Title ABC/123 Version X 1 Respiratory System – Analyzing a Progress Note HCS/214 Version 2 1Respiratory 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:Portablechestx-ray, Xopenex aerosol 0.625mg x1, completebloodcount, sputumculture, arterialblood 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 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 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 organismReferences 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 Copyright © XXXX by University of Phoenix. All rights reserved. Copyright © 2016 by University of Phoenix. All rights reserved. Respiratory Provider Newsletter View more » Expand view Write a 260- to 350-word section for Part 2 of the newsletter you started in Week Two of the class. Include the following: Part 2: Respiratory System · Identify the structure and function of the respiratory system. · Identify the major structures found in the system. · Define the function of this system. · Describe major disease ...

1. Title
ABC/123 Version X
1
Respiratory System – Analyzing a Progress Note HCS/214
Version 2
1Respiratory 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.

2. Plan:Portablechestx-ray, Xopenex aerosol 0.625mg x1,
completebloodcount, sputumculture, arterialblood 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
1.
2.
3.
4.

3. 5.
6.
7.
8.
9.
10.

4. 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
organismReferences
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

5. Copyright © XXXX by University of Phoenix. All rights
reserved.
Copyright © 2016 by University of Phoenix. All rights reserved.
Respiratory Provider Newsletter
View more »
Expand view
Write a 260- to 350-word section for Part 2 of the newsletter
you started in Week Two of the class. Include the following:
Part 2: Respiratory System
· Identify the structure and function of the respiratory system.
· Identify the major structures found in the system.
· Define the function of this system.
· Describe major diseases that affect the respiratory system.
· Identify one to two major diseases that affect the system.
· Describe the disease(s) identified.
· Describe major laboratory and diagnostic tests that are used to
assess respiratory diseases.
· Using the disease(s) discussed in the previous prompt, identify
the most common laboratory and diagnostic test used to assess
the disease(s).
· Describe the test identified.
· Describe the main health care providers for the respiratory
department.
· Identify the main health care providers in this department.
· Describe the roles they play (to the patient, facility, or
community) and the types of patients they see (typical
demographics, age, gender, etc.).
Cite at least 2 peer-reviewed, scholarly, or similar references.
For additional information on how to properly cite your sources,
check out the Reference and Citation Generator and Plagiarism
Checker resources in the Center for Writing Excellence.
Format your assignment according to APA guidelines.