iHuman Management Plan Assignment

1. Problem Statement – 5 pts

18-months-old male presents with worsening cough tachypnea, 40 nasal flaring. SP02 92%, difficulty labored breathing, intercostal retractions, febrile 102, lungs with variations of exp wheezing  all fields. Bilateral lower bases with crackles. Appetite decreased, skin tenting, pharynx erythema w/no exudates, bilateral turbinates gray/boggy, tenacious yellow drainage, enlarged left submandibular lymph node, Onset: runny nose difficulty breathing 5 days ago followed by productive cough w/ yellow sputum and fever 2 days ago. iHuman Management Plan Assignment

2. Primary Diagnosis, Differentials & Coding—10 points (all areas must be addressed)
   1. What is the primary dx ICD-10 code (1 point):

Bronchiolitis (ICD 10 code – J21.9)

1. What is your rationale for arriving at this primary diagnosis? You must integrate the pertinent finding and support your rationale with evidence-based literature (resources) (4 points) iHuman Management Plan Assignment
   

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The rationale for bronchiolitis as the primary diagnosis is supported by the clinical presentation of worsening cough, tachypnea, nasal flaring, Sp)2- 92%, difficulty beathing, intercostal retractions, fever, wheezing, crackles, gray/boggy turbinates, tenacious yellow drainage, and an enlarged left submandibular lymph node. These symptoms match with bronchiolitis.

1. Include CPT codes, and any procedural codes (such as nurse lab draws, vaccinations given, biopsies) (2 points): iHuman Management Plan Assignment

CPT Code – 99214: Established patient office visit, extended.

1. Differential diagnoses (ddx)with rationale and resources. Minimum of 3-5 differentials (primary dx does not count as a differential). For well-child visit, if there are no other health issues, then differentials are not needed. (3 points)
   1. DDx#1– Influenza; Influenza may present similar symptoms such as fever, cough, and respiratory distress. Influenza is an acute respiratory disease caused by influenza A or B virus, with clinical presentations including high-ever, body ache, headache, severe malaise, dry cough, sore throat, and runny nose (Chow et al., 2019). While influenza can cause similar respiratory symptoms, it typically presents with a more sudden onset and includes muscle aches, headache, and fatigue, which the patient in this case did not present. iHuman Management Plan Assignment
   2. DDx#2- Pharyngitis – Pharyngitis is an inflammation of the throat that present with symptoms such as sore throat, fever, and difficulty swallowing. It may be caused by either viral or bacterial infections. This was however ruled out since it does not present with wheezing, crackles, or significant respiratory distress.

• DDX #3- Pharyngitis group A Streptococcal – This is caused by Group A Streptococcus bacteria and presents with symptoms including swollen lymph nodes, and red, swollen painful throat, fever, headaches, chills, nausea, and vomiting (Mustafa & Ghaffari, 2020). In this patient, this was ruled out as the primary diagnosis since it does not present with severe respiratory symptoms as evident in this case. iHuman Management Plan Assignment

1. DDX #4 -Pneumonia – Pneumonia is likely to present with similar symptoms to bronchiolitis, but often presents with high fever, chills, and chest pain (Douros & Everard, 2020). In this case the patient did not present with chills and chest pain, which informed the decision to rule it out as a primary.
2. DDX #5 – Reactive airway disease (RAD) – According to Faria et al. (2021) reactive airways dysfunction syndrome is an acute and persistent respiratory symptoms and nonspecific bronchial hyperreactivity. RAD is likely to result to symptoms such as wheezing, coughing, and difficulty breathing. It is not typically associated with fever, crackles, and the rapid progression of symptoms, which informed the decision to rule it out as a primary diagnosis. iHuman Management Plan Assignment

3. Medications

Med: Albuterol Sulfate inhalation solution (0.083mg/mL)

Sig: Nebulized treatment with 2.5mg (0.3mL) every 4 hours for 3 days, then reassess for continued treatment.

Disp: 25-unit dose vials, 2 refills

Albuterol is a bronchodilator that helps to relax the muscles in the airway, thereby making it easier for the patient to breathe. iHuman Management Plan Assignment

4. Treatment plan / SDOH / Health Promotion – 20 pts
   1. Treatment plans-should be supported by clinical guidelines (10 points)

Supportive care; The parents were encouraged to give frequent feedings with small volumes of fluids to prevent dehydration. Another supportive car was monitoring of the oxygen saturation and using a humidified to loosen the moisture and help with congestion. Suctioning may be needed to help clear the nasal passage in case the blockage persisted. iHuman Management Plan Assignment

Monitoring the respiratory status; It is important to closely monitor the child’s breathing, oxygen saturation, and fever levels. In case the symptoms worsened such as labored breathing or oxygen saturation being below 92%, the parents were advised to seek immediate medical attention.

1. SDOH: address all 6 areas of social determinants of health

Lives in single family home with parents and sister. Parents employed full-time (father accountant, mother hygienist). Has health insurance with access to care. Does not face food insecurity.

1. Health Promotion/Anticipatory guidance: (5 points)

Vaccinations; Are up-to-date; including DTaP at 2 months, 4 months, 6 months, and 15 months, haemophilus influenza vaccine, hepatitis B, pneumococcal conjugate, and MMR. iHuman Management Plan Assignment

Second-hand Smoke exposure- The patients will be educated on the dangers of second-hand smoke exposure and encourage to provide a smoke free home environment.

Hygiene practices – The parent was educate on the importance of proper handwashing using soap and water to help prevent the spread of respiratory viruses.

5. education (10 points)- – Educate parent and patient about today’s visit/diagnosis/meds etc. iHuman Management Plan Assignment

Medication Administration: This will include provision of clear instructions on how to use the nebulizer and administer albuterol treatments safely and effectively. According to Zhao and Yu (2019) nebulization therapy fulfills the needs of pre-hospital care in the treatment of respiratory diseases by delivering a therapeutic dosage of a drug through inhalation of the drug-aerosol. iHuman Management Plan Assignment

Importance of Hydration: The importance of keeping the child well-hydrated with frequent feedings of small volumes of fluids was emphasized. According to Smith et al. (2019) maintaining nutrition and hydration status of infants with bronchiolitis is a critical aspect in management.

Suctioning (when needed): If nasal suctioning is recommended, the parents got a demonstration on the proper technique and safe use at home. Nasal suction has been shown to be an effective means of relieving the patient to help in the breathing (Schuh et al., 2023).

Fever Management: Advise parents on using lukewarm baths or cool cloths to reduce fever.

Signs of Worsening: The parents were educated about the warning signs that may need immediate medical attention, such as difficulty breathing, increased work of breathing, significant decrease in appetite iHuman Management Plan Assignment

6. Follow up- 10 pts

The parents were required to return in 2-3 days for follow-up or sooner in case the symptoms persisted. The specific instructions were to keep hydrated, appropriate use of saline drops, albuterol as needed. The parents were advised to be on the look-out for red flags such as increasing work of breathing, lethargy, dehydration, and apnea. iHuman Management Plan Assignment