Office Visit Note
Narrative: CHIEF COMPLAINT Noisy/labored breathing, day 3 of illness, possible croup HISTORY OF PRESENT ILLNESS Phone consultation with parent regarding their daughter who is on day 3 of a respiratory illness. Parent reports noisy breathing that has become more noticeable. The child sounds "wet and juicy" per parent description. No fever — parent has checked temperature. No retracting noted at this time. The child's voice and cry were discussed. Sleep has been affected. Day 3 to 4 is expected to be the worst of the illness course. REVIEW OF SYSTEMS Respiratory: Noisy breathing, congestion-type sounds described as "wet and juicy." Possible barky cough component discussed. Denies retracting. Denies fever. General: No acute distress described. ASSESSMENT 1. Respiratory illness, day 3, with noisy breathing — likely upper airway congestion with possible croupy component. No signs of respiratory distress or fever at this time. Phone assessment without physical exam; clinical picture consistent with a viral upper respiratory process near its expected peak. PLAN 1. Respiratory illness: Discussed that child does not appear to need urgent care or ER evaluation at this time. Advised parent to monitor the child before going to bed tonight and ensure no dramatic change in respiratory status. Reviewed red flags to watch for: high fever (e.g., 104°F), significantly increased respiratory rate (consistently in the 50s–60s suggesting increased work of breathing), or signs of significant distress — reassured parent that worsening would not be subtle. Discussed supportive measures including humidity (steamy shower), and if cough becomes more barky/croupy, placing ice in a bowl and directing cool mist near the child's face. Advised not to wake the child to administer treatments if she is sleeping comfortably. Expectation set that tonight (day 3–4) is likely the worst night and improvement is anticipated thereafter. Parent to contact the office if symptoms worsen or new concerns arise. FOLLOW-UP Parent to follow up as needed if symptoms worsen, new fever develops, or breathing becomes more labored. ICD-10 CODES J06.9 - Acute upper respiratory infection, unspecified J05.0 - Acute obstructive laryngitis [croup] CPT CODES 99441 - Telephone E/M service, 5-10 minutes ───────────────────────────────────────── CODES: CPT 99441 | ICD-10 J06.9, J05.0