The lack of more than one antibiotic therapy administered as per such guidelines prior to the phage therapy represents a limitation to this report. Multiple antibiotic treatments were administered empirically in the patients home country over a period of four months. The prostate and other sex glands produce the fluid that transports sperm during ejaculation (semen). If the chronic prostatitis is bacterial, you should use an additional code from categories B95- through B97- to identify the infectious agent, if known. This involves the collection and testing of four samples: first catch urineurethral specimen, midstream urinebladder specimen, expressed prostatic secretion (EPS) and voided urine after EPS expression (Sharp, et al., 2010). N20.0 OR Q61.5. Chronic prostatitis is prostate inflammation that lasts for at least three months. Approximately 13% of patients with acute bacterial prostatitis experience recurrence necessitating a longer course of antibiotics.6 Patients with persistent or recurrent symptoms should have a repeat urine culture to evaluate for repeat bacterial prostatitis and be treated based on culture results. Efficacy of Repeated Cycles of Combination Therapy for the Eradication of Infecting Organisms in Chronic Bacterial Prostatitis. Additional risk factors for chronic prostatitis/chronic pelvic pain syndrome may include: Complications of acute or chronic prostatitis can include: Complications of chronic prostatitis/chronic pelvic pain syndrome may include: There's no direct evidence that prostatitis can lead to prostate cancer. Penetration of Antimicrobial Agents into the Prostate. Quality of Life Is Impaired in Men with Chronic prostatitisQuality of Life Is Impaired in Men with Chronic Prostatitis: The Chronic Prostatitis Collaborative Research Network. They can include: (1) Urinary symptoms like urethral burning, difficulty starting a stream, urgency or increased frequency, nocturia, dribbling, and incomplete voiding of bladder; (2) Pain in the perineum, suprapubic region, lower back, abdomen, penis, testicles, groin, and rectum, and pain during ejaculation and dysuria; and. Acute pancreatitis is K85.9 and chronic pancreatitis is K86.1; in accordance with the Guideline, report K85.9 first followed by K86.1.ACUTE AND CHRONIC (Answers are located in Appendix B)Using multiple codes, fill in the code (s) for the following diagnoses: 1 Chronic prostatitis due toStreptococcus Codes:________________,________________ 2 Acute Evo 750mg Tablet | ePharma Typical antibiotic regimens include ceftriaxone and doxycycline, ciprofloxacin, and piperacillin/tazobactam. Curr. The use of phage therapy as an alternative treatment in CBP is a longstanding practice of both the EPTC in Georgia as well as in the Hirszfeld Institute of Immunology and Experimental Therapy in Poland (Letkiewicz, et al., 2010; Grski, et al., 2018; Ujmajuridze, et al., 2018). 6 Articles, Review: UK Department of Health, Review on Antimicrobial Resistance, This article is part of the Research Topic, https://doi.org/10.3389/fphar.2021.692614, https://emedicine.medscape.com/article/458391-treatment#d9. 27 (1), 97101. Nonbacterial prostatitis: If the prostatitis is nonbacterial, the prostate may be inflamed but uninfected. doi:10.1016/s0022-5347(06)00498-8. Administering antibiotics before transrectal prostate biopsies reduces postoperative complications such as urinary tract infections, acute prostatitis, bacteriuria, and bacteremia; new approaches to prevention are needed to reduce fluoroquinolone resistance and extended spectrum beta-lactamaseproducing E. coli infections.13,14 A 500-mg oral dose of ciprofloxacin 12 hours before transrectal prostate biopsy with a repeat dose at the time of biopsy is the typical prophylactic regimen.25 Preoperative enemas do not reduce infection rates.24 In patients who are at increased risk of harboring fluoroquinolone-resistant bacteria, preoperative stool cultures may allow for tailoring of antibiotics at the time of the procedure.17,30. Bacteriophage 1 (2), 111114. (2000). You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. Prostate-specific antigen testing is not indicated in the evaluation of acute bacterial prostatitis. Inflammatory and pain conditions of the male genitourinary tract: Prostatitis and related pain conditions, orchitis, and epididymitis. Results of analysis and cultures of fluids from the infected regionNovember 2016. No calculus was observed. from PhagoBurn: Available at: http://www.phagoburn.eu. This number puts the estimated deaths due to antibiotic-resistant infections to be higher than cancer (ONeill, 2016). 10 (5), 685688. Res. 9 (1), 3439. doi:10.1111/j.1574-695x.2010.00659.x, McNaughton Collins, M., Fowler, F. J., Elliott, D. B., Albertsen, P. C., and Barry, M. J. Urinary Tract Infection (UTI) in Males - Medscape If the patient has problems with urinating, your urologist may use a catheter to drain their bladder. information highlighted below and resubmit the form. Hoyle, N., and Kutter, E. M. (2021). (2017). The other bacteria were treated with Intesti and Fersis phage preparations from March till June 2017. Most patients can be treated with outpatient antibiotics; fewer than one in six patients will require hospitalization.6 Admission criteria are listed in Table 4. However, this is a time-consuming and costly process, rarely conducted by urologists. Recurrent prostate infection: What are the treatment options? The cultures were tested for sensitivity against Eliava Institutes standard phage cocktail preparations. Symptoms can come on quickly and include fever, chills, urinary changes, ejaculatory pain and pain in the pelvis or nearby zones. 12th ed. Patients with acute bacterial prostatitis often present with acute onset of irritative (e.g., dysuria, urinary frequency, urinary urgency) or obstructive (e.g., hesitancy, incomplete voiding, straining to urinate, weak stream) voiding symptoms. Standard Phage Preparations made by the Eliava Institute of Bacteriophages, Microbiology and Virology. chronic hypertrophy of tonsils and adenoids J35.3 fibrocystic disease of breast (female) N60.19 acute suppurative mastoiditis with subperiosteal abscess H70.019 recurrent direct left inguinal hernia with gangrene K40.41 acute upper respiratory infection with influenza J11.1 benign cyst of right breast N60.01 bunion, right great toe M21.611 Patients may also have cloudy urine or blood in the urine. Dont miss: If the chronic prostatitis is bacterial, you should use an additional code from categories B95- through B97- to identify the infectious agent, if known. (2020). Chronic prostatitis (N41.1) N41.0 N41.1 N41.2 ICD-10-CM Code for Chronic prostatitis N41.1 ICD-10 code N41.1 for Chronic prostatitis is a medical classification as listed by WHO under the range - Diseases of the genitourinary system . Resistance to one can make bacteria more sensitive to the other. O'Neill, J. Accessed May 13, 2019. NDC 0527-1948 Levofloxacin Label Information Unauthorized use of these marks is strictly prohibited. This content does not have an Arabic version. Copyright 2023 American Academy of Family Physicians. https://www.uptodate.com/contents/search. This infection may start when bacteria in the patients urine leaks into their prostate. Use of phages is known to alter the antibiotic resistance of bacteriaas bacteria evolve to resist phage action, they may become more sensitive to certain antibiotics, as antibiotics and phages have different mechanisms of action against bacteria (Hanlon, 2007). Chronic prostatitis (CP) is one of the most frequently occurring andrological and urological diseases, accounting for more than 90% of prostatitis outpatients. mBio 11 (4), e0146220. 64 (1). Scientists from the Eliava Institute collaborated with Swiss colleagues to study phage therapy as a method for reducing bacterial infection after transurethral resection of the prostate. Chronic Bacterial Prostatitis Treatment & Management. American Hospital Association ("AHA"), Checkpoint: Test Your Real-World PCNL Knowledge, Code Updates: Watch for These New Code Options in 2020, Reader Question: Steer Clear of Reporting Fluoroscopic Guidance with Lithotripsy. In this case, treatment courses with antibiotics in the patients home country may not have been adequate, with the exception of the 33-day fluoroquinolone therapy. The .gov means its official. Intravesical Bacteriophages for Treating Urinary Tract Infections in Patients Undergoing Transurethral Resection of the Prostate: a Randomised, Placebo-Controlled, Double-Blind Clinical Trial. Institute of Medical Sciences, Banaras Hindu University, India, Mehr Chand Mahajan DAV College for Women Chandigarh, India, Department for Cardiovascular and Thoracic Surgery, German Heart Center Berlin, Germany, Mazandaran University of Medical Sciences, Iran. Re-Establishing a Place for Phage Therapy in Western Medicine. Dis. A convincing history and physical examination are typically sufficient to diagnose acute bacterial prostatitis. Nonbacterial prostatitis is divided into two types: prostatitis with inflammatory cells in semen or urine and prostatitis with no signs of inflammatory cells. A., Byren, I., and Hoey, C. T. (2010). FIGURE 1. The prostate gland, about the size of a walnut, is located just below the bladder in men. "It's the base of the pyramid. AVJ and PJ are joint owners of Vitalis Phage Therapy. Viruses 5 (3), 806823. The patient had a daily low-grade fever and chills: 37.537.7C. Many cases of CBP are complicated by infections caused by both nosocomial and community acquired multidrug resistant bacteria. Urethral instillations were not done after the initial 10days to avoid urethral irritation. Specific Guidelines For Using Icd-10-cm Flashcards | Quizlet Phage-Antibiotic Synergy Is Driven by a Unique Combination of Antibacterial Mechanism of Action and Stoichiometry. You may opt-out of email communications at any time by clicking on A TRUS performed in November 2017 revealed that the prostate size had reduced to 14.38ml, with no prostatic inflammation present. Cdd 13 (3), 309323. Anatomical limitations and antimicrobial . It is a long-lasting and debilitating condition that severely deteriorates the patients quality of life. A., et al. The antimicrobial agents available for treatment of enterococcal infection are reviewed here, followed by treatment approaches for clinical syndromes caused by enterococci. Patients who remain febrile after 36 hours or whose symptoms do not improve with antibiotics should undergo transrectal ultrasonography to evaluate for prostatic abscess. Biofilms are at the root of many chronic bacterial infections, including CBP (Costerton, et al., 1999). information and will only use or disclose that information as set forth in our notice of Relieving urinary obstruction is an important treatment consideration in clearing the infection and providing pain relief.6 However, the best approach to this intervention has not been determined. Prevalence of a Physician-Assigned Diagnosis of Prostatitis: The Olmsted County Study of Urinary Symptoms and Health Status Among Men. Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Meyrier A, et al. Phages have numerous advantages in the treatment of chronic bacterial infections such as CBP. chronic prostatitis due to proteus. No pathogenic bacteria grew in these cultures, and the leukocyte counts in the EPS and semen were normal. These included single dose Azithromycin 1g, followed by a course of Doxycycline 200mg for 10days, then the third course of antibiotics with Ofloxacin 400mg for 23days, and finally a combination of Ciprofloxacin 1g taken orally and Amikacin 750mg given intravenously for 10days. If there is concern for obstructed voiding, postvoid residual urine volumes should be measured using ultrasonography. Perioperative antibiotics have reduced the rates of postoperative prostatitis to between 0.67% and 2.10% of cases, but have increased the incidence of prostatitis caused by fluoroquinolone-resistant bacteria and extended spectrum beta-lactamaseproducing E. coli.1318. The physical examination should include an abdominal examination to detect a distended bladder and costovertebral angle tenderness, a genital examination, and a digital rectal examination. Table 2 shows the outcomes of the tests. 12:692614. doi: 10.3389/fphar.2021.692614. This failure of antibiotics in providing clinical improvement led to his pursuit of an alternative treatment. This may be due to irritation caused by . A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This content is owned by the AAFP. Phage therapy is a viable treatment method for patients suffering from bacterial infections untreatable with antibiotics due to bacterial resistance, antibiotic allergy, or undesirable side effects of long-term use of antibiotics. information highlighted below and resubmit the form. AJ, PJ, and NH have written the case report. Prostatitis - Symptoms and causes - Mayo Clinic 116 (4), 509525. Urologists may also use alpha-blockers to help relax a patients muscles around their prostate and the base of their bladder, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook. Microbiol. Chronic prostatitis due to proteus Phimosis and balanoposthitis Encysted right hydrocele , male Open hydrocelectomy of hydrocele of spermatic cord Benign prostatic hypertrophy with urinary obstruction Total transurethral prostatectomy via cystoscope Acute and chronic cervicitis Vaginal hysterectomy Acute Bacterial Prostatitis: Diagnosis and Management | AAFP He had no history of urological problems before this diagnosis. Semen analysis can complement but not replace the 4-glass test. Classification, Epidemiology and Implications of Chronic Prostatitis in North America, Europe and Asia. Prospective cohort study, retrospective cohort study, Blood cultures are indicated in patients with a body temperature greater than 101.1F (38.4C), a possible hematogenous source of infection (e.g., endocarditis with. Su, Z. T., Zenilman, J. M., Sfanos, K. S., and Herati, A. S. (2020). In November 2016, the patient traveled to Tbilisi, Georgia, to explore phage therapy at the EPTC as a potential treatment for his condition. (2011). AskMayoExpert. It is most common in men under 50 years of age. Most patients can be treated as outpatients with oral antibiotics and supportive measures. Click here for an email preview. If you are a Mayo Clinic patient, this could *Correspondence: Apurva Virmani Johri, apurva@vitalisphagetherapy.com, Pharmacological and Immunological Action of Bacteriophages: Focus on Phage Therapy, View all A urologist can look for any underlying problems, such as a blockage, that would prevent treatment from being effective or make you more vulnerable to infection. Prostatic abscesses occur in 2.7% of patients with acute bacterial prostatitis and require urology consultation for drainage.6 Risk factors for prostatic abscess include long-term urinary catheterization, recent urethral manipulation, and an immunocompromised state. Frequently encountered strains include Vancomycin resistant Enterococci, Extended Spectrum Beta Lactam resistant Escherichia coli, other gram-positive organisms such as Staphylococcus and Streptococcus, Enterobacteriaceae such as Klebsiella and Proteus, and Pseudomonas aeruginosa, among others. N41.1 is a valid billable ICD-10 diagnosis code for Chronic prostatitis . Mayo Clinic; 2021. On the fifth day after starting phage therapy, the patients body temperature normalized, and did not subsequently increase beyond 37C. M21.42 12. Krieger, J. N., Lee, S. W. H., Jeon, J., Cheah, P. Y., Liong, M. L., and Riley, D. E. (2008). Imaging studies are usually unnecessary during the initial evaluation, but may help when the diagnosis remains unclear or when patients do not respond to adequate antibiotic therapy. Answer: You should report N41.0 (Acute prostatitis) for acute prostatitis. Trends Microbiol. Yes Inflammation of the prostate gland. This reduces future probability of development of conditions caused by chronic inflammation, such as cancer (Grski, et al., 2018). The patients urinary stream may be slower or interrupted. Fever, chills, muscle aches and other flu-like symptoms (with acute bacterial prostatitis) Frontiers | Case Report: Chronic Bacterial Prostatitis Treated With Answer: The four types of prostatitis are as follows: Dont miss: Prostatitis can be bacterial or nonbacterial. information submitted for this request. Continuing targeted research would allow more countries to adopt this treatment methodology for infection control. The prostate's primary function is to produce the fluid that nourishes and transports sperm (seminal fluid). When a patient has prostatitis, which means their prostate is swollen, tender, and inflamed, you must check the medical documentation for specific details. Nefrol 56 (2), 99107. Bacteriophage therapy is the use of lytic bacterial viruses to treat bacterial infections. Night sweats, chills, excessive perspiration, and weakness had fully subsided by the end of June 2017. At the clinic, a full urologic workup was performed. Assoc. In this review . This will aid in their voiding. (1998). Chemotherapy 49 (6), 269279. Chronic prostatitis 2016 2017 2018 2019 2020 2021 2022 2023 Billable/Specific Code Adult Dx (15-124 years) Male Dx N41.1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Copyright 2021 Johri, Johri, Hoyle, Pipia, Nadareishvili and Nizharadze. Nerve damage in the lower urinary tract, caused by surgery or trauma, can cause nonbacterial prostatitis. Urine testing before and after prostatic massage (also known as the Meares-Stamey 2-glass or 4-glass test) is useful in diagnosing chronic prostate and pelvic disorders; however, such testing should not be performed in patients with suspected acute bacterial prostatitis because prostatic massage increases the risk of bacteremia, and subsequently, sepsis. 39, 4856. Microbiol. Microbiol. The reduction in quality of life is comparable with that of patients suffering from congenital heart failure and diabetes mellitus (McNaughton Collins, et al., 2001). ICD-10-CM: 5 FAQs Solve All of Your Prostatitis ICD-10-CM Coding Conundrums, 5 FAQs Solve All of Your Prostatitis ICD-10-CM Coding Conundrums, Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), Acute (sudden) bacterial prostatitis (ABP). doi:10.1128/mBio.01462-20, Loc-Carrillo, C., and Abedon, S. T. (2011). Levofloxacin tablets are indicated in adult patients for the treatment of chronic bacterial prostatitis due to Escherichia coli, Enterococcus faecalis, or methicillin-susceptible Staphylococcus epidermidis [see Clinical Studies ( 14.6)]. doi:10.1016/s0966-842x(00)01913-2, Mazzoli, S. (2010). AskMayoExpert. Infiltration of inflammatory cells into the parenchyma of prostate. Chronic bacterial prostatitis (CBP) Front. While these are commercial interests of the authors, the study was conducted in the absence of commercial or financial relationships that could be construed as potential conflict of interest. The Subgingival Microbiome of Periodontal Pockets With Different Several conditions present with similar symptoms and must be differentiated from acute bacterial prostatitis (Table 3). Significant improvements in symptoms and re-testing of samples after bacteriophage treatment indicated a reduction in the bacterial load and resolution of the infection. Symptoms of CBP are usually prolonged. Future Microbiol. The details of these phage preparations are given in Appendix Table A1. doi:10.2174/156720181303160520193946, Charalabopoulos, K., Karachalios, G., Baltogiannis, D., Charalabopoulos, A., Giannakopoulos, X., and Sofikitis, N. (2003). Chronic bacterial prostatitis due to Escherichia coli, Enterococcus faecalis, or Staphylococcus epidermidis. It entails cultures and microscopic examination of urine samples collected pre and post-prostatic massage (Nickel, et al., 2006; Sharp, et al., 2010). 21 (3), 427436. Treatment with antibiotics often leads to quick relief. The patient decided to undergo phage therapy. Lytic phages propagate by injecting their DNA into the bacterial cell, disrupting bacterial metabolism and replicating inside the cell. Acute bacterial prostatitis is an acute infection of the prostate gland that causes urinary tract symptoms and pelvic pain in men.1 It is estimated to comprise up to 10% of all prostatitis diagnoses, and its incidence peaks in persons 20 to 40 years of age and in persons older than 70 years.2 Most cases can be diagnosed with a convincing history and physical examination.3 Although prostatitis-like symptoms have a combined prevalence of 8.2% in men, the incidence and prevalence of acute bacterial prostatitis are unknown.4, Most cases of acute bacterial prostatitis are caused by ascending urethral infection or intraprostatic reflux and are facilitated by numerous risk factors (Table 1).410 These infections may occur from direct inoculation after transrectal prostate biopsy and transurethral manipulations (e.g., catheterization and cystoscopy).68 Occasionally, direct or lymphatic spread from the rectum or hematogenous spread via bacterial sepsis can cause acute bacterial prostatitis.11 Overall, community-acquired infections are three times more common than nosocomial infections.3, Acute bacterial prostatitis is most frequently caused by Escherichia coli, followed by Pseudomonas aeruginosa, and Klebsiella, Enterococcus, Enterobacter, Proteus, and Serratia species.3,5,7,10 In sexually active men, Neisseria gonorrhoeae and Chlamydia trachomatis should be considered.12 Patients who are immunocompromised (e.g., persons with human immunodeficiency virus) are more likely to have uncommon causes for prostatitis, such as Salmonella, Candida, and Cryptococcus species (Table 2).3,7,10,12, Infections that occur after transurethral manipulation are more likely to be caused by Pseudomonas species, which have higher rates of resistance to cephalosporins and carbapenems.7 Transrectal prostate biopsies can cause postoperative infections. A few countries have allowed therapeutic use of phages in a regulated manner. (Retrieved April 2020), Pires, D., Melo, L., Vilas Boas, D., Sillankorva, S., and Azeredo, J. All Rights Reserved. For example, your urologist will give a patient with acute bacterial prostatitis antibiotics to take for at least 14 days. Inflammation of the prostate. (2006). Current Opinion in Infectious Diseases. Authors Rong-Hai Li , Qi Li , Xiao-Hong Shang , Qing-Yong Wang PMID: 30549978 DOI: 10.7754/Clin.Lab.2018.180602 No abstract available Publication types Case Reports MeSH terms Adult FAQ 4: What are common symptoms of prostatitis? 40 (4), 326331. Microb. Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. 2021; doi:10.3390/ijms22157854. Urinary tract infections (UTIs) occur among adult males. N28.89. from Medscape: Available at: https://emedicine.medscape.com/article/458391-treatment#d9. Phage Therapy as an Alternative or Complementary Strategy to Prevent and Control Biofilm-Related Infections. The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). (2018). When a patient has prostatitis, which means their prostate is swollen, tender, and inflamed, you must check the medical documentation for specific details. impacted renal calculus with medullary sponge kidney. Since 1968, the standard diagnostic test to detect pathogens causing CBP is the Meares-Stamey 4-glass test (Magri, et al., 2009). Phage Therapy: Bacteriophages as Natural, Self-Replicating Antimicrobials, in In Practical Handbook Of Microbiology. We hope that case reports of patients recovering from chronic bacterial infections by undergoing phage therapy would provide valuable data to researchers around the world, and further their conviction to pursue research in this field. Urgent need to urinate. Table 1. If youve ever wondered how risk adjustment works, instructor Sheri [], Question: My urologist made a transverse inguinal incision with a 15-blade and dissection was carried [], Note Whether Patient Has Interstitial Cystitis or Not, Question:My urologist performed a cysto, bladder biopsy, fulguration, hydrodistention, and heparin instillation. No evidence of any calculus or hydronephrosis was noted. ICD-10 Code for Chronic prostatitis- N41.1- Codify by AAPC Management of acute bacterial prostatitis should be based on severity of symptoms, risk factors, and local antibiotic resistance patterns (Figure 1). J. Antimicrob. Phage therapy is a promising new approach for the treatment of CBP and related conditions, with patients from around the world seeking treatment with bacteriophage (Su, et al., 2020). Answer: The four types of prostatitis are as follows: Patients may report suprapubic, rectal, or perineal pain.6,9,11 Painful ejaculation, hematospermia, and painful defecation may be present as well.19 Systemic symptoms, such as fever, chills, nausea, emesis, and malaise, commonly occur, and their presence should prompt physicians to determine if patients meet clinical criteria for sepsis. Nonbacterial prostatitis: If the prostatitis is nonbacterial, the prostate may be inflamed but uninfected. Cancers | Free Full-Text | Insights into the Human Microbiome and Its 11 (4), 461477. doi:10.3390/v5030806. Oral antimicrobial agents are commonly used to treat CBP, chief among them fluoroquinolones, tetracyclines, macrolides, and trimethoprim-sulfamethoxazole. Initial empiric antibiotic therapy should be based on the suspected mode of infection and the presumed infecting organism (Table 5).5,79,1517,24,25 Antibiotics should be adjusted based on culture and sensitivity results, when available.10,15 Men younger than 35 years who are sexually active and men older than 35 years who engage in high-risk sexual behavior should be treated with regimens that cover N. gonorrhoeae and C. trachomatis.12 Patients with risk factors for antibiotic resistance require intravenous therapy with broad-spectrum regimens because of the high likelihood of complications.7,8,15,24, The duration of antibiotic therapy for mild infections is typically 10 to 14 days (with a two-week extension if the patient remains symptomatic), or four weeks for severe infections.9,26 Febrile patients should generally become afebrile within 36 hours of starting antibiotic therapy.27 Otherwise, imaging with transrectal ultrasonography, CT, or MRI is required to rule out prostatic abscess.27 After severe infections improve and the patient is afebrile, antibiotics should be transitioned to oral form and continued for another two to four weeks.5,28 Repeat urine cultures should be obtained one week after cessation of antibiotics to ensure bacterial clearance.12, Supportive measures include providing antipyretics, hydrating fluids, and pain control.
