Office Visit Note
Narrative: ``` SUBJECTIVE: Chief Complaint: URI symptoms x 4-5 days HPI: Almost 6-year-old with upper respiratory symptoms for 4-5 days. Mild cough present. Fever for 3 days, now resolved. Siblings experiencing similar illness. Child currently improving. OBJECTIVE: Physical Examination: - General: Well-appearing, alert, appropriate activity level, afebrile - HEENT: Nasal congestion noted, oropharynx mildly erythematous without exudate ASSESSMENT: 1. Upper respiratory infection, viral (ICD-10: J06.9) Clinical presentation consistent with viral URI. Fever resolved, improving course. Household contacts with similar illness supports viral etiology. PLAN: Supportive care with adequate hydration and rest. Honey for cough suppression as needed. Acetaminophen or ibuprofen for discomfort if needed. Return if develops high fever, difficulty breathing, worsening symptoms, or no improvement within 7-10 days. Follow-up PRN. CPT: 99212 REFERENCES: 1. American Academy of Pediatrics. Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics. Pediatrics. 2013;132(6):1146-1154. 2. Harris AM, et al. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults. Ann Intern Med. 2016;164(6):425-434. CODES: CPT 99212 | ICD-10 J06.9 [routine normal findings assumed unless specified] ```