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An otherwise healthy established office patient with a cold
CC : “ Cough and congestion.”
Interval History : Patient states he developed nasal congestion and a runny nose about five days ago. More recently, these symptoms have been associated with a non-productive cough.
Physical Ex am
General appearance: No acute distress; conversant
Vitals: 98.6, 72, 20, 110/74
HEENT: Oropharynx is clear with normal posterior pharynx without erythema or exudate.
Lungs: CTA
Assessment
- Common cold
Plan
- Push fluids
- Rest
- Tylenol, if needed
For a detailed breakdown of this note with tips and advice see 99212 E/M Insight
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