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3 Click or tap here to enter text. 8 Click or tap here to enter text. 13 Click or tap here to enter text. 4 Click or tap here to enter text. 9 Click or tap here to enter text. 14 Click or tap here to enter text. 5 Click or tap here to enter text. 10 Click or tap here to enter text. 15 Click or tap here to enter text. Diagnosis ICD-10 Code Pertinent Findings Mild persistent asthma, exacerbation J45.51 Expiratory wheezes, shortness of breath, chest tightness, accessory muscle use, worsening cough and chest tightness when lying down (Domino, Baldor, Golding, & Stephens, 2019). COPD J44.9 Cough, prior history of smoking, current exposure to secondhand smoke, shortness of breath (Domino et al., 2019). Gastro esophageal reflux disease K21.9 Nocturnal cough, worsening cough chest tightness when lying down, obesity (Domino et al., 2019). Diagnostics: List tests you will order this visit Test Rationale/Citation Spirometry Performing a full spirometry exam will provide more information on the severity of the patient’s asthma and level of obstruction. A spirometry test can also help rule out differential diagnosis of chronic obstructive pulmonary disease (Domino et al., 2019). Chest x-ray A chest x-ray can rule out other etiologies of cough such as pneumonia (Domino et al., 2019). CBC A CBC can help rule out infectious etiology (David & Esherick, 2019). CMP Kidney function test before steroid administration due to uncontrolled diabetes (David & Esherick, 2019). Click or tap here to enter text. Click or tap here to enter text. A: Assessment Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis. P: Plan Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention.
Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent. Drug Dosage Length of Treatment Rationale/Citation Prednisolone 1mg/kg (50 mg) once a day in the morning 7 days For mild to moderate asthma exacerbations, 1mg/kg of an oral corticosteroid is standard per clinical guidelines (David & Esherick, 2019). Beclomethasone dipropionate (QVAR) 80 mcg daily 4-6 weeks. To help control her asthma, an inhaled corticosteroid should be added to her SABA to help control her symptoms in the future (Woo & Robinson, 2016). A stepwise approach should be used to taper medications as need, therefore a low dose should be start first (Woo & Robinson, 2016). If symptoms control is not obtained in 4-6 weeks, then a step-up of patient QVAR dose may be needed (Woo & Robinson, 2016). Continue Albuterol 90 mcg every 4 hours prn Indefinitely Continuing Tina’s SABA medication is appropriate due to her symptoms to help prevent severe exacerbations and hospitalization (Woo & Robinson, 2016).

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