Office Visit Note
Narrative: PATIENT: Elsie Sawatzke (referred to as 'unknown child' in dictation) CHIEF COMPLAINT Cough with choking episodes, noisy breathing, and vomiting from coughing fits for 3-4 days HISTORY OF PRESENT ILLNESS Peanut is an infant/young child presenting for a sick visit with 3-4 days of cough, noisy breathing, and episodes of choking on mucus. Parent reports last night was particularly bad, with severe coughing fits during which the child would choke on mucus. The child vomited during a coughing fit but seemed to feel better afterward. The symptoms follow a pattern of sounding terrible, having a big coughing fit, then improving temporarily. Parent reports the child sounds better today compared to last night. No fever reported. No family history of asthma. REVIEW OF SYSTEMS Positive for cough with choking episodes, noisy/labored breathing, and vomiting associated with coughing fits. Denies fever. Child noted to be smiling and happy in office. PHYSICAL EXAM General: Alert, smiling, happy-appearing child. No apparent respiratory distress at rest. ENT: Ears examined; at least one ear noted to be okay. Throat with visible inflammation in the upper airway. Respiratory: **Noisy, congested-sounding breathing.** Lungs auscultated — no significant distress noted on exam. Air movement present. ASSESSMENT 1. Bronchiolitis — infant/young child with 3-4 days of cough, noisy breathing, choking on mucus, and vomiting from coughing fits. Currently on approximately day 3-4 of illness, which is typically the peak. No respiratory distress on exam today. No family history of asthma. Child appears well and happy despite noisy breathing. PLAN 1. Bronchiolitis: Supportive care recommended. Humidity directed at the child's head during sleep to help with secretions. Cold air may help reduce inflammation. Parent advised to keep the child home today and tomorrow. Return precautions discussed: contact the office if the child worsens again tomorrow, develops a significant fever, or if parent has any concerns. The physician will be available tomorrow and Saturday if needed. If the child does not improve as expected, a trial of albuterol breathing treatment will be considered. Additionally, if the child has a recurrence of similar symptoms with a future illness (e.g., in 3 months), a breathing treatment trial will be pursued to evaluate for reactive airway component. FOLLOW-UP Contact the office if worsening, fever develops, or any parental concern. Saturday appointment available if not turning the corner as expected. Otherwise follow up as needed. ANTICIPATORY GUIDANCE Education provided on bronchiolitis pathophysiology — the virus infects the airway lining, causing sloughing of cells and mucus accumulation in the small airways. Explained that day 3 is typically the worst, and improvement is expected from here. Discussed how bronchiolitis differs from croup, bronchitis, pneumonia, and upper respiratory infections based on the anatomic level of inflammation. Reassured that the child's breathing pattern, despite being noisy, appears adequate. ICD-10 CODES J21.9 - Acute bronchiolitis, unspecified CPT CODES 99213 - Office visit, established patient, low complexity MDM ───────────────────────────────────────── CODES: CPT 99213 | ICD-10 J21.9 Source: Cloud iOS recording (2026-06-04), archived-transcript recovery, backfilled 2026-08-23; identity verified from visit transcript