Office Visit Note
Narrative: ``` SUBJECTIVE: Chief Complaint: URI symptoms HPI: 8-year-old presenting on day 4 of upper respiratory infection symptoms with cough and low-grade fever. Siblings at home with similar illness. PMH: Psoriasis, recently started on biologic therapy (parent unsure of specific medication name). Parent reports significant skin improvement since starting new medication. OBJECTIVE: Physical Examination: - General: Alert, well-appearing, no acute distress - HEENT: Nasal congestion noted. Oropharynx mildly erythematous. TMs clear bilaterally. - Respiratory: Clear to auscultation bilaterally, no respiratory distress at rest, no retractions - Skin: Psoriatic lesions significantly improved compared to prior visits, no active flares ASSESSMENT: 1. Acute upper respiratory infection (ICD-10: J06.9) Typical viral URI presentation, day 4 of illness. Exam reassuring with no complications. 2. Psoriasis, stable on biologic therapy (ICD-10: L40.9) Excellent response to recently initiated biologic treatment. Will continue current regimen. PLAN: URI: Supportive care with rest, hydration, and symptomatic management. Acetaminophen or ibuprofen as needed for fever and discomfort. Honey (over age 1) or cough suppressant for nighttime cough if needed. Return if develops difficulty breathing, high fever persisting beyond 5-7 days, significant worsening, or new concerning symptoms. Most URIs resolve within 7-10 days. Follow-up PRN. Psoriasis: Continue current biologic therapy with excellent response. Will coordinate with dermatology for ongoing management and monitoring. Parent to follow up with dermatology as scheduled. CPT: 99213 REFERENCES: 1. American Academy of Pediatrics. Caring for Your Child's Cold or Flu. HealthyChildren.org. 2024. 2. Harris JM, et al. Biologic therapies for pediatric psoriasis. Pediatric Dermatology. 2023;40(1):22-31. 3. Menter A, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. J Am Acad Dermatol. 2019;80(4):1029-1072. CODES: CPT 99213 | ICD-10 J06.9, L40.9 [routine normal findings assumed unless specified] ```