Asthma exacerbation
According to the symptoms and history of the child, he is likely experiencing asthma exacerbation triggered by a recent upper respiratory infection (URI). Fukuda et al. (2020) discussed that asthma exacerbation that is induced by viruses causes airway inflammation, results in worsening of asthma and deterioration of quality of life. The increased wheezing despite frequent albuterol use suggests that the exacerbation is moderate to severe.
A key diagnostic procedure to assist with diagnosis is pulse oximetry to assess oxygen saturation. This helps determine the severity of hypoxia and guides treatment decisions.
CPT code: 94760 NONINVASIVE EAR/PULSE OXIMETRY, OXYGEN SATURATION; SINGLE DETERMINATION
Based on evidence-based guidelines the best plan of care includes (DynaMed, n.d.):
Immediate Treatment:
Will administer a short course of systemic corticosteroids (e.g., oral prednisone) to reduce airway inflammation.
Will continue albuterol treatments, increasing frequency if needed. May consider adding ipratropium bromide if severe exacerbation is noted.
Oxygen therapy will be initiated if oxygen saturation is below 92%.
Follow-up and Monitoring:
I would schedule a follow-up visit in 2-3 days to reassess the child’s condition.
Will also provide a written asthma action plan with instructions on managing symptoms and when to seek emergency care.
Anticipatory Guidance and Health Promotion:
Will educate the parents on the importance of adherence to the asthma action plan.
Environmental control measures will be discussed to reduce exposure to asthma triggers (e.g., smoke, dust, pet dander).
Will emphasize the importance of follow-up visits and regular monitoring of the child’s asthma control.
Differential Diagnoses
1. Asthma Exacerbation:
Rationale: The child\’s history of asthma and current symptoms of wheezing, cough, and respiratory distress are consistent with exacerbation.
ICD-10 Code: J45.901 UNSPECIFIED ASTHMA WITH (ACUTE)
2. Viral Bronchiolitis:
Rationale: The recent URI symptoms and age of the patient are suggestive of viral bronchiolitis, a common condition in young children that causes wheezing and respiratory distress. Erickson et al. (2023) mentioned that viral bronchiolitis starts with mild symptoms and then may progress to tachypnea, retractions, and wheezing.
ICD-10 Code: J21.9 ACUTE BRONCHIOLITIS, UNSPECIFIED
3. Pneumonia:
Rationale: The presence of a recent infection with fever, cough, and respiratory distress could indicate pneumonia, particularly if the symptoms worsen or do not respond to asthma treatment.
ICD-10 Code: J18.9 PNEUMONIA, UNSPECIFIED ORGANISM
For this visit, I would use the billing code of 99214 as the visit requires moderate level decision.
99214 OFFICE/OP VISIT, EST PT, MEDICALLY APPROPRIATE HX/EXAM; MODERATE LEVEL MED DECISION; 30-39 MIN
References:
DynaMed. (n.d.).
Erickson, E. N., Bhakta, R. T., & Mendez, M. D. (2023, June 26). Pediatric bronchiolitis. StatPearls – NCBI Bookshelf.
Fukuda, Y., Akimoto, K., Homma, T., Baker, J. R., Ito, K., Barnes, P. J., & Sagara, H. (2020). Virus-Induced Asthma Exacerbations: SIRT1 Targeted approach. Journal of Clinical Medicine, 9(8), 2623.
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