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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