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Otherwise healthy adolescent with a common cold
CC : Sore throat
HPI : Patient is a 15 year old male who presents with a sore throat which began three days ago.
ROS : Negative for fevers or chills; positive for mild malaise
Physical Exam
General appearance: No acute distress; conversant
. Vitals: 98.6, 72, 20, 110/74
HEENT: Oropharynx is clear with no mucosal ulcerations; normal posterior pharynx without erythema or exudate. External auditory canals patent with pearly TMs
Lungs: CTA with normal respiratory effort and no intercostal retractions
Assessment
- Viral URI
Plan
- Push fluids
- Tylenol as needed
- Rest
- Return to clinic if no improvement in 7 to 10 days
For a detailed breakdown of this note with tips and advice see 99202 E/M Insight
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