Asthma Case Study 6 year old male,
Asthma Case Study 6 year old male, established patient. Mother states son has had an exacerbation of asthma symptoms during their family vacation to a dude ranch in Arizona last week. Mom stated that there was a lot of second hand smoke at the ranch. Mother states the albuterol inhaler was last used this morning, about 90 minutes prior to arrival, but seems less effective than usual. Father also has asthma. Exam Vital Signs: BP 110/67, HR 100, T 98.9°F, R 28, Wt. 25kg, SpO2 95% General appearance: mild respiratory distress, alert. ENT: oropharynx clear, no plaques or exudates, minimal nasal flaring noted, no accessory muscle use. Respiratory: diminished breath sounds with mild expiratory wheezing heard throughout. Cardiovascular: no murmurs, no rubs, no gallops. Assessment and Plan Intermittent asthma with acute exacerbation caused by exposure to second-hand smoke Nebulizer treatment given, with improvement; 3-day course of oral prednisoine Family history of asthma Image transcription text Step 1: Receive an Activity assignment and an assignment from your instructor. Step 2: Review the Code Set you are assigned to. Use your coding manual(s) to assign the correct code(s) in the proper sequence. In addition to assigning the cod… Show more
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