Question

Directions: Read through this progress note on Roy A. Takashima. Abstract information from the note about the subjective symptoms, objective findings, and diagnoses. List the diagnostic and procedure codes you think this case would warrant.

The Case:

Takashima, Roy A.

October 5, 20xx

Patient presents with many things going on. First, he's had no difficulties after the feral cat bite, and the cat was normal on quarantine. He seemed to be recovering from the flu but is plagued with a persistent cough and pain down the center of his chest attributed to bronchitis without fever or grossly discolored phlegm. Physical examination shows expiratory rhonchi and gross exacerbation of his cough on forced expiration. Spirometry before and after bronchodilator was remarkably good: he is symptomatically improved with a Proventil inhaler, which he is given as a sample. I don't think other antibiotics would help. His reflux is under good control with proprietary antacids with a clear examination. He has several areas of seborrheic keratoses on his face and head that need attention. Finally, in follow-up, he needs a complete physical examination. - Ting Cho, MD

Diagnosis, Influenza and acute bronchitis

Question:

Subject symptoms found in this case?

Answer 1

Book picture of bronchitis.

A complete history must be obtained, including information on exposure to toxic substances and smoking. Symptoms of bronchitis include the following.

Cough (the most commonly observed symptom)

Sputum production (clear, yellow, green, or even blood-tinged)

Fever (relatively unusual; in conjunction with cough, suggestive of influenza or pneumonia)

Nausea, vomiting, and diarrhea (rare)

General malaise and chest pain (in severe cases)

Dyspnea and cyanosis (only seen with underlying chronic obstructive pulmonary disease [COPD] or another condition that impairs lung function)

Sore throat

Runny or stuffy nose

Headache

Muscle aches

Extreme fatigue.

The complaints that the patient presented are.

Persistent cough

Pain in the centre of the chest

phelgam

Book picture of physical examination in acute bronchitis.

The physical examination findings in acute bronchitis can vary from normal-to-pharyngeal erythema, localized lymphadenopathy, and rhinorrhea to coarse rhonchi and wheezes that change in location and intensity after a deep and productive cough.

Patient symptoms.

Expiratoroty rhonchi

Exacerbaration of cough on expiration.

Diagnosis of acute bronchitis.

Bronchitis may be suspected in patients with an acute respiratory infection with cough; yet, because many more serious diseases of the lower respiratory tract cause cough, bronchitis must be considered a diagnosis of exclusion.

Complete blood count (CBC) with differential

Procalcitonin levels (to distinguish bacterial from nonbacterial infections)

Sputum cytology (if the cough is persistent)

Blood culture (if bacterial superinfection is suspected)

Chest radiography (if the patient is elderly or physical findings suggest pneumonia)

Bronchoscopy (to exclude foreign body aspiration, tuberculosis, tumors, and other chronic diseases)

Influenza tests

Spirometry

Laryngoscopy (to exclude epiglottitis)