NR511 Final Exam Study Guide, Study Guides, Projects, Research of Nursing

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NR511 Final Exam Study Guide

Week 1

1. Define diagnostic reasoning -To solve problems, to promote health, and to screen for disease or illness all require a sensitivity to complex stories, to contextual factors, and to a sense of probability and uncertainty. -Diagnostic reasoning can be seen as a kind of critical thinking. Critical thinking involves the process of questioning one’s thinking to determine if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence. Diagnostic reasoning then includes a systematic way of thinking that evaluates each new piece of data as it either supports some diagnostic hypothesis or reduces the likelihood of others. 2. Discuss and identify subjective & objective data -Subjective: -reports -complains of -tells you in response to your questions. -Includes ROS, CC, and HPI -Objective: -what you can see, hear, or feel as part of your clinical exam. -It also includes laboratory data and test results. 3. Discuss and identify the components of the HPI -O: Onset of CC -L: Location of CC -D: Duration of CC -C: Characteristics of CC -A: Aggravating factors for CC -R: Relieving factors for CC -T: Treatments tried for CC -S: Severity of CC 4. Describe the differences between medical billing and medical coding Medical coding: is the use of codes to communicate with payers about which procedures were performed and why. -Medical billing: is the process of submitting and following up on claims made to a payer in order to receive payment for medical services rendered by a healthcare provider.

5. Compare and contrast the 2 coding classification systems that are currently used in the US healthcare system -The CPT system offers the official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and non- physician providers. -CPT codes are recognized universally and also provide a logical means to be able to track healthcare data, trends, and outcomes. -ICD-10 codes are shorthand for the patient’s diagnoses, which are used to provide the payer information on the necessity of the visit or procedure performed. 6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the diagnostic data -Specificity of a test, we are referring to the ability of the test to correctly detect a specific condition. -Predictive value is the likelihood that the patient actually has the condition and is, in part, dependent upon the prevalence of the condition in the population. -When a test is very sensitive, we mean it has few false negatives. 7. Discuss the elements that need to be considered when developing a plan Acknowledge the list -Negotiate what to cover -Be Honest -Make a follow-up 8. Describe the components of Medical Decision Making in E&M coding

• There are three key components that determine risk-based E&M codes. -History -Physical -Medical Decision Making (MDM) E&M coding requires a medical decision maker -Medical decision making is another way of quantifying the complexity of the thinking that is required for the visit. -Complexity of a visit is based on three criteria: -Risk -Data -Diagnosis -Now, medical decision making is a special category. Why is this so important? Well, the MDM score gives us credit for the excess work involved in management of a more complex patient.

9. Correctly order the E&M office visit codes based on complexity from least to most complex

99212 - 99214

10. Discuss a minimum of three purposes of the written history and physical in relation to the importance of documentation -It is an important reference document that gives concise information about a patient's history and exam findings. -It outlines a plan for addressing the issues that prompted the visit. This information should be presented in a logical fashion that prominently features all data immediately relevant to the patient's condition. -It is a means of communicating information to all providers who are involved in the care of a particular patient. -It is an important medical-legal document -It is essential in order to accurately code and bill for services. 11. Accurately document why every procedure code must have a corresponding diagnosis code -Every procedure code needs a diagnosis to explain the necessity whether the code represents an actual procedure performed or a nonprocedural encounter like an office visit. 12. Correctly identify a patient as new or established given the historical information - Patient status -New patient: one who has not received professional service from a provider from the same group practice within the past 3 years. -Established patient of your practice: has received professional service from a provider of your office within the last 3 years 13. Identify the 3 components required in determining an outpatient, office visit E&M code

-Place of service -Type of service

-Inpatient -Consultation’s -Outpatient -Office visit -Hospital admission -Patient status -New patient: one who has not received professional service from a provider from the same group practice within the past 3 years. -Established patient of your practice: has received professional

14. Describe the components of Medical Decision Making in E&M coding

• There are three key components that determine risk-based E&M codes. -History -Physical -Medical Decision Making (MDM) E&M coding requires a medical decision maker -Medical decision-making is another way of quantifying the complexity of the thinking that is required for the visit. -Complexity of a visit is based on three criteria: -Risk -Data -Diagnosis -Now, medical decision making is a special category. Why is this so important? Well, the MDM score gives us credit for the excess work involved in management of a more complex patient. 15. Explain what a “well rounded” clinical experience means -Includes both children from birth through young adult visits for well child and acute visits, as well as adults for wellness and acute or routine visits 16. State the maximum number of hours that time can be spent “rounding” in a facility <25% 17. State 9 things that must be documented when inputting data into clinical encounter -date of service -visit E&M code (e.g., 99203) - age -gender and ethnicity -chief concern -procedures -tests performed or ordered -diagnoses -level of involvement 18. Identify and explain each part of the acronym SNAPPS -S: Summarize -N: Narrow -A: Analyze -P: Probe -P: Plan -S: Self-directed learning Week 2 1. Identify the most common type of pathogen responsible for acute gastroenteritis -Viral: Norovirus (Leading cause for adults)

-Rotovirus (Leading cause for peds up to 2 years old)

2. Recognize that assessing for prior antibiotic use is a critical part of the history in patients presenting with diarrhea Due to risk of C Diff infection 3. Describe the difference between Irritable Bowel Disease (IBS) and Inflammatory Bowel Disorder (IBD)

• IBS (Irritable bowel syndrome): disorder of bowel function not from anatomic abnormality -constipation, diarrhea, bloating, urgency w/ diarrhea -NOT assoc w/ serious medical consequences, IBD or CA +S/S: result from disordered sensation or abnormal function of the small and large bowel
• IBD (Inflammatory bowel disease): chronic immunologic disease that manifests in intestinal inflammation
• UC/CD 4. Discuss two common Inflammatory Bowel Diseases
• Ulcerative colitis (UC ): the mucosal surface of the colon is inflamed and ultimately results in friability, erosions, and bleeding.
• Most common in recto-sigmoid colon. Can involve entire colon
• Pain in RLQ
• Crohns (CD ): the inflammation extends deeper into the intestinal wall and can involve all or any layer of the bowel wall and any portion of the GI tract from the mouth to the anus.
• Skipped lesions
• Pain in LLQ 5. Discuss the diagnosis of diverticulitis, risk factors, and treatments Symptoms: LLQ pain/ tenderness, fever, N/V/D Need imaging especially if perforation or peritonitis is suspected; free air = perforation; patient may have ileus, small or large bowel obstruction Can use plain x-ray CT or barium enema are preferred CT with contrast is more sensitive and accurate 6. Identify the significance of Barrett’s esophagus After repeated exposure to gastric contents, inflammation of the esophageal mucosa becomes chronic. · Blood flow increases, erosion occurs

· As erosion heals, normal squamous epithelium replaced with metaplastic columnar epithelium containing goblet and columnar cells · More resistant to acid and supports esophageal healing · Premalignant tissue · 40-fold risk for development of esophageal adenocarcinoma · Fibrosis and scarring during healing of erosions; leads to strictures

7. Discuss the diagnosis of GERD, risk factors, and treatments

• Diagnosis made on history alone; sensitivity of 80%
• If symptoms are unclear/patient doesn’t respond to 4 weeks of empiric treatment
• Dx made by ambulatory esophageal pH monitoring
• pH < 4 above the lower esophageal sphincter and correlates with symptoms = GERD
• EGD with biopsy – Barrett’s esophagus
• Normal results in 50% of symptomatic patients
• Risks o Obesity o Increases after age 50 o Equal across gender, ethnic, and cultural groups
• Treatment o Small, frequent meals – main meal at midday o Avoid trigger foods o No bedtime snacks; no eating < 4 hours prior to bed o Eliminate caffeine o Stop smoking o Avoid tight fitting clothing o Sleep with head elevated
• Medication: o Step 1: antacids or OTC H2 (Tagamet, zantac, axid) o Step 2: Rx-strength H2 (ranitidine 150mg BID, famotidine 20mg BID) or PPI (pantoprazole 40mg daily, omeprazole 20mg daily) o Step 3: PPI (omeprazole 40mg daily) o Step 4: surgery (fundoplication) 8. Discuss the differential diagnosis of acute abdominal pain, work-up and testing, treatments Diff Diagnosis Acute appendicitis: ▪ Inflammation of the vermiform appendix; due to obstruction or infection ▪ Most common surgical emergency of the abdomen

▪ Hollow tube – most common cause is obstruction of appendix

▪ Fecaltih – hard lump of fecal matter ▪ Undigested seeds ▪ Pinworm infections ▪ Lymphoid follicle growth/lymphoid hyperplasia Symptoms ▪ Symptoms ▪ Nausea/vomiting ▪ RLQ pain ▪ Guardin g Acute pancreatitis: ▪ Sudden inflammation and hemorrhaging of the pancreas due to destruction by its own digestive enzymes

1. Autodigestion ▪ Most of the time mild, but can be severe ▪ Pancreas ▪ Long skinny gland, length of dollar bill ▪ Located in upper abdomen ▪ Behind the stomach ▪ Endocrine ▪ Alpha/beta cells produce insulin & glucagon that are secreted into the blood stream ▪ Exocrine ▪ Leading causes:
2. ETOH abuse
3. Gallstones
4. Other Causes of acute pancreatitis

1. I Get Smashed ▪ I – idoipathic ▪ G- gallstones ▪ E- ETOH abuse ▪ T – trauma ▪ S – steroids ▪ M – mumps virus ▪ A – autoimmune diseases ▪ S – scorpion stings ▪ H – hypertriglyceridemia & hypercalcemia ▪ E – ERCP ▪ D – drugs Symptoms Nausea ▪ Vomiting ▪ Hypocalcemia ▪ Cullen’s sign – bruising around umbilicus ▪ Grey-Turner’s Sign - Bruising along flank ▪ Necrosis induced hemorrhaging spreads Acute cholecystitis: Inflammation of gallbladder (GB) Usually due to gallstone in cystic duct
2. Cystic duct – leaves gall bladder & connects to common bile duct Symptoms: Patient will have mid-epigastric pain ▪ Because GB is still squeezing, increasing pressure w/ nowhere

for bile to go ▪ Can lead to nausea/vomting

▪ Stone can get more stuck w/ more squeezing Bile starts to irritate mucosa Mucosa starts to produce mucous and inflamm enzymes ▪ Leads to inflammation, distention, pressure build up ▪ Bacterial growth (E. coli, enterococci, bacteroides fragilis, colstriduim) As GB “balloons”, pain shifts to RUQ, R scapula/shoulder Bacteria invades in & through GB wall, into peritoneum, causing peritonitis ▪ Rebound tenderness Murphy’s Sign = Put pressure on right side under ribs. This will hold GB in place. Have patient take a deep breath. The diaphragm will push on the GB & a painful response = Cholecystitis Immune response ▪ Neutrophilic leukocytosis ▪ Fever Workup and testing : All patients with abdominal pain should undergo rectal, gential, and pelvic exam. It is important to isolate the location of the pain. Acute appendicitis: ▪ Diagnosis is made clinically and based on history and physical ▪ Elevated WBC ▪ Mild Fever, 99- ▪ RLQ pain/McBurneys point ▪ CT abd may help rule out other diagnostic possibilities ▪ ABD ultrasound helps to visualize the inflamed appendix

Acute pancreatitis:

▪ Pain in epigastrium which radiates to back ▪ Labs ▪ Increase in amylase; gold standard in diagnoses (up to 3x the normal level) ▪ Increase in lipase ▪ CT scan ▪ US to look for gallstones Acute cholecystitis: ▪ US confirmed ▪ Detects stones ▪ Sonographic murphy sign ▪ Tenderness when sonogram is over gallbladder ▪ GB wall thickening ▪ Sludge ▪ Distention of GB or common bile duct ▪ Cholescintigraphy (HIDA scan) ▪ Radiolabeled marker used to visualize the biliary system ▪ Acute cholecys – ducts are blocked, GB can’t be seen ▪ Endoscopic Retrograde Cholangiopancreatography (ERCP) ▪ Endoscope down to pancreas ▪ Dye injected & viewed via fluoro ▪ Magnetic Resonance Cholangiopancreatography (MRCP) ▪ Visualizes bili system with MRI Treatment:

Acute appendicitis:

• Appendectomy
• Antibiotic
• Drain abscesses
• Can be removed prophylactically Acute pancreatitis: o pain management o hydration o electrolytes o rest bowels ▪ NPO ▪ IV nourishment o Treat complications ▪ O ▪ AT B Acute cholecystitis: o Supportive measures ▪ IV ▪ Pain management ▪ ATB o Surgical Removal ▪ Cholecystectomy

1. Laparoscopic

9. Discuss the difference between sensorineural and conductive hearing loss

• Sensorineural: Results from deterioration of cochlea -Loss of hair cells form the organ of Corti -Gradual and progressive -Not correctable but preventable
• Conductive: Obstruction between middle and outer ear -Most types are reversible 10. Identify the triad of symptoms associated with Meniere's disease -Meniere’s Disease: Sensory disorder of labyrinth (semi-circular canal system) and cochlea -S/S: -Vertigo -Hearing loss -Tinnitus 11. Identify the symptoms associated with peritonsilar abscess -Increasing unilateral ear and throat pain ipsilateral to the affected tonsil -Dysphagia -Drooling -Trismus -Erythema -Edema of the soft palate with fluctuance on palpation 12. Identify the most common cause of viral pharyngitis
• Adenovirus: MOST common -RSV -Influenza A&B -Epstein-Barr -coxsackie -enteroviruses -herpes simplex 13. Identify the most common cause of acute nausea & vomiting Gastroenteritis 14. Discuss the importance of obtaining an abdominal xray to rule out perforation or obstruction even though the diagnosis of diverticulitis can be made clinically Abdominal xray films should be obtained on all patients with suspected diverticulitis to look for free air (indicating perforation), ileus, or obstruction

15. Discuss colon cancer screening recommendations relative to certain populations -Anyone over age 50 should have a routine c-scope -African American’s should start screenings at age 40 -Individuals with a single first-degree relative with CRC or advanced adenomas diagnosed at age ≥60 years can be screened like average-risk persons. **Red flag symptoms should be sent to GI – unintentional weight loss, rectal bleeding, diffuse lower abdomen pain, new onset diarrhea/constipation, early satiety, loss of appetite 16. Identify at least two disorders that are considered to be disorders related to conductive hearing loss -Chronic Otitis Media (OM) -middle ear effusion -mass -vascular anomaly -cholesteatoma – abnormal noncancerous skin growth in ear canal 17. Identify the most common bacterial cause of pharyngitis -Group A Beta Hemolytic Streptococcus (GABHS) -Absence of cough -Tonsillar exudates -History of fever -Tender anterior cervical adenopathy 18. Identify the clinical findings associated with mononucleosis -Fever -Malaise -Severe sore throat -Exudative tonsillitis (50% of cases) -Palatal petchiae -Rash -Anterior/posterior cervical lymphadenopathy -Splenic enlargement -POC Monospot test: (+) 19. Identify common characteristics in a rash caused be Group A Strep Sandpaper rash Fine, red, sparing hands & soles 20. Discuss that the diagnosis of streptococcal pharyngitis can be made clinically based on the Centor criteria -Absence of cough

-Tonsillar exudates -History of fever -Tender anterior cervical adenopathy

21. Describe an intervention for a patient with gastroenteritis -Supportive care: fluid and nutrients -Low residue diet (BRAT) – no evidence that this helps, but may be more tolerable for pt -Viral cause = NO antibiotics -Education surrounding not prescribing antibiotics/not spreading germs/eating safe foods -Imodium/Zofran/Phenergan 22. Discuss an appropriate treatment for prophylaxis or treatment of traveler's diarrhea

• empirical antimicrobial therapy: Trimethoprim-sulfamethoxazole (Bactrim) 1 PO BID ×3d -ciprofloxacin (Cipro) 500 mg -norfloxacin (Noroxin) 400 mg -ofloxacin (Floxin) 300 mg 23. Identify at least one effective treatment for Irritable Bowel Syndrome (IBS)
  • For IBS - C o Psyllium (fiber) o docusate (softner) o bisacodyl/senna (stimulant/irritant) o loperamide (antidiarrheal) - For IBS – D o dicyclomine (bentyl), hycosamine sulfate (Levsin) phenobarb/hycosamine (donnatal) ▪ anticholenergics – decrease motility of smooth muscle tone/decrease cramping, relaxes muscles in stomach/intestines o Linzess (linaclotide), Trulance (plecanatide), and Amitiza (lubiprostone): drugs work by acting locally on the apical membrane of the GI tract to increase intestinal fluid secretion and improve fecal transit - Antidepressants for depression/anxiety component 24. Identify at least one prescription medication for the treatment of chronic constipation -Linzess (linaclotide), Trulance (plecanatide), and Amitiza (lubiprostone): drugs work by acting locally on the apical membrane of the GI tract to increase intestinal fluid secretion and improve fecal transit

• Movtantik (naloxegol) and Relistor (methylnaltrexone) for Opioid induced Miralax is a gentle but effective laxative that is safe for long-term use - OTC

25. Discuss at least one treatment for Meniere's disease -Meniere’s Disease: Sensory disorder of labyrinth (semi-circular canal system) and cochlea -S/S: -Vertigo -Hearing loss -Tinnitus Week 3 1. Discuss that the majority of dyspnea complaints are due to cardiac or pulmonary decompensation -2/3 of symptomatic patients the etiology is due to cardiopulmonary disease -1/3 of all cases the cause of dyspnea is multifactorial -Common cardiopulmonary conditions: 2. Explain the differences between intra-thorax and extra-thorax flow disorders -Flow Disorders -Intrathorax -Obstruction of distal/smaller airway -Extrathorax -Obstruction of proximal/larger airway 3. Identify at least three examples of flow and volume disorders (intra and/or extra thorax) -Intrathorax flow disorders: originate from obstruction of distal/smaller airways -asthma -bronchiolitis -vascular ring -solid foreign body aspiration -lymph node enlargement pressure -These types of disorders cause expiratory effort in infants and also in children less than 5 years of age (bronchiolitis)

-Extrathorax flow disorders: originate from obstruction of the larger airways -rhinitis with nasal obstruction, nasal polyp -cranio-facial malformation -obstructive sleep apnea -tonsil-adenoid hypertrophy -laryngo-tracheo-malacia -larynx papilloma -Diphtheria -croup, epiglottitis -thymus hypertrophy -Infants or children ages 5 and younger are affected, and they have clinical findings of inspiratory stridor -Intrathorax volume disorders include lung parenchyma disorders -pneumonia (infection, aspiration) -atelectasis -pulmonary edema -near drowning -These disorders affect inspiratory effort -Extrapulmonary volume disorders -pneumothorax, pneumomediastinum -cardiomegaly, heart failure (perfusion) -pleural effusion (including empyema, hematothorax) -hernia diaphragmatica -diaphragmatica eventration -intra-thorax mass (nonpulmonary) -chest trauma (rib fracture, lung contusion) -thorax deformity (pectus excavatum, scoliosis) -These disorders also affect inspiratory effort -Extrathorax volume disorders due to lung compliance issues -neuromuscular disorders (CP, GBS, MG) -gastritis, peptic ulcer -extreme obesity -peritonitis, appendicitis, acute abdomen -aerophagia, meteorismus -ascites -hepato-splenomegaly -abdominal solid tumor -These disorders cause inspiratory constraint -Extrathorax volume disorders that are due to respiratory center disorders -anemia -metabolic acidosis -CNS infections: meningitis, encephalitis -encephalopathy (typhoid, DHF, metabolic)

-psychologic (anxiety, usually adolescent) -poisoning (salycylate, alcohol) -trauma capitis -CNS disease sequelae -These disorders cause deep rapid breathing

4. Discuss diagnosis, risk factors and treatments for asthma Diagnosis- Essential elements to consider- HX- cough (especially nocturnal), recurrent wheeze, recurrent episodic dyspnea, recurrent chest tightness Symptoms worsen in relation to specific factors- changes in weather, exercise, environmental allergens, GERD, Beta blockers, sensitivity to ASA, strong emotional expression To establish the diagnosis of asthma, episodic symptoms of airflow obstruction must be present, airflow obstruction must be at least partially reversible, and must rule out other diagnoses. Spirometry measurements are helpful in diagnosis & in evaluation of management The diagnosis is made by demonstrating the reversibility of the airway obstruction from the pre- and post- PFTs. Reversibility is defined as a 15% or greater increase in the FEV1 after 2 puffs of a beta- adrenergic agonist have been inhaled. When spirometry is non-diagnostic, bronchial provocation testing maybe useful with histamine, methacholine, or exercise. Risk Factors Family or personal history- allergic rhinitis, eczema/atopic diseases Residing in urban area Exposure to smoke or air pollution Cockroaches and dust Viral respiratory infections Cold air intolerance obesity Classifications of Asthma Severity Mild Intermittent Symptoms < 2 days per week OR < 2 nights per month. Exacerbations brief Mild Persistent Symptoms > 2 times per week, but not daily; OR 3-4 times per month at nighttime Moderate Daily symptoms OR >1 night per week but not nightly

Persistent Severe persistent Symptoms throughout the day; often 7 nights per week Pharmacological Management *Short acting bronchodilator (albuterol) is a mainstay of treatment for ALL asthma patients Intermittent Short-acting bronchodilator (albuterol): for exacerbations (inhaled or nebulized) Mild Persistent Short acting bronchodilator + Preferred tx- Low-dose inhaled corticosteroids (fluticasone/Flovent, budesonide/Pulmicort, mometasone/asmanex Moderate Persistent Short acting bronchodilator + Preferred tx- low to medium dose inhaled corticosteroid AND Long acting inhaled bronchodilator (salmeterol/serevent, formoterol/Foradil) Alternative tx-low to med dose inh. Corticosteroid AND Either leukotriene blocker (Montelukast/singulair) OR theophylline Severe Persistent Short acting bronchodilator + High dose inhaled corticosteroids AND Long acting inhaled bronchodilator AND If needed, oral corticosteroids (2mg/kg/day, 60mg/day max)

5. Describe appropriate tests in the work up for dyspnea

• CXR: rule out tumors, TB, pneumonia, and other major pulmonary disorders
• CBC with differential: rule out anemia and infection
• Peak expiratory flow test (in office): to determine the degree of expiratory airflow obstruction in patients with asthma and COPD
• EKG, Echo
• Spirometry: to determine obstructive, restrictive and mixed lung disease 6. Discuss clinical findings and PFTs for asthma, chronic bronchitis, emphysema, and COPD
• Asthma o Subjective: c/o breathlessness, unable to talk, short sentences, profuse sweating, c/o air hunger. In patients who are severely obstructed, there may be no wheezing and only cough may be present. Wheezing, persistent and recurrent cough, difficulty breathing, tightness in chest, endurance problems during exercise. Symptoms are usually worse at night. o Objective: Nasal discharge, mucosal swelling, frontal tenderness, nasal polyps, and allergic “shiners” (dark discoloration beneath both eyes). Allergic rhinitis and eczema often accompany the dx of asthma.
• Asthma PFTs o Mild intermittent asthma- FEV1: >80%, PFT >20% o Mild persistent asthma- FEV1: >80%, PFT 20%-30%

o Moderate persistent asthma- FEV1: 60%-80%, PFT >30% o Severe persistent asthma- <60%, PFT >30%

• Chronic Bronchitis/Emphysema/COPD o Subjective: frequent colds, persistent morning cough, upper respiratory infections, dyspnea, fatigue, SOB. Hemoptysis, loss of appetite, nausea, dizziness. Sleep sitting up on >3 pillows to relieve dyspnea. Paroxysmal nocturnal dyspnea. o Objective: In emphysema, hyperinflation of chest, flattening of diaphragm, tachypnea, use of accessory muscles of respiration, end expiratory wheezes may be heard on forced expiration. Coarse crackles during acute exacerbation.
• Chronic Bronchitis (chronic productive cough) o more common form of COPD o Airflow obstruction in chronic bronchitis is caused by bronchiole edema, hyperplasia of mucus-producing goblet cells, and bronchiole smooth muscle hypertrophy. Presents as long-term cough or recurrent sputum production, mainly upon awakening, extending over 3 months for a period of at least 2 years o Hallmark of episode-increased purulent sputum production and worsened SOB
• Emphysema (increasing shortness of breath) o destruction of alveolar walls due to an imbalance of proteinase- antiproteinase enzymatic activity o Overdistended, hyperinflated, less elastic alveoli over time o Weak elastic recoil of alveoli leads to air trapping, increased residual lung volume, reduced expiratory flow, and retained CO2
• COPD PFTs o Mild COPD (Stage 1)- FEV1/FVC <0.7; FEV1 >80% predicted o Moderate COPD (Stage 2)- FEV1/FVC <0.7; FEV1 50%-79% predicted o Severe COPD (Stage 3)- FEV1/FVC <0.7; FEV1 30%-49% predicted o Very severe COPD (Stage 4)- FEV1/FVC <0.7; FEV1 <30% predicted or 50% predicted w/chronic respiratory failure 7. Differentiate between the following common rashes: rubeola, rubella, varicella, roseola, 5ths disease, pityriasis rosea, hand, foot and mouth disease and molluscum contagiosum. Rubeola: Measles: skin is a reddish purple generalized macular and papular rash. o Lesions start out on the head, particularly on the face or behind