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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.DiagnosisICD-10 CodePertinent FindingsMild persistent asthma, exacerbationJ45.51Expiratory wheezes, shortness of breath, chest tightness, accessory muscle use, worsening cough and chest tightness when lying down (Domino, Baldor, Golding, & Stephens, 2019).COPDJ44.9Cough, prior history of smoking, current exposure to secondhand smoke, shortness of breath (Domino et al., 2019). Gastro esophageal reflux diseaseK21.9Nocturnal cough, worsening cough chest tightness when lying down, obesity (Domino et al., 2019).Diagnostics: List tests you will order this visitTestRationale/CitationSpirometryPerforming 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-rayA chest x-ray can rule out other etiologies of cough such as pneumonia (Domino et al., 2019). CBCA CBC can help rule out infectious etiology (David & Esherick, 2019).CMPKidney 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: AssessmentMedical 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:PlanAddress 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 foreach intervention.
Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent.DrugDosageLength of TreatmentRationale/CitationPrednisolone1mg/kg (50 mg) once a day in the morning7 daysFor mild to moderate asthma exacerbations, 1mg/kg of an oral corticosteroid is standard per clinical guidelines (David & Esherick, 2019). Beclomethasone dipropionate (QVAR)80 mcg daily4-6 weeks.To help control her asthma, an inhaled corticosteroid should be added to her SABA to help controlher 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 Albuterol90 mcg every 4 hours prnIndefinitely Continuing Tina’s SABA medication is appropriate due to her symptoms to help prevent severe exacerbations and hospitalization (Woo & Robinson, 2016).