The Virus (Biology)

•HIV belongs to the lentivirus group of the retrovirus family.

•Types

HIV-1

HIV-2 (exclusively in West Africa)

•HIV1 is a single strand of RNA enclosed in a protein envelope

•Viral replication is dependent upon a DNA polymerase(reverse transcriptase) which is responsible for copying the viral RNA into DNA

•Incorporation of DNA then takes place into the host cell genome(T-helper CD4 cell genome)

•Additional transcription of the DNA results in new viral particles that are extruded from the cell membranes

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Risk Factors/Mode of transmissions

•Sexual intercourse (homosexual vs Bisexual)

•Intravenous Drug Abusers

•Blood transfusion

•Hemophiliacs and recipients of other blood products

•Sexual partners of these groups

•Contaminated needles (IVDA, needlestick injury)

•Vertical Transmission (mother to fetus- 30-50% )

In Africa, hetrosexual transmission is most common

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Pathogenesis

•T-helper cell coordinates the immune response of T & B lymphocytes, monocytes and macrophages

•Both quatitative and qualitative defects lead to both cell mediated and humoral impaired immunity

•HIV is also neurotropic

•Macrophages engulf and plays a role in its dissemination in the CNS

•The host cellular receptor that is recognized by the HIV is CD4 molecule

•This interraction of HIV and CD4 molecule leads to the entry of HIV into the cell

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Laboratory diagnosis

Diagnosed by

virus-specific antibodies

direct identification of viral material

HIV enzyme immunoassay-screening test--ELISA technique (99.9% sensitive) detection of IgG to envelope comp-gp20

Western-Blot---detects Antibody to HIV proteins--confirmatory test (99.9% specific)

HIV isolation--culture, p24 antigen detection by EIA or HIV genome detect by PCR

p24 antigen represents active HIV replication

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Physical Examination

•Low grade fever

•Marked weight loss

•Facial seborrhea

•Diffuse lymphadenopathy

•Splenomegaly

•oral candidiasis

•Evidence of present or past herpes zoster

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Clinical Features

Nonspecific features include

•Asymptomatic for years

•Persistent fevers and chills

•Drenching night sweats

•Fatigue

•Unintentional weight loss

•Depression

•Apathy

•Memory loss and personality changes

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Specific Clinical features

•Most common complaint

•Blood cultures should be drawn for bacteria, fungus, atypical mycobacteria and CMV

•Lymphoma when organomegaly and marked lymphadenopathy present

•Chest X-ray for pneumocystis carinii infection

•Serum cryptococcal antigen for fungal infection

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Weight

•Decrease in the muscle mass

•Decrease in the fat

•Increase TNF leads to decrease in lipoproptein lipase activity

•Anorexia, nausea, and vomiting

•Malabsorption

•Diarrhea

•Increase metabolic rate

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Lymphadenopathy

•It is a common finding

•Biopsy indicated in the presence of fever, or marked enlargement of a single node.

•Extensive differential diagnosis including atypical mycobacteria, disseminated tuberculosis, toxoplasmosis and histoplamosis.

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Skin lesions

•Pruritis and folliculitis common

•kaposi’s sarcoma most frequent in homosexuals and bisexual men and far less common in intravenous drug abusers

–appear as nodular dark red or purple lesins

–frequently on head or neck, though they can occur anywhere including the respiratory tract and gastrointestinal tract and cause localized bleeding.

–Chemotherapy may be effective

–cryptococcus and histoplamosis may cause necrotic cutaneous ulcers or papules

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Dyspnea

•Pneumocystic carinii pneumonia is most common etiology (75%)

•usually present as subacute illness with constitutional symptoms: fever, night sweats and progressive non productive cough.

•Chest X-ray typically shows diffuse interstitial infiltrates although many radiographic appearances are possible.

•Diagnosis with cyst or trophozites in sputum or bronchio alveolar lavage (98%)

•Treatment with either trimethoprim sulphamethoxazole or pentamidine.

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Other causes of pulmonary disease

•

Tuberculosis( drug resistant, apical infiltrates on CXR

•

atypical mycobacteria(mycobacterium avium cellulare)

•

disseminated fungal disease (cryptococcus, histoplasma, coccioides

•

encapsulated bacteria with streptococcus and hemophilus

•

pulmonary lymphoma is less common

•

pulmonary kaposi’s sarcoma

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Dysphagia

•Candidal esophagitis, often in the presence of oral thrush, treatment with fluconazole or ketoconazole.

•Esophageal herpetic ulcers are treated with acyclovir.

•Esophageal CMV ulcers are treated with gancyclovir

•idiopathic HIV ulcers are treated with oral prednisolone

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Diarrhea

•Distinguish between high volume watery (small bowel infection) versus small volume, bloody with tenesmus (colonic infection)

•Small bowel infections are most commonly cryptosposridium, microsporidium, giardia and entamoeba histolytica

•other small bowel infections that may be accompanied by bacteremias include salmonella, shigella and campylobacter

•Colitis is most frequently caused by CMV

•Proctitis may be caused by infection of the “gay bowel syndrome” with treponema, herpes, gonorrhea

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Headache

•

Symptoms of CNS infections is often only headache; it should be evaluated since many oppurtunistic infections possible

•

Toxoplasma is the most common finding with patients presenting with headache, confusion and seizures

–

CT shows classic single or multiple ring enhancing lesions

–

Treatment is with pyrimethamine and sulfadiazine; life long maintenance medication is required

Other CNS lesions include, CNS lymphoma, Progressive multifocal leukoencephalopathy, Herpes simplex encephalitis, CMV encephalitis, Mycobacterial or fungal brain abscesses, cryptococcal meningitis

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Crypotoccal Meningitis

•Headache with meningeal signs should prompt the search for cryptococcal meningitis

•Diagnosis made with CSF identification of cryptococcal antigen on india ink stain

•Candidal esophagitis, often in the presence of oral thrush Treatment with fluconazole or ketoconazole

•Esophageal herpetic ulcers are treated with acyclovir

•Esophageal CMV ulcers are treated with gancyclovir

•Idiopathic HIV ulcers are treated with oral prednisone

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Dementia (Mental Status Change)

•Early HIV encephalopathy with depression and apathy

•Neurological examination is usually unremarkable at this point

•Distinguish dementia from depression with progressive infection, paraparesis, incontinence and global dementia occur

•CT scan reveals diffuse atrophy. CT scan is not specific but it is done to rule out mass lesions

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Blindness

•CMV retinitis can cause rapid visual loss and is treated with gancyclovir, Retinal cotton wool spots may be sen in patients with pneumocystis

•Disseminated candidiasis or toxoplasmosis may also cause visual disturbances

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Hematologic abnormalities

Immune thrombocytopenia resembling ITP
Amenia of chronic disease
Lymphocytopenia
Polyclonal gammopathy

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Therapy

Antiviral therapy with AZT with CD4 count under 500
with CD4 count under 200 in addition to pneumocysits prophylaxis is given
Vaccination with pneumococcal vaccine, influenza vaccine and hepatitis vaccine is advised
Patients are also at risk for reinfection for tuberculosis and syphilis
Prophylaxis for mycobacterium avium intracellulare when CD4 count under 100
If CD4 count decreases to <>

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Family Practice & Internal Medicine
ANEMIA
Anemia during Antenatal period.	ANTNTL-ANEMIA-1
CRF – Inv- Hb <>	CRF-ANEMIA-1
CRF - Inv - Hb <>	Chronic renal failure
CRF- Inv- Hb <>	Chronic renal failure
PCPI End stage kidney disease 4 A / Measure hemoglobin	Consortium Measures
PCPI End stage kidney disease 4 B/ Plan of care for Anemia	Consortium Measures
Causes of low hemoglobin levels in patients with heart failure	Revised Rules\Google-investigations\Chemistry
Causes of lowered hematocrit	Revised Rules\Google-investigations\Chemistry
EPSDT Anemia screening in infants	Reproductive health and pediatrics\Pediatrics
EPSDT Family history of children at initial well baby exam	Reproductive health and pediatrics\Pediatrics
EPSDT Hemoglobin less than 10 gm/dl in infants	Reproductive health and pediatrics\Pediatrics
EPSDT Sickle cell screening in infants of African - American origin	Reproductive health and pediatrics\Pediatrics
EPSDT Sickle cell screening in infants of Puerto Rican origin	Reproductive health and pediatrics\Pediatrics
ESRDA: 4. Plan of Care for Anemia	Test cat
Erythropoiesis stimulating agents in case of renal disease and Hemoglobin <11gm/dl>	Revised Rules\Google-investigations\Chemistry
PQRI 38A. Perform hematocrit in patients with ESRD (Measure 38)	Quality Measures
PQRI 38B. Investigations for hematocrit <>	Quality Measures
PQRI 38C. Treatment of hematocrit <>	Quality Measures
Folate level in case of Low hemoglobin level and high mean corpuscular volume >100fl	Revised Rules\Google-investigations\Chemistry
Hemoglobin Decreased Levels In Females	Revised Rules\Google-investigations\Chemistry
Hemoglobin X Anemia	Revised Rules\Google-investigations\Chemistry
Hemoglobin electrophoresis in case of low hemoglobin level and low mean corpuscular volume <>	Revised Rules\Google-investigations\Chemistry
Hemoglobin level 6.5-7.9 g/dL	Revised Rules\Google-investigations\Chemistry
Hemoglobin level 8.0-9.4 g/dL	Revised Rules\Google-investigations\Chemistry
Hemoglobin level 9.5-10.9 g/dL	Revised Rules\Google-investigations\Chemistry
Hemoglobin level <6.5>	Revised Rules\Google-investigations\Chemistry
Hemoglobin level >11.0 g/dL	Revised Rules\Google-investigations\Chemistry
Hemoglobin: Low Levels associated with Bone marrow diseases	Revised Rules\Google-investigations\Chemistry
Hemoglobin: When is it low to be anemic in men?	Revised Rules\Google-investigations\Chemistry
Hemoglobin: When is it low to be anemic in women?	Revised Rules\Google-investigations\Chemistry
Homocysteine x Inv x Anemia
Iron studies in case of Low hemoglobin level and low mean corpuscular volume <>	Revised Rules\Google-investigations\Chemistry
Low Ferritin x Inv x Iron deficiency anemia	Revised Rules\Google-investigations\Chemistry
Low hemoglobin level associated with chronic diseases	Revised Rules\Google-investigations\Chemistry
Low hemoglobin level in patients with renal disease	Revised Rules\Google-investigations\Chemistry
Low hemoglobin levels during pregnancy	Revised Rules\Google-investigations\Chemistry
Low hemoglobin level associated with high Mean Corpuscular Volume (MCV) >100fl	Revised Rules\Google-investigations\Chemistry
Low hemoglobin level associated with low MCV <>	Revised Rules\Google-investigations\Chemistry
Low hemoglobin level associated with normal Mean Corpuscular Volume (MCV) 80 - 100fl	Revised Rules\Google-investigations\Chemistry
Causes of Below - normal hemoglobin levels	Revised Rules\Google-investigations\Chemistry
Mean corpuscular volume (MCV) for identifying the cause of low hemoglobin	Revised Rules\Google-investigations\Chemistry
Hemoglobin levels > 8 gm / dl in patients with Thalassemia	Revised Rules\Google-investigations\Chemistry
Hemoglobin levels below 7gm/dl in patients with Thalassemia	Revised Rules\Google-investigations\Chemistry
Hemoglobin levels between 7-8gm/dl in patients with Thalassemia	Revised Rules\Google-investigations\Chemistry
Hemoglobin: Low Levels associated with Bone marrow diseases	Revised Rules\Google-investigations\Chemistry
Perform reticulocyte count in patients with low hemoglobin level and low mean corpuscular volume <>	Revised Rules\Google-investigations\Chemistry
Symptoms associated with low hemoglobin level	Revised Rules\Google-investigations\Chemistry
Treatment of low hemoglobin levels in patients with cancer	Revised Rules\Google-investigations\Chemistry
Treatment of low hemoglobin levels in patients with heart failure	Revised Rules\Google-investigations\Chemistry
Vitamin B12 deficiency and low hemoglobin level	Revised Rules\Google-investigations\Chemistry
Vitamin B12 level in case of Low hemoglobin level and high mean corpuscular volume >100fl	Revised Rules\Google-investigations\Chemistry
PQRI 61E. Anemia in a patient with gastro esophageal reflux disease (Measure 61)	Quality Measures
ASTHMA
PCPI Asthma 1a/ History Assessment	Consortium Measures
PCPI Asthma 1b/ Annual Spirometry	Consortium Measures
Anti-IgE monoclonal antibodies for treatment of Asthma	Patient ED/Asthma
Chest X-Rays in patients of Asthma	Patient ED/Asthma
Classification of Asthma	Patient ED/Asthma
Complications of Asthma	Patient ED/Asthma
Immunotherapy for treatment of Asthma	Patient ED/Asthma
Inhaled corticosteroids for treatment of Asthma	Patient ED/Asthma
Ipratropium for treatment of Asthma	Patient ED/Asthma
Leukotriene modifiers for treatment of Asthma	Patient ED/Asthma
Living with asthma	Patient ED/Asthma
Long-acting beta-2 agonists (LABAs) for treatment of asthma	Patient ED/Asthma
Mast Cell Stabilizers	Patient ED/Asthma
Methacholine bronchial challenge test in Asthma	Patient ED/Asthma
Oral and intravenous corticosteroids for asthma attacks	Patient ED/Asthma
Peak expiratory flow (PEF) measurement in patients of Asthma	Patient ED/Asthma
Prevention of asthma	Patient ED/Asthma
Risk factors of asthma	Patient ED/Asthma
Self-care for asthma patients	Patient ED/Asthma
Short-acting beta-2 agonists for treatment of Asthma	Patient ED/Asthma
Signs and Symptoms of Asthma	Patient ED/Asthma
Smoking cessation in Asthma	Patient ED/Asthma
Spirometry in patients of Asthma	Patient ED/Asthma
Theophylline for treatment of Asthma	Patient ED/Asthma
What is Asthma	Patient ED/Asthma
PQRI 53A. Treatment of mild intermittent asthma with bronchodilators (Measure 53)	PQRI II
PQRI 53B. Treatment of persistent asthma with bronchodilators (Measure 53)	PQRI II
Asthma spirometry recommendations	Revised Rules/ Asthma
Perform chest X ray in asthma patients	Revised Rules/ Asthma
Ac Severe Asthma and Inv and ABG's	Rule Catalog/Asthma
Ac Severe Asthma and Inv and Theophylline level	Rule Catalog/Asthma
Asthma and Follow up and Spirometry	Rule Catalog/Asthma
Asthma and Inv and Bronchial provocation testing	Rule Catalog/Asthma
Asthma and Inv and CBC	Rule Catalog/Asthma
Asthma and Inv and Sputum Exam	Rule Catalog/Asthma
Asthma and Inv and Total IgE	Rule Catalog/Asthma
Asthma and Inv and and X- Ray Chest	Rule Catalog/Asthma
Asthma and Treatment and PEF <>	Rule Catalog/Asthma
Asthma and Treatment and PEF <> 60%	Rule Catalog/Asthma
Asthma and Treatment and PEF > 80%	Rule Catalog/Asthma
Spirometry for investigating asthma	Rule Catalog/Asthma
Treatment Summary for acute severe asthma	Rule Catalog/Asthma
Treatment monitoring in patients of asthma	Rule Catalog/Asthma
Ac Severe Asthma and Inv and ABG's	Data Analysis\Respiratory Disease\Asthma
Ac Severe Asthma and Inv and Theophylline level	Data Analysis\Respiratory Disease\Asthma
Asthma and Follow up and Spirometry	Data Analysis\Respiratory Disease\Asthma
Asthma and Inv and Bronchial provocation testing	Data Analysis\Respiratory Disease\Asthma
Asthma and Inv and CBC	Data Analysis\Respiratory Disease\Asthma
Asthma and Inv and Sputum Exam	Data Analysis\Respiratory Disease\Asthma
Asthma and Inv and Total IgE	Data Analysis\Respiratory Disease\Asthma
Asthma and Inv and and X- Ray Chest	Data Analysis\Respiratory Disease\Asthma
Asthma and Treatment and PEF <>	Data Analysis\Respiratory Disease\Asthma
Asthma and Treatment and PEF <> 60%	Data Analysis\Respiratory Disease\Asthma
Asthma and Treatment and PEF > 80%	Data Analysis\Respiratory Disease\Asthma
Atrial fibrillation
AF Treatment -Anticoaggulation -Hyperthyroidism x Risk factor	Consortium Measures
AF - Treatment - Anticoagulants -Hypertension	Consortium Measures
AF -Treatment -Anticoagulants x Mitral valve disease	Consortium Measures
AF x Treatment x Anticoagulants x Prosthetic valve	Consortium Measures
AF x Treatment x Anticoaggulation x LA thrombus	Consortium Measures
AF x Treatment x Anticoaggulation x Prior thromboembolism	Rule Catalog/Atrial Fibrillation
AF x Treatment x Aspirin	Rule Catalog/Atrial Fibrillation
AF x Treatment x Catheter ablation	Rule Catalog/Atrial Fibrillation
AF x Treatment x DCC x Hypotension	Rule Catalog/Atrial Fibrillation
AF x Treatment x DCC x Heart failure	Rule Catalog/Atrial Fibrillation
AF x Treatment x DCC x MI	Rule Catalog/Atrial Fibrillation
AF x Treatment x DCC x Pregnancy	Rule Catalog/Atrial Fibrillation
AF x Treatment x DCC x Pulmonary disease	Rule Catalog/Atrial Fibrillation
AF x Treatment x IAD	Rule Catalog/Atrial Fibrillation
AF x Treatment x Oral anticoagulants x Pregnancy	Rule Catalog/Atrial Fibrillation
AF x Treatment x Rate control x Amiodarone	Rule Catalog/Atrial Fibrillation
AF x Treatment x Rate control x Beta blockers	Rule Catalog/Atrial Fibrillation
AF x Treatment x Rate control x Calcium channel blockers	Rule Catalog/Atrial Fibrillation
AF x Treatment x Rate control x Digoxin	Rule Catalog/Atrial Fibrillation
AF x Treatment x Surgical ablation	Rule Catalog/Atrial Fibrillation
AF x Treatment x WPW x Catheter ablation	Rule Catalog/Atrial Fibrillation
AF x Treatment x WPW x Type 1 antiarrythmic	Rule Catalog/Atrial Fibrillation
AF x WPW X Contraindication x Calcium channel blockers and digoxin	Rule Catalog/Atrial Fibrillation
AF x WPW x Treatment x Amiodarone	Rule Catalog/Atrial Fibrillation
AF x WPW x Treatment x Type 1 antiarrythmic	Rule Catalog/Atrial Fibrillation
Atrial fibrillation and blood thinning treatment in individuals younger than 60 yrs	Rule Catalog/Atrial Fibrillation
Blood thinners in atrial fibrillation for patients older than 75 years	Rule Catalog/Atrial Fibrillation
Blood thinning treatment consideration for atrial fibrillation patients	Rule Catalog/Atrial Fibrillation
Post MI AF x Contraindication x Class 1c drugs	Rule Catalog/Atrial Fibrillation
Post MI AF x treatment x Anticoagulation	Rule Catalog/Atrial Fibrillation
Atrial fibrillation and blood thinning treatment in individuals younger than 60 yrs	Rule Catalog/Atrial Fibrillation
Atrial fibrillation and use of stimulants	Rule Catalog/Atrial Fibrillation
Blood thinners in atrial fibrillation for patients older than 75 years	Rule Catalog/Atrial Fibrillation
Blood thinning treatment consideration for atrial fibrillation patients	Rule Catalog/Atrial Fibrillation
Causes of atrial fibrillation	Rule Catalog/Atrial Fibrillation
Chemical cardioversion in atrial fibrillation	Rule Catalog/Atrial Fibrillation
Electrical cardioversion in atrial fibrillation	Rule Catalog/Atrial Fibrillation
Heart disease as a risk factor of atrial fibrillation	Rule Catalog/Atrial Fibrillation
INR - Monthly monitoring of patients taking warfarin	Rule Catalog/Atrial Fibrillation
INR- Value greater than 9 requires immediate medical attention	Rule Catalog/Atrial Fibrillation
Other conditions which are risk factors of atrial fibrillation	Rule Catalog/Atrial Fibrillation
Perform CBC in atrial fibrillation	Rule Catalog/Atrial Fibrillation
Perform Digoxin levels in patients of atrial fibrillation taking digoxin	Rule Catalog/Atrial Fibrillation
Perform ECG in atrial fibrillation	Rule Catalog/Atrial Fibrillation
Perform echocardiography in atrial fibrillation	Rule Catalog/Atrial Fibrillation
Perform renal function tests in atrial fibrillation	Rule Catalog/Atrial Fibrillation
Perform serum electrolytes in atrial fibrillation	Rule Catalog/Atrial Fibrillation
Perform thyroid function tests in atrial fibrillation	Rule Catalog/Atrial Fibrillation
Race as a risk factor for atrial fibrillation	Rule Catalog/Atrial Fibrillation
Self care in atrial fibrillation	Rule Catalog/Atrial Fibrillation
Signs and symptoms of atrial fibrillation	Rule Catalog/Atrial Fibrillation
Stroke as a complication of atrial fibrillation	Rule Catalog/Atrial Fibrillation
Warning Signs of Heart Attack	Rule Catalog/Atrial Fibrillation
Warning Signs of Stroke	Rule Catalog/Atrial Fibrillation
ACC HF: 4. Warfarin Therapy for Patients with Atrial Fibrillation (AF)	Rule Catalog/Atrial Fibrillation
AFF: 1. Assessment of Thromboembolic Risk Factors	Rule Catalog/Atrial Fibrillation
AFF: 2. Chronic anticoagulation therapy	Rule Catalog/Atrial Fibrillation
AFF: 3. Monthly INR measurement	Rule Catalog/Atrial Fibrillation
CHRONIC COUGH
Patient with chronic cough and normal spirometry have stage 0 COPD	Patient ED\COPD
Patient with chronic cough should have spirometry	Patient ED\COPD
CHRONIC OBSTRUCTIVE PULMONARY DISEASE [COPD]
PCPI Chronic Obstructive Pulmonary Disease (COPD) 10/ Influenza Immunization documented	Custom Rules Catalog\Consortium Measures
PCPI Chronic Obstructive Pulmonary Disease (COPD) 11/ Pneumococcal Immunization	Custom Rules Catalog\Consortium Measures
PCPI Chronic Obstructive Pulmonary Disease (COPD) 12/ Pneumococcal Immunization documented	Custom Rules Catalog\Consortium Measures
PCPI Chronic Obstructive Pulmonary Disease (COPD) 2/ Assessment of Symptoms	Custom Rules Catalog\Consortium Measures
PCPI Chronic Obstructive Pulmonary Disease (COPD) 3/ Smoking Assessment	Custom Rules Catalog\Consortium Measures
PCPI Chronic Obstructive Pulmonary Disease (COPD) 3/ Smoking Cessation Intervention	Custom Rules Catalog\Consortium Measures
PCPI Chronic Obstructive Pulmonary Disease (COPD) 6a/ Assessment of Oxygen Saturation with FEV1<>	Custom Rules Catalog\Consortium Measures
PCPI Chronic Obstructive Pulmonary Disease (COPD) 6b/ Assessment of Oxygen Saturation with respiratory failure	Custom Rules Catalog\Consortium Measures
PCPI Chronic Obstructive Pulmonary Disease (COPD) 7/ Long Term Oxygen Therapy	Custom Rules Catalog\Consortium Measures
PCPI Chronic Obstructive Pulmonary Disease (COPD) 8/ Pulmonary Rehabilitation	Custom Rules Catalog\Consortium Measures
PCPI Chronic Obstructive Pulmonary Disease (COPD) 9/ Influenza Immunization	Custom Rules Catalog\Consortium Measures
COPD: 1. Spirometry Evaluation	test cat\catB\COPD
COPD: 10. Assessment of Pneumococcal Immunization Status	test cat\catB\COPD
COPD: 11. Pneumococcal Immunization Administered	test cat\catB\COPD
COPD: 12. Pulmonary Rehabilitation: Exercise Training Recommended	test cat\catB\COPD
COPD: 2. Assessment of Symptoms	test cat\catB\COPD
COPD: 3. Smoking Assessment	test cat\catB\COPD
COPD: 4. Smoking Cessation Intervention	test cat\catB\COPD
COPD: 5. Inhaled Bronchodilator Therapy	test cat\catB\COPD
COPD: 6. Assessment of Oxygen Saturation	test cat\catB\COPD
COPD: 7. Long Term Oxygen Therapy	test cat\catB\COPD
COPD: 8. Recommendation of Influenza Immunization	test cat\catB\COPD
COPD: 9. Influenza Immunization Administered	test cat\catB\COPD
PQRI 51A. Spirometry evaluation in chronic obstructive pulmonary disease (COPD) (Measure 51)	PQRI II
PQRI 51B. Perform spirometry evaluation in patients with chronic obstructive pulmonary disease (COPD) annually (Measure 51)	PQRI II
PQRI 52A. Treatment of COPD with inhaled bronchodilator therapy (Measure 52)	PQRI II
PQRI 52B. Treatment of COPD with long acting bronchodilator therapy (Measure 52)	PQRI II
Chest X Ray should be done in a patient with COPD	Patient ED\COPD
Long term oxygen for COPD patient	Patient ED\COPD
Nutritional assessment in a COPD patient	Patient ED\COPD
Oral steroids for acute exacerbation of COPD	Patient ED\COPD
Patient with FEV1/FVC <70%>	Patient ED\COPD
Patient with FEV1/FVC <70%>80% predicted have stage 1 COPD	Patient ED\COPD
Patient with chronic cough and normal spirometry have stage 0 COPD	Patient ED\COPD
Patient with chronic cough should have spirometry	Patient ED\COPD
Perform CBC in a patient with COPD	Patient ED\COPD

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