Office Visit Note
Narrative: PATIENT: Penelope Hampton (referred to as 'Missy' in dictation) CHIEF COMPLAINT Cold with fever, headache, sore throat, and chest congestion for about 8 days HISTORY OF PRESENT ILLNESS Missy is seen today for a sick visit for an upper respiratory illness that began approximately 8 days ago (last Wednesday). She was reportedly improving, but yesterday developed a recurrence of fever along with headache, sore throat, and cough. Mom reports chest congestion. Mom requested a strep test given the symptom progression. Rapid strep test was performed in office and was negative. REVIEW OF SYSTEMS Positive for fever (onset yesterday), headache, sore throat, cough, and chest congestion. No ear complaints reported. PHYSICAL EXAM General: Well-appearing, alert. Skin appears clear, no significant concerns noted. Head/Neck: Cervical lymph nodes not swollen. Ears: Bilateral tympanic membranes clear and normal. Oropharynx: Examined (strep swab obtained); no specific abnormalities described. Lungs: **Not totally clear**, though not severely abnormal. **Audible chest congestion with productive-sounding cough on exam.** ASSESSMENT 1. Upper respiratory illness with secondary worsening — approximately 8 days into illness with initial improvement followed by recurrence of fever, headache, sore throat, and chest congestion. Rapid strep test negative. Ears clear bilaterally. Lungs not fully clear but not significantly concerning at this time. Fever may represent a late immune response as the illness resolves. PLAN 1. Upper respiratory illness with chest congestion: Strep test was negative. Discussed that the recurrent fever may represent a final immune system push at the tail end of the illness. Advised parents to monitor for persistent or worsening fever. Return precautions given — contact office if fever lingers, respiratory symptoms worsen, or new concerns arise. Supportive care in the interim. FOLLOW-UP Return if fever persists or symptoms worsen. ICD-10 CODES J06.9 - Acute upper respiratory infection, unspecified R05.09 - Other cough CPT CODES 99213 - Office visit, established patient, low complexity ───────────────────────────────────────── CODES: CPT 99213 | ICD-10 J06.9, R05.09 Source: Cloud iOS recording (2026-04-30), archived-transcript recovery, backfilled 2026-08-23; identity verified from visit transcript