIIIIII,EGGocrl1Jllmmoniter

:~B~or,"rrentu"ofll1tt:cBGulll1t

U ... "hentl1.d ...... ntJilionml''''''. llI!e .. e.ndkr~rdooofSAnod.

'hrai,.illJ'II1idJCllf"diB,.im-ll1Ii~ISA) 1,IiJji1ilDnon-Oin"'rflthm,briidyt>l"iII

lndycarIi.jllithocllllt!1out_1IIIII dilllJ10tllldbyEGGorlhlthmnmiIDr

=lojNOTE:Aillte.i1U.lI1idyrJrdl.

U ... "hentl1.d ...... ntJilionml''''''. N .... IIlJ.rhythmd"ll""edbyECG ...

'""iB::..mythmi .. c:oJdi"''''rflthmill,i~- rhythmmonnalo~rhythm,nod"rI1JIImdlme~oItermtlng

jIJB.,blg .... ny,llIGemln .. rI1JIIm,t!llJ!IIlln~ trigomin~rhythm,jIJ~"oIterI1ll1',.-.nOO-

~rflthm,o:;qi'rI1JIIm,"'08I'rIItOO .... rt

rhythm,,," .... okerrhythm,II1idJl3'dI.,,

mdTjcordl"-wtmomore",,,m,t¥Peof

onhythnill.i'linOllll'1jo,g.,Iitri"filnllotiln

::~~'::::;::=~e~~:::

""dooded~;r1ateIy

U ... "hentl1.d ...... ntJilionml''''''. 'liIlIIidlltan"i',mmoilofOllf1l!idirtll'j =o~:'I=d"'I"ion

StenodBor"",lu.lonof,orntkjlltery lIIIt!1outGI'II.""pImE,dillllmtllld<*1i O8I~lI1dlDrbyim~ni.wd;"

ltiG"doi.",dlllh,ntholi>::lJmon1aloo Ind"",,"CVAorllmke

DowI'pmontofbtxld~otinth'''''briI

""" "'th briln~'!lJedomOJll!leadlng

motnr, ory,ondmr"'eerf1defl'it,

=,~tlIld~ini::lllylinlViJrbyimIillO

N<I'OjIGCiIi:: .... tonthoni_i.fi1Jm CllAdllV'olll!ddlnbty

OIlS!JtRBIKlNG loa -~

Utllldllhonthod<>::UllOntJilionmi,lito, CllIooi,lnr<:I1iti,IIIth""",,"ing

_iilionof,hrooi,bronc:tili,orbluo <XlJih,"1Ortn .. ,of_orh!llOllill

_lIIthorure""""rIlmIon iIlOO<BOl,d"lln .. edd~I'oI~

Ulll!dllhend ...... ntJilionlml''''''.8Rth1llll R""""I~ereoctlve'*WllYd!""'e"'ult-

Iindttoroi,mindi::atil1ofll1""",rbltim. ingfnmll1~IOIlli'''octiontofIJroign tJJb,tlllllDlSU,h"¥iIU.!don.oto. dllV'olll!ddlnbtyondiorbyPFT "'OIIo1ngolllltllJotIvelEttem(FEV11FVC dll%)lI1d ........ ~iIy

ltiG"doi.",dlllh,nthooowmon1aloo inli."."""piitlJryflilu",lIJmonory fIlIllJ'e,orlDJle"",*"",rylDllure

AIlJIopulnmoryflilu .... d_1lJ ...... ~.(p[l2<OO)orhyp'''opri.

~:,~~.':~~:~~ent

ltiG"doi.",dlllh,ntholi>::lJmontodtyp' Lul1ldi ..... i1~udi1iluI1lClll<ili"'"on.

~~:u:t~~:n."'"'.!~iiIi~~ IIJm,lrtnilloi'.'to

flJlI",*,g:lme"jCfJl"iltung,irmrf1lol"'I., pWJ'lithillo;;.c:aldfi::alooof~ni,oclung d;;, .. ,lIIthnofurttorEllll*niilion,Whon 1D~~e,thelYl"oftungdl"""le_g_, emlt¥lemo,ohrml'Inr<:I1~~.houtobe do::ulllllllodlindc:odoo.

_""of.toma::hfUdl,liJji1iio oddl'mote~themouth,,,,,lgam1' _nol..,dllV'olll!ddlnbty IinlViJrbyEW

B_ofolDm",hnutoto .. ,phIg" leliJj~gtooddl'motelnthermuth, eplgoBtrt:aIljomll'lllllllind"lln .. ed ~ini::lllylinlViJrbyEW N<I1lI"di1iinflllnmiilionof_oc

duooonumlililln""d'Ii'i'~IYll1d1a'llJ

:~:::::i;';;;;;;';;,"i';;;;;~ "~,,"-,, ...

Utllldllhond<>::UllOntJilion_,dioor- Non-ilIEllllillc:ornlilorlw"i,dilillnotlGd

by",*",~orolhorimlill'sllJdi ..

U .. llhond,oulllllllBtion_"n""iilion N<I'OjlGCili::c:onotipotil1.dtogn",dby

hlotory

U .. ""an;"ulllllllB1ioninli"""n""hritiG .oJoocOOollllYdlJmiI1JM.,prctaiI1JM.

orn""h~dLl!to..,und_gdl.,",e renalp"liloryneorn.I',gl<m!l1Jlo-

(e.G_, dl_ orSlEl_ll1e.mmentmjon ne~rn_,"'nolllllli ",,;tjn~e or

mu.tin;i::Bt&thlltth."""hritiGor"""h~.- ibram~GFR(soo"'"",,l1Jmbal»

thyi;tlGCOO;oryto..,oth"Ii ..... ' .. IGO--li

::, .. ~~~=.~~!=~n:.!:e

thi.t:lwld....,.b' •• o::cndllrycooo

EnIifyOlllllltofjlllJ_llritlwtoomuotivo .... (UMn...,notontion,dMlIIlingoc h"Imn"YI,d"lln",ed'I~'oI~

I'aInl ... lmlgn.~n_-IIeGrnWlh ;illlJ1'tlOd~ini::Blyorby~'""

UI"ralooof __ EIIOronity,diliQ,"",oo ~Inbty

GENORALOSTEONITHROOIS

_1","OAln"'l¥i1gmlJtl~ej_ ;illlJ1'tlOd~ini::BlyorbyimliQ.otu;;"

OAiMJllini __ EIIOronity,diliQmtlOd ~ini::Bly

,~.'"

N<JHjEIIIoQA""''''cten","llyj'*'l: ;U1"'d_.,dlllgn",ed'II"08I~ orbyl-rayfi1;il1l'(nlllllJllli,int.jIIiO'. Ilm,.jIUll,otI:) N<JHjlGCili::Pltp~niMJl~ni __ extrI!IrIt!r,dl"lJ'o"'oIInIOlliIy

'''~ .. ""

..ant;i",mflJrtinwl¥i1it:l1ouklor. ;illlJ1'tlOd~ini::Bly

UtlOdllhan;<>::UIIOntmjon_"OIIIIIIIii. h"poln,"'I"I~,poln

..ant;i",mflJrtinwl¥i1ijllllii'''''· dllV'o"'~lnbty

TIiB "del. u"dlllhenthedooumenmioo Ind""",thatthejllltml:h .. kn .. ""ln pIItotlfolmral'll'llt,m',ocplltoll_ ~.

lnIIlerertremlty .... nIn."l¥i1gtheknee jolnt,dl"lJ'o"'oIInIOlliIy

..ant;i",mflJrt/plininwl¥i1ilillklll dllV'o"'~lnbty

lLIIIIlA..UM OO~~ DEGeN

OAmllini~mbirlll11/a"'.I;rIll ...... dllV'o"'dlnbty

tI1e "mjml.lon oftl1e ",Inlll",,...,d ",1W'I'iidil1lrop~nlilldIDrlill1'rmaI IlII1Ii11i11.dillgno"d'liri::lll~lII11IIJrlly ImlJlll!lIiJJieJJ

U ... "hentl1ed......,ntIlJjonftjl''''''' ..... lIngln.llmb.lndwlngdglto

5lll!llIngln.llmbMud~gdlGlIlI dllV'o"'dlnbty

N jEllt:lB:re ... ~bonema" ...

d, ity.dillgno"d'lini::lll~""'DEXA

ll::III1 ... otI1"illllll,·tud"

ltiJ;oodoi.u"dlllh,ntholi>::lJmontaloo Doo::rooo,inlm,m ... "dilnJilfduo Ind"""'om"I.""'I.,"nlle_olD"'~" tnold!lJl.dIIgn",ed'II"""I~IlyDEXA

;nt-menolDJoaI"'teojD'lld! ,.,..,..,d/a'lm!lJl.lliJdl ..

U ... "hentl1.d......,ntIlJjonftjl''''''. N .... jEllt:liII1orrnltljrln."..,g"''''

1mo1oiU1."IooIJlj::I .. ion.bonom .. , IiIldClirtloi'.dlilln""ddi1i'~ly

'~i,p~n.o""dyniB.'~i .. 1me""ln.OIItII!lJl.,,,*,,~~.poln.lIP1old

",*"",""ullllGl .. Ilji1<llynIo.q,holdlllgla"

Imo....,i"·

NOO-OjlGCili::c:hIll1l'inmonlllloretu,. indwingd'liriJm._' ... ."..... ",",,,"'_.Io,"of,,,,dou,,,e .. ............. mlrnnlldou",e .. " 1DII1,I,rco

ltiJ;oodoi.u"dlllh,nthoool1Jmontaloo indoa1&,i'o<lll1i .. ,I",*",""'.Birypri!l. d~rqltjonln.le",,~~otjon ... molnten..,"" "hYl'l"mnla

Inlilility ... diffiouityflillniliSl"p ... romlli1ing .. l"",

U ... "hend......,ntIlJjonlml''''''.lIIIIIoI .. fliliiUO.iiSIhoni ..... ..,"ni::Epotoi1l111fT,

SympttmBofmolol"ondfol(JJe, dilV',llJlddini::Bly

N .... jlGCili::gon'rlII~',dililln",d,lini::Bly

U"'"hentl1 • .mmentllJjonftjl,""" ==U~htl''','''lIOiihtl''''of

lo~ngm ... thlln'O%oftheulll.llll ""iihtO¥llr~-ti mooth',dililln,1lJld dini::Bly

lIiB "d. I. u"dlllhenth.ootlJmenmloo ...... '-""II1Io,hYI., .. 'ln!lotjon,l'n!IJJlor _ing ... l.lllllldbrootti1i~"dyo"",· onllllOltion,,,,,,irBl<lJd_'lI1dro'~1lItnryl"umden~

N .... jEllt:pJlmonll'joyrrclttm!lrdJd Ing.h<ltne .. of_,i1ypCMlntlmlon dyoll1,.oo_o,llypimIlI1i11,olo

N<I'OlI'Cifi:;ocmn,ordio::c:h..tpairi dl"omfnrt,d"lln .. edd~I'oIly N""IEfIIo ... mn,ordlBoc:heot dl"omfn~ot!1erth..,..,g~o,dlBGnooed

,,~,"" .. '"

U ... "henthelinmentmjonftjl,,,,,,.the lI""rcooflxltlHw ... ..,dYOOilini,Fa" n ....... VIIowmiting."'7117D2,fa"wmitInglllonouoe.do,,"_,LOe7B70l

SymptmlBofnouoe.ond\lJll~ng dilllJ1'tlOO~ini::llly

lti'e:od ..... utlOOlllhonth.li>::lJmon1i~onlml''''''.dormeo,"'utedllrTh ... oururmdlorr11eo,blll .... dllrTh ... ,~ ...... dilfTh"',c:a1lITh .. diorm, .. c:h<*ni,

dllrTh ... ,""rnnledorrheo,dllrTh ... g ..... g""",dllll11"',lnfmTtjledormeo,llentI!r1, dilfTh"',nonilf&oIDJ,dorrho"lI"'un,d n<rinfooli,,,.dilfTh"',jlJtrofB::Ii .. diorm, .. .....,dorydllll11 ... ,.ID!ldI'dllrTh ... IIIJmmerdormeo,lI'jI'T1ptm111t1,dormeo,or th,mi,dorm, ..

SymptmlBofdlorr11e·tfrequentotnol· >ldllllyl,dl"llrcoedd~I'oIl~AI'" dilllJ1'tlOObIis,donolool'_"'" ,..,

ltiG"d.i,u"dlllh,nth.li>::lJmon1iloo Un",,,m'db;'ofe:on~ofui'"

only_thlitth,piilionth .. uri1oryin"n- dilllJ1'tlOO~ini::llly ~n""""lIIthout.mll'1ltheetlology ... type

U ... "hend ...... ntmjonlltDta.oIljomln .. .,..,d.quadmntl.not"",rflled

Noo-olEflloalljomll'llllpoln,dl"llm'" dlnbty

lIiB "d. I. uoedlllhenth.li>::lJmenmloo ind ...... thlltth.pIItionth .. ..,iioslli, _in"""n.

Eplgootrl,polnMI.....rM,dlBGnooed ~ini::llly

ltiG"d.i,u"dlllh,nth.li>::lJmon1iloo Indmteogenemll>ed_ln ...... n

_ilOd.IJj",*,~poil/Di;"mfiJrt dllllJ1o ... dlnbty

lIiB "d. I. uoedlllhenth.li>::lJmenmloo d .. tJ1beo_ln .. ""lnln.., ..... ofthe _onth.td' .. noth .... 'II"ifi::"d' ltiGiltiJd"d,o:;rijiivotorm,,",h ..

_Inalglo, ... .",.'

lIiBr ~-~d Bl!'IIltedl'SAlevel,dlllgn .. ed"'edoo

Al>j ..... nol;Hlld~"'mfn~,dl"llm ... dlnbty

lIiBood.l.onlyu ... ""enth.d ..... entationimi,iiIil,thltthoEIIGi,"",rm .. t1Jt ~=drooftho .. m'rIlllllilJi,un"'OIII1oc

='~~~~=~~~':d~':!

tI1ed"""_onlml,,,,,,.tI1attl1.patmt tIIffllradlilli1julYintl1oi"h,mo

ltE"doi.u"dlllh,ntl1ooowmontaloo U","IDi1dic:m:etl1'''iIJ"ofll1injulY

inlic:m:e,thllttl1oplltiontfol.";tlwtfuth"

Infmn;tj'n.lhe"""eoed"maBXh .. "'1Y

·1"rfII'''''"'' ... foIB.b .... onh'''''

~.:=.~~:.::.:==

m'rellAl~""'''de"''oulObe''I'''""

'l.'t;ClNFOR INFUDIlA

lIiB"d.l.uoedlllhenth.ootlJmentaloo Admlrl_onofpneum""""_

Ind_.th.patmtre" ..... trI!Il=J! ~n.loo IIfWmonioo[p1oum""""""I¥liO~",

lIiB "d. I. uoedlllhenth.ootlJmentalonimi,ata,thlttholB1i,nthiShad "Ion OIiIlcorll1d hiSCDqllatadtrolltmont ~IIllIOlllIy.redllltm,'hell"<lth!m!rl<rony "m'*';tjonlllhentl1 ... ~noM'.loo

:'~=~n~~:::~d='"

IIIJrvelll.....,ARE"noldereO' .... d .. ond ""oulObedooumenll!OlI1d"ded ... hl. IDlYof""mOll1wr.

ltE"doi.u"dlllh,ntholil::lJmontaloo HioioryoflroastOlillca;noactivo

inli ...... thlltthoplltionthiShlldlnlEt dilllJ1''''"iII'timr,

,on"romh .. ",rqlIetedtre.tment ~IIllIOlllIy.redllltm,'hell"<lth!m!rl<rony

"mbi1ii1i'rOllhonth ... ilnoi1di,iilioo thlltth,roiltumorotillp-otlllltl'llti,ntIl umerg,*,gl'I'1l-tl!lmad)Nonttl1l!1ql'1

""ouldNOTbedooumenll!O .... hlotolYof _t'IiIl,,,·liIld.h,lldba,,d,d .. 1iIl

=~::===~:::e~:r-

..... lon"'NlE ..... lOered .. oureO .. .mllhould ::!.";':',~dlilldcOOodiS.tiGtDlYof

U",""honyoornofaimi,ata,thlltthom, oftl1eeyeh .. lleen,"~"",d

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V7231 ROUTINE GYN Used only when the documentation indicates Performance of routine gynecological
EXAMINATION that the patient presented for a routine gyne- exam
cological examination. This code is not to be
used for patients with a known gynecological
condition.
V7281 PREOP This code is used when the documentation Performance of pre-operative cardiovas-
CARDIOVSCLR indicates that the examination is for cardio- cular evaluation
EXAM vascular clearance preoperatively.
V7283 OTH SPCF This code is used to indicate a specified Performance of specific preoperative
PREOP EXAM pre-operative examination that does not have examination
a more specific code, e.g. renal function
studies in a patient with kidney disease,
before undergoing surgery.
V7284 PREOP EXAM Use only when your documentation indicates Performance of H & P prior to surgical
UNSPCF you are doing a history and physical examina- procedure
tion for a patient having a surgical procedure
V7612 SCREEN MAM- Used by the screening mammography center Performance of mammogram for breast
MOGRAM NEC or interpreting radiologist when the patient is cancer screening
seen for a screening mammogram.
V7651 SCREEN MALIG Use this code when the patient has no symp- Performance of colon cancer screening,
NEOP-COLON toms and you are performing a colonoscopy including colonoscopy, checking stool for
or stool for occult blood. occult blood, or barrium enema. »

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Variable Community Factors Institutional Factors
Age/Sex Factors
Female 0-34 Years 0.223 1.240
Female 35-44 Years 0.224 0.879
Female 45-54 Years 0.304 0.879
Female 55-59 Years 0.370 0.879
Female 60-64 Years 0.422 0.879
Female 65-69 Years 0.298 0.945
Female 70-74 Years 0.371 0.885
Female 75-79 Years 0.468 0.822
Female 80-84 Years 0.546 0.757
Female 85-89 Years 0.637 0.694
Female 90-94 Years 0.788 0.617
Female 95+ Years 0.783 0.482
Male 0-34 Years 0.107 1.059
Male 35-44 Years 0.167 0.822
Male 45-54 Years 0.197 0.842
Male 55-59 Years 0.297 0.916
Male 60-64 Years 0.401 0.970
Male 65-69 Years 0.330 1.140
Male 70-74 Years 0.416 1.093
Male 75-79 Years 0.520 1.093
Male 80-84 Years 0.617 1.056 variable Community Factors InstitllliDnalFactors
Male 85-89 Years 0,744 1.033
Male 90-94 Years 0,830 0.895
Male 95+ Years 0,960 0.775
Medicaid & Originally Disabled Interactions willi Age & Sex
Medicaid Female, Disabled 0,137 0.077
Medicaid Female, Aged 0,1n 0.077
MedicaidMale,DiS8.~ed 0,090 0.077
Medicaid Male, Aged 0,202 0.077
Originally-Disabled Female 0,232 0.Q19
Originally-Disabled Male 0,181 0.Q19
Disease Group Factors
~ HCC1 HIVIAIDS 0,933 0.735
HCC2 Septicemia/SlIlck 0,8n 0.762
~ HCC5 Op~rtunisticlnfections 0,410 0.476
HCC7 Metastatic Cancer and Acute Leukemia 1,648 0.568
" HCC8 Lung, Upper Digestive Tract, and Other Severe Cancers 1,648 0.568
0
~ HCC9 Lymphlrtic, HeadandNeck,Brain, am Other Major Cancers 0,771 0.402
HCC10 Breast,ProstHte,ColorectaiandOtherCancersandTumors 0,258 0.241
~ HCC15 DiatllteswithRenai or Peripheral CircullrtoryManifestation 0,608 0.466
HCC16 Diatllteswith Neurologic or Other Specified ManifeslHtion 0,452 0.466
HCC17 DiatllteswithAcuteCompliCHtions 0,364 0.466
g HCC18 Diatllteswith Ophthalmologic or Unspecified Manifestation 0,265 0.466
HCC19 DiatllteswithoutComplication 0,181 0.257
~ HCC21 Protein-Calorie Malnutrition 0,820 0.395 > variable Commun!!}'Factors InstitllliDnalFactors
~ HCC25 End-Stage Liver Disease 0,996 0.768
~ HCC26 Cirrhosis of Liver 0,519 0.363
HCC27 Chronic Hepatitis 0,303 0.363
" HCC31 IntestinalObstruction/Penoration 0,347 0.349
> HCC32 Pancreatic Disease 0,383 0.277
~ HCC33 Inflammatory Bowel Disease 0,270 0.263
~ HCC37 BDneJJoint1MusclelnfectionsINecrosis 0,550 0.482
HCC38 Rheumlrtoid Arthritis and Inflammlrtory Connective Disease TIssue 0,363 0.233
HCC44 Severe Hematological Disorders 1,136 0.477
HCC45 Disorders of Immunity 0,841 0.443
n HCC51 Drug!AlcohoIP&yChosis 0,250 0.000
~ HCC52 Drug!'AlcoholDepemence 0,250 0.000
I HCC54 Schizophrenia 0,515 0.347
n
n HCC55 MaiorDepressive,Bi~lar,andParanoidDisorders 0,370 0.308
f HCC67 auadri~egialOtherExtensiveParalYSis 0,961 0.337
HCC68 Paraplegia 0,961 0.291
HCC69 Spinal Cord Disordersllnjuries 0,511 0.152
HCC70 Muscular Dystrophy 0,468 0.000
HCC71 Polyneuropathy 0,324 0.253
HCC72 Multiple Sclerosis 0,472 0.174
HCC73 Parkinson's am Huntington's Diseases 0,547 0.089
HCC74 Seizure Disorders am Convulsions 0,280 0.165
HCC75 Coma, Brain Com~ssion/Anoxic Damage 0,448 0.000
HCCn Res~rlrtorDepemenceITracheostomyStatus 1,860 1.360 variable CommunityFactlIrs InstitllliDnalFactlIrs
HCG79 Cardio-Respiratory Failure and Shock 0.629 0.464
HCCBO Congestive Heart Failure 0.395 0.231
HCCB1 AcuteMyocardiallnfarc'tion 0.349 0.474
HCCB2 Unstable ArY;jina and OtherAcute Ischemic Heart Disease 0.332 0.474
HCCB3 AnginaPectorislOld Myocardial Infarction 0.231 0.296
HCC92 Specified HeartArrtr{thmias 0.295 0.198
HCC95 Cerebral Hemorrhage 0.366 0.175
HCC96 Ischemic or Unspecified Stroke 0.303 0.175
HCC100 Hemiplegia/Hemiparesis 0.410 0.065
HCC101 Cerebral Palsy and DtherParalytic Syndromes 0.212 0.000
HCC104 VascularOiseasewithCompliclrtions 0.645 0.495
~ HCC105 VascularOisease 0.324 0.164
HCC107 Cystic Rbrosis 0.398 0.327
~ HCC108 ChronicObstlllctivePulmonaryOisease 0.398 0.327
HCC111 Aspiration and Specified Bacterial Pneumonias 0.761 0.644
" HCC112 Pneumococcal Pneumonia, Emphysema, wl"lJAbscess 0.233 0.188
0
~ HCC119 Proliferlllive Diabetic Retinoplrthy and Vitreous Hemorrhage 0.278 0.527
HCC130 OialysisSlHtus 1.432 2.211
~ HCC131 Renal Failure 0.389 0.411
HCC132 Nephritis 0.182 0.290
HCC148 Deanns Ulcer of Skin 1.167 0.474
g HCC149 Chronic Ulcer of Skin, ExceptOecubitus 0.463 0.239
HCC150 ExtensiveThird-DegreeBurns 0.818 0.000
~ HCC154 Severe Head Injury 0.446 0.000 > variable Commun!!}'FactlIrs InstitllliDnalFactlIrs
~ HCC155 Major Head Injury 0.182 0.000
~ HCC157 Vertebral Fractures without Spinal Cord Injury 0.501 0.109
HCC158 Hip FractureiOisloclrtion 0.450 0.000
" HCC161 TraumaticAm~ion 0.736 0.224
> HCC164 Major Compliclrtionsof Medical Care and Trauma 0.299 0.219
~ HCC174 Major 0lJlanTransplant Status 1.073 0.449
~ HCC176 Artificial Openings for Feeding or Elimination 0.758 0.843
HCC177 Amputation Status, Lower LimtYAm~ion Complications 0,653 0.224
DisablediDiseaselnteractions
DHCC5 Oisabled"Op~rtunisticlnfections 0,941 0.280
n o HCC44 Disabled"SevereHematologicalDisorders 0,551 0.419
~ DHCC51 Oisabled·Dru!l!'AlcoholPsychosis 0.801 0.425
I DHCC52 Oisabled·Dru!l!'AlcoholDependence 0.358 0.425
n
n DHCC107 Oisabled·CysticFibrosis 1.391 0.000
f Diseaselnieraciions
INT1 OM"CHF 0.204 0.088
1N12 OM"CVD 0.149 0.026
INTI CHF*COPO 0.216 0.194
INT4 COPO·CVO·CAD 0.174 0.042
IN" RF*CHF 0.246 0.000
INT6 RF*CHF*OM 0.664 0.203 15
16
17
18
~ 25
26
~ 51
54
" 67
0 6B
~ 69
n
~ 7B
81
82
g 95
100
~ 104 Hierarchical Condition Category (HCC) II the Disease Group is Listed in This Column ...

...Then Drnp 1I1e Associlrted Disease

APPENDIX 2. LIST OF HIERARCHIES FOR THE CMS·HCC MODEL

DISEASE HIERARCHIES

Disease Group Label

Group(S) Listed in This Column

O~ortunisticlnfections

112

Metastatic Cancer and Acute teuema

8,9,10

llIng, Upper Digestive Tract, and DtherSevere Cancers

9,10

Lymphalic, Head and Neck,BrainandOtherMajorCancers

10

Diabetes with Renal ManifestHtions or Peripheral Circulatory Manifestation

16,17,18,19

Diabeleswilh Neurologic or Other Specified Manifestalion

17,18,19

DiabeteswithAcuteCompliclllions

18,19

Diabetes with Ophthalmologic or Unspecified ManifestHtions

19

End-SlageUverDisease

26,27

Cirrhosis of Liver

27

Drug!AlcoholPsychosis

52

Schizophrenia

55

QuadriplegialOtherExtensiveParalysis

68,69,100,101,157

Paraplegia

69,100,101,157

Spinal Cord Disordersllnjuries

157

Respirator DependenceiTracheostomySIHtu5

78,79

RespiratoryArrest

79

AcuteMyocardiallnlarction

82,83

Unstable Angina and OtherAcute Ischemic Heart Disease

83

CerebralHemorrh e

96

Hemiplegia/Hemiparesis

101

VascularDiseasewithCom~ications

105,149

n

~

I

n n

f

111

As~r8l:ionandSpeciliedBacterialPneumonias

112

Hierarchical Condition Category (HCC) If the Disease Group is Listed in This Column ...

. .. Then Drop tile Associated Disease

Group(s) Listed in This Column

107 Cystic Fibrosis

108

130

Dialysis Status

131,132

131

Renal Failure

132

148

Decubitus Ulcer 01 Skin

149

154

SevereHeadln'ury

75,155

161

Traumatic Arnputalion

vrr

How Payments are Made with a Disease Hierarchy EXAMPLE: II a beneficiary triggers HCCs 148 (Decu~tus Ulcer of the Skin) and 149 (Chronic Ulcer of Skin, Except Decubitus), then HCC 149 will be dropped. In other words, payment will always 00 associated with the HCC in column 1 if a HCC in column 3 also occurs during the same collection period, Therefore, the MA organization's payment will be based on HCC 148 rather than HCC 149

APPENDIX 3. APPROVED PHYSICIAN SPECIALTIES FOR RISK ADJUSTMENT
CO"' SPECIAllY CODE SPECIALTY CO"' SPECIALTY
01 General Practice 29 Pulmonary Disease 72 Pain Management
02 General Surgery 33· Thoracic Surgery 76 Peripheral Vascular Disease
03 ~Iergy/lmmunology 34 Urology 77 Vascular Surgery
0' Otolaryngology 35 Chiropractic 78 Cardiac Surgery
05 Anesthesiology 36 Nuclear Medicine 79 Addiction Medicine
06 Cardiology 37 PedialricMedicine SO ucensec Clinical SocialWofiwf
07 Dermatology 38 Geriatric Medicine B1 Critical Care (Intensivists)
08 Family Practice 39 Nephrology B2 Hematology
09 InterventionalPainManagement '0 Hand Surgery B3 Hematology/Oncology
10· Gastroenterology " Optometry (specifically means optometrisQ B4 Preventive Medicine
~ 11 IntemalMedicine 42 Certified Nurse (Midwife) B5 Maxillofacial Surgery
12 OstoopathicManipulaliveTherapy 43 Certified Regislered NurseAneslhetist B6 Neuro~hiatry
~ 13 Neurology 44 Infectious Disease ". Certified Glinical Nurse Specialist
" Neurwurgery ". Endocrinology 90 Medical Oncology
". Obstetrics/Gynecologv 48· Pooiatry 91 Surgical Oncology
" 18 Ophthalmology 50· NursePractilioner 92 Radiation Oncology
0
~ 19 Oral Surgery (Dentists only) 62· Psycoologist 93 EmergercyMedicine
20 Orthopedic Surgery 64 Audiologist 94 InterventionalRadiologySurgery
~ ". Pathology 65 Physical Therapist 97" Physician Assistant
24 Plastic and and Reconstructive Surgery 66 Rheumatology 98 GynecologisVOncologist
25 Physical Medicine and Rehabilitalion 67 Occupational Therapist 99 UnkrKlwn Physician Specialty
26 Psychiatry 6B GlinicalPsychologist
g 28· ColoreclalSurgery 70- Mullispeciatty Clinic or Group Practce "Indicatesthatanumoorhasooenskipped.
~ Qualified physician data for riskadjustmenl requires a face-to-face visit with t heexceplion of pathology services (professional component only) n i
~
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ni
"I dl. DECllITER

OM DIABETES MELlITUS

DVRTCLO. DVI.

DIVERTICULOSIS DEEP VENOUS THROMBOSIS

ECG ELECTROCARDIOGRAM

EF. EFF ...

EJECTION FRACTION ..... EFFECTS

EGD ESOPHAGOGASTRODUODENOSCOPY

EKG ELECTROCARDIOGRAM

EMG ... ESR.

........ ELECTROMYOGRAM

· .... ERYTHROCYTE SEDIMENTATION RATE

ESRD END-STAGE RENAL DISEASE

FVC .FORCED VITAL CAPACITY

GERD ..

· ... GASTROESOPHAGEAL REFLUX DISEASE

GFR GLOMERUlAR FILTRATION RATE

GFT. GRAFT

H&P ... H/O.

HISTORY AND PHYSICAL .. HISTORYOF

HEMORR OR HMRRHG HEMORRAGE

HF HEART FAILURE

Hgb ...

· HEMOGLOBIN

HIV HUNoAN WMUNODEFICIENCYVIRUS

HRT OR HT. HEART

HTN ... HX.

..... HUNoAN WMUNODEFICIENCYVIRUS . . . . . HISTORY

HYP HYPERTENSIVE

IDIO IDIOPATHIC

INFRCfn. INT ...

.. INFARCTION ..... INTERNAL

IVP INTRAVENOUS PYELOGRAM

KG .

KID .

... KILOGRAM ...... KIDNEY

KUB KIDNEYS, URETERS, BlADDER

................................................................................................................... ~~

LE ...

· LOWER EXTREMITY

PAGE 146 I

ACCURACY IN DOCUMENTATION AND CODING:

LG lARGE

LN LYMPH NODE

LOC.

. LOCALIZED

LUTS. . LOWER URINARY TRACT SYMPTOMS

NoA MICROALBUMIN

MAL MCP .

.............................. NoALIGNANT

· . . . . . . . .... . . . . . .. . .METACARPOPHAlANGEAL

MCV MEAN CELL VOLUME

MG MILLIGRAM

MI ...

.. MYOCARDIAL INFARCTION

ML... . MILLILITER

MRA NoAGNETIC RESONANCE ANGIOGRAPHY

NCS NERVE CONDUCTION STUDIES

NEC.

... NOT ELSEWHERE ClASSIFIED

NED NEDPlA,S,o\A

NEURO NEUROLOGICAL

NOS .

OCD .

· NOT OTHERWISE SPECIFIED

· OBSESSIVE-COMPULSIVE DISORDER

PFT PUlMONARY FUNCTION TESTS

PVC PRENoATURE VENTRICUlAR CONTRACTION

PVD... . PERIPHERAL VASCUlAR DISEASE

RA RHEUNoATOID ARTHRITIS

RBC RED BLOOD CELL

SA ... SLE .

· . . . . . . . . . . . . . .. . SINOATRIAL

· SYSTEMIC LUPUS ERYTHEMATOSUS

SOAP SUBJECTIVE, OBJECTIVE, ASSESSMENT PlAN

SOB SHORTNESS OF BREATH

5 x. TIA.

. SYMPTOMS

· TRANSIENT ISCHEMIC ATIACK

TIBC TOTAL IRON BINDING CAPACITY

TSH. UA.

· THYROID-STMUlATING HORMONE

· URINALYSIS

URI UPPER RESPIRATORY INFECTION

US ULTRASOUND

A GUIDE TO RISK ADJUSTMENT AND THE CMS-HCC MODEL

I PAGE 147

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