Office Visit Note
Reason: Office Visit Narrative: **SUBJECTIVE:** Chief Complaint: Sore throat HPI: 11-year-old presenting for evaluation of sore throat. Low-grade temperature documented. Patient denies upper respiratory symptoms including cough, rhinorrhea, or congestion. No gastrointestinal symptoms reported. No rash noted. **OBJECTIVE:** Physical Examination: - General: Fatigued appearance noted. Alert and cooperative. No acute distress. - HEENT: **Posterior pharyngeal erythema present**. No tonsillar exudates noted. No peritonsillar fullness. Mucous membranes moist. No trismus. No drooling. Able to swallow secretions without difficulty. Labs: Rapid streptococcal antigen test negative **ASSESSMENT:** 1. Viral pharyngitis (ICD-10: J02.9) Clinical presentation consistent with viral pharyngitis given negative rapid strep test and constellation of symptoms. Posterior pharyngeal erythema with absence of upper respiratory symptoms noted. Supportive care appropriate at this time. **PLAN:** Supportive care for viral pharyngitis including adequate hydration and rest. Ibuprofen or acetaminophen as needed for throat pain and fever management. Encourage cool liquids and soft foods for comfort. Discussed that antibiotics are not indicated given negative strep test and viral etiology. Return precautions include worsening sore throat, difficulty swallowing or breathing, development of respiratory symptoms, persistent or worsening fatigue beyond 5-7 days, abdominal pain, or fever persisting beyond 3-4 days. These could indicate development of secondary bacterial infection or other process requiring reassessment. Follow-up if symptoms not improving within 5-7 days or if new concerns arise. CPT: 99213 **REFERENCES:** 1. Shulman ST, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis. 2012;55(10):e86-e102. 2. Wessels MR. Streptococcal pharyngitis. N Engl J Med. 2011;364(7):648-655. 3. American Academy of Pediatrics. Red Book: 2021-2024 Report of the Committee on Infectious Diseases. 32nd ed. ───────────────────────────────────────────────── CODES: CPT 99213 | ICD-10 J02.9 [Routine normal findings assumed unless specified]