Nursing Homework week 12

Acute Bronchitis

Patient Demographics

· Age: 34 years

· Sex: Female

· Race: Hispanic

· Insurance: PPO

· Referral: None

Reason for Visit

· New consult

Chief Complaint

· Cough, chest congestion, and fatigue x5 days

Type of H&P

· Expanded problem-focused

Decision-Making Type

· Low complexity

Clinical Notes Patient presents with productive cough, mild wheezing, sore throat, afebrile. Lungs: scattered rhonchi, good air entry. No respiratory distress. Diagnosed with acute bronchitis. Encouraged hydration, OTC antitussives, albuterol PRN. No red-flag symptoms. Return precautions given.

ICD-10 Codes

· J20.9 — Acute bronchitis, unspecified

· R05.1 — Acute cough

· R09.81 — Nasal congestion

CPT Codes

· 99213 — Established patient visit, low complexity