Resources
- Acute Conditions at Ambulatory Visits CVA
- Acute Conditions in Ambulatory Setting DVT
- Acute Conditions in Ambulatory Setting Ischemic Stroke
- Acute Conditions at Ambulatory Visits MI
- Acute Conditions in Ambulatory Setting PE
- Aortic Atherosclerosis
- Aortic Dilation
- Cancer and Neoplasms
- Cerebral Atrophy
- Coronary Artery Disease with Stable Angina
- Dementia
- Diabetes Mellitus with Hyperglycemia
- Diabetes Mellitus with Nephropathy
- Major Depressive Disorder
- Peripheral Vascular Disease
- Protein Calorie Malnutrition
- Secondary Hyperparathyroidism of Renal Origin
- Severe Obesity
Additional Resources
Diagnosis Overview
Atrial fibrillation (AFib) isa common, often chronic arrhythmia characterized by rapid, chaotic electrical signals causing the heart's upper chambers (atria) to quiver instead of beating effectively. It causes an irregular rhythm due to disorganized atrial activity, often leading to palpitations, fatigue, dizziness, and shortness of breath, though some patients have no symptoms. While not immediately life-threatening, untreated AFib significantly increases risks of stroke, blood clots, and heart failure.
Risk Factors
- Coronary heart disease
- Hypertension
- Heart Failure
- Left Ventricular diastolic dysfunction
- Diabetes
- Hyperthyroidism
- Obesity
- Valvular heart disease
- COPD
- OSA
- Left ventricular hypertrophy
- CKD
- Subclinical atherosclerosis
Diagnosis Types and Classes
| Atrial Fibrillation Examples | Duration |
| Paroxysmal I48.0 | Self-terminating spontaneously or with intervention, within 7 days of onset; may recur with variable frequency. |
| Persistent I48.9 | Fails to self-terminate within 7 days and may require intervention (pharmacologic or electrical cardioversion) to restore sinus rhythm. |
| Long-standing persistent I48.11 | Atrial fibrillation that has lasted for more than 12 months. |
| Permanent I48.21 | Persistent atrial fibrillation for which a joint decision by the patient and clinician has been made to no longer pursue a rhythm control strategy. |
| Unspecified I48.91 | No documentation of timeline/specificity. |
Documentation Tips & Examples
- When documenting atrial fibrillation, it is important to include acuity, type, duration and underlying etiology.
- If “controlled” with meds, for example a patient on Sotalol may no longer be in a fib, however the diagnosis remains active and not history of.
Pearls
Anticoagulationshould be startedin patients with a CHA₂DS₂-VASc score of≥2 if male or ≥3 if female. If no anticoag is prescribed in eligible patient, assess contraindications or clinical rationale and document in your note.
Resources
Diagnosis Overview
Generalized anxiety disorder (GAD) is a type of anxiety disorder that is characterized by chronic excessive worry and stress about various domains (such as work and school performance) and is associated with clinically significant distress with functional and physical impairment(s).
The diagnosis of GAD is made clinically based on the Diagnostic and Statistical Manual of Mental Disorders, 5th edition text revision (DSM-5- TR) which includes the below criteria:
- Patient reports excessive anxiety and worry occurring more days than not for at least 6 months about various events or activities such as school or work performance.
- Patient reports difficultly in controlling worry.
- Patients report excessive anxiety and worry that are associated with 3 or more of the symptoms below with at least some of the symptoms occurring most days of the week for 6 months or greater.
- Restlessness or feeling "on edge"
- Fatigue
- Concentration difficulties
- Irritability
- Muscle tension
- Sleep disturbances (such as insomnia)
- These symptoms are not due to underlying medical condition or substance use.
- These symptoms are not better explained by an alternative mental disorder.
Diagnostic Screening Tools
The 7 item Generalized Anxiety Disorder Scale (GAD-7) is one of the most frequently used tools to screen for generalized anxiety disorder.
| Over the last 2 weeks, how often have you been bothered by any of the following problems? | Not at all | Several days | More than half the days | Nearly every day |
| Feeling nervous, anxious or on edge | 0 | 1 | 2 | 3 |
| Not being able to stop or control worrying | 0 | 1 | 2 | 3 |
| Worrying too much about different things | 0 | 1 | 2 | 3 |
| Trouble relaxing | 0 | 1 | 2 | 3 |
| Being so restless that It's hard to sit still | 0 | 1 | 2 | 3 |
| Becoming annoyed or irritable | 0 | 1 | 2 | 3 |
| Feeling afraid as If something awful might happen | 0 | 1 | 2 | 3 |
Total each column |
Q: How difficult have these problems made it for you to do your work, take care of things at home, or get along with other peope?
- Not difficult at all
- Somewhat difficult
- Very difficult
- Extremely difficult
This is calculated by assigning scores of 0, 1, 2, and 3 to the response categories, respectively, of "not at all," "several days," "more than half the days," and " nearly every day." G.AD-7 total score for the seven items ranges from 0 to 21.
- 0-4: minimal anxiety
- 5-9: mild anxiety
- 10-14: moderate anxiety
- 15- 21: severe anxiety
Documentation Example
Patient reports feeling worried, restless and irritable the past 8 months about family life and work performance. Patient also reports insomnia four or more nights of the week. Denies any substance use. Scored 16 on GAD-7 scale in office today. Will start patient on escitalopram at 10mg orally once a day. Referral to BH for counseling. Will follow up with1 patient in 3-4 weeks in office. Strict return precautions discussed for worsening or progression of symptoms.