Mild intermittent asthma
A 3 year old Hispanic boy with a past medical history of mild intermittent asthma is brought to the clinic by his mom who reports a chief complaint of increased wheezing for the past three days. She also reports a recent upper respiratory infection with cough, congestion, and runny nose with a low-grade fever of 100.8 degrees. She has been giving albuterol with a home nebulizer machine every 4-6 hours. The albuterol helped with the wheezing initially, but doesn’t seem to help as much now.
What is your initial assessment?
What is a diagnostic procedure that can assist with your diagnosis? What is the CPT code for it?
Using evidence-based guidelines, what is the best plan of care for this patient? Include anticipatory guidance and health promotion.
What are your top 3 differential diagnoses? Include rationale and ICD-10 code for each.
What is the billing code(s) for this visit?
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