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1. what is the most probable diagnosis. explain 2. should any additional diagnostic tests be performed to confirm the diagnosis? 3. suggest the treatment strategy

1. what is the most probable diagnosis. explain 2. should any additional diagnostic tests be performed to confirm the diagnosis? 3. suggest the treatment strategy

Understanding Health Insurance: A Guide to Billing and Reimbursement
Understanding Health Insurance: A Guide to Billing and Reimbursement
14th Edition
ISBN:9781337679480
Author:GREEN
Publisher:GREEN
Chapter6: Icd-10-cm Coding
Section: Chapter Questions
Problem 199R
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1. what is the most probable diagnosis. explain
2. should any additional diagnostic tests be performed to confirm the diagnosis?
3. suggest the treatment strategy

Patient L., a 25-year-old female, a painter Complaints: dyspnea attacks during physical exercises daily. Medical history: suffers from episodes of suffocation since 14 years old. These attacks were usually provoked by strenuous exercises and sometimes occurred at night (1-2 times per month). She used was administrated short-acting beta2 agonists as required to alleviate her symptoms. Current exacerbation since last week (after a meticulous inquiry, she remembered that she have purchased new primer for her art workshop at this very time), when dyspnea attacks became daily and nocturnal symptoms appeared. Family history: her mother suffers from polypose rhinosinusitis. Allergy history: penicillin, mold and pollen cause a runny nose, cough, and attacks of dyspnea.
Transcribed Image Text:Patient L., a 25-year-old female, a painter Complaints: dyspnea attacks during physical exercises daily. Medical history: suffers from episodes of suffocation since 14 years old. These attacks were usually provoked by strenuous exercises and sometimes occurred at night (1-2 times per month). She used was administrated short-acting beta2 agonists as required to alleviate her symptoms. Current exacerbation since last week (after a meticulous inquiry, she remembered that she have purchased new primer for her art workshop at this very time), when dyspnea attacks became daily and nocturnal symptoms appeared. Family history: her mother suffers from polypose rhinosinusitis. Allergy history: penicillin, mold and pollen cause a runny nose, cough, and attacks of dyspnea.
Physical examination: Lungs auscultation: respiration rate - 16 per min, vesicular breathing, singular dry and whistling rales increasing on forced expiration. HR - 68 per min. BP - 110/60 mm Hg. Laboratory tests: Full blood count: WBC - 5 x109/L (N 4 - 10 x109/L); Hb – 13.5 (N 12 to 18 gm/dL); RBC – 4,7x1012/L (N 3.6-4.85x1012/L); bands – 1% (N 2%), segments - 65% (N 36-75%), lymphocytes - 22% (N 10-50%), monocytes - 5% (3-8%), eosinophils - 7% (0-5%); platelets 240 (N 150 – 450 x10 x10°/L); ESR – 9 mm/h (N 10 mm/h). Ig E- 200 IU (0-100 IU). Sputum analysis: leucocytes - 20-40 in I/p/f, eosinophils - 40-60-80 in I/p/f, Curschmann's spirals and Charcot- Leyden crystals are found.
Transcribed Image Text:Physical examination: Lungs auscultation: respiration rate - 16 per min, vesicular breathing, singular dry and whistling rales increasing on forced expiration. HR - 68 per min. BP - 110/60 mm Hg. Laboratory tests: Full blood count: WBC - 5 x109/L (N 4 - 10 x109/L); Hb – 13.5 (N 12 to 18 gm/dL); RBC – 4,7x1012/L (N 3.6-4.85x1012/L); bands – 1% (N 2%), segments - 65% (N 36-75%), lymphocytes - 22% (N 10-50%), monocytes - 5% (3-8%), eosinophils - 7% (0-5%); platelets 240 (N 150 – 450 x10 x10°/L); ESR – 9 mm/h (N 10 mm/h). Ig E- 200 IU (0-100 IU). Sputum analysis: leucocytes - 20-40 in I/p/f, eosinophils - 40-60-80 in I/p/f, Curschmann's spirals and Charcot- Leyden crystals are found.
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