Problem:
A 10-year-old female established patient presents to the pediatrician complaining of a cough x 3 days. She had associated fever of 101º F yesterday. Mom treated her with Tylenol. The fever this a.m. is 99º F. She has had some chills and cough as well as some difficulty breathing. No nausea or vomiting. The physician performed a detailed exam of the ENT as well as a limited exam of GI, Lungs, and Heart. Vital signs were taken in the office. The physician diagnosed the patient with an Upper Respiratory Infection and recommended OTC medication. 99213, J06.9 99213, R05.1, J06.9 99212, R05.1, R50.9, J06.9 99212, J06.9