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CLINICAL EXAMPLE 99212
 

 
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

  1. Common cold
Plan
  1. Push fluids
  2. Rest
  3. Tylenol, if needed

For a detailed breakdown of this note with tips and advice see   99212 E/M Insight

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