Office Visit Note
Narrative: ─────────────────────────────── CLINICAL PEARLS ─────────────────────────────── • Oseltamivir window has closed at 4-5 days of illness—supportive care is appropriate. Worth noting that post-influenza cough can persist 2-3 weeks and doesn't by itself warrant antibiotics. • Coarse bronchial breath sounds with clear lungs and afebrile status suggest airway inflammation without consolidation. If fever recurs after this initial defervescence, consider secondary bacterial pneumonia—that "second sick" pattern is the one to watch for. ─────────────────────────────── SUBJECTIVE: Chief Complaint: Influenza B with persistent cough HPI: 11-year-old male with confirmed influenza B presenting with 4-5 days of fever, now afebrile for approximately 24 hours. He has developed a coarse cough that is interfering with sleep. No difficulty breathing, chest pain, or worsening symptoms reported. OBJECTIVE: Physical Examination: - General: Alert, tired-appearing, non-toxic, in no acute distress - HEENT: Ears clear bilaterally, oropharynx without erythema or exudate, mucous membranes moist - Respiratory: Coarse bronchial breath sounds, no wheezing, no crackles, no retractions, good air entry bilaterally - Hydration: Normal ASSESSMENT: 1. Influenza B, confirmed (ICD-10: J10.1) Day 4-5 of illness with defervescence over the past 24 hours, consistent with expected viral course. No signs of secondary bacterial infection or lower respiratory complication at this time. 2. Acute bronchitis, post-influenza (ICD-10: J20.9) Coarse bronchial breath sounds with clear lung fields suggest airway inflammation without consolidation. Cough interfering with sleep is consistent with post-viral bronchial irritation. PLAN: Supportive care with adequate hydration, rest, and honey for cough suppression at bedtime. Oseltamivir not indicated given duration of illness well beyond the 48-hour treatment window. Anticipate cough may persist for 2-3 weeks as airways recover. Return if fever recurs after this period of defervescence, as this pattern would raise concern for secondary bacterial pneumonia. Also return for any new difficulty breathing, increased work of breathing, or inability to maintain hydration. May return to school when afebrile for 24 hours without antipyretics and clinically improving. Follow-up PRN. CPT: 99213 ───────────────────────────────────────── CODES: CPT 99213 | ICD-10 J10.1, J20.9