HCS 214 Week 3 Respiratory System–Analyzing a Progress Note

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HCS 214 Week 3 Respiratory System–Analyzing a Progress Note
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Respiratory System – Analyzing a Progress Note

 

Part 1

 

Using the following progress note, define the highlighted terms within the chart provided. 

 

This patient was transported to the Pediatric Emergency Room and is being assessed by the E.R. doctor on call.

 

Progress Note:

 

Subjective: The patient is a 5 y.o. female who presents with her mother to the emergency room with a 3 day history of low grade fever 99.5, productive cough with yellow sputum, runny nose, and some wheezes. The patient has a history of asthma that is noted as being well controlled. She does have a history of pneumonia 12/2013. Her current medications include Flovent 44mcg 2 puffs bid, Proair inhaler 2 puffs every 6 hours prn. Patient has used Proair every 6 hours over 48 hours with little relief of symptoms.

 

Objective: Vital signs 99.8 orally, 100/60, pulse 88, respirations 26. Audible wheezes noted. Lungs fine expiratory wheezes throughout. Pulse ox 93% on room air.

 

Assessment: 5 y.o. with asthmatic exacerbation and acute bronchitis.

Plan: Portable chest x-ray, Xopenex aerosol 0.625mg x1, complete blood count, sputum culture, arterial blood gases: Start oxygen at 1 Liter, recheck pulse ox after aerosol. Consult pulmonologist for further orders.

 

Lisa Jones, PA

*Do not forget to include the sources for your definitions.
Medical term
Definition
Sources
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Part 2

 

Using the information in the progress note, decide which code correctly represents the diagnosis. Underline the code of your choice.

 

Medical term
Medical code
Asthma with acute exacerbation
J44.9 COPD unspecified

 

J45.902 Asthma, unspecified type, with status asthmaticus

 

J45.901 Asthma, unspecified type, with (acute) exacerbation

 

J45.2 Mild intermittent asthma
Bronchitis, acute
J68.0 Bronchitis and pneumonitis due to fumes and vapors

 

J22 Uspecified lower respiratory infection

 

J20.5  Acute bronchitis due to RSV

 

J20.9 Acute bronchitis
Pneumonia
P23.9 Congenital pneumonia

 

J18.9 Pneumonia, unspecified organism

 

J12.89 Pneumonia, viral

 

J18.2 Hypostasis- Hypostatic pneumonia unspecified organism
References
Centers for Medicare & Medicaid Services (23 Oct. 2014). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.” Retrieved from

https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx

 
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