Acute Bronchitis
Patient Demographics
- Age: 34 years
- Sex: Female
- Race: Hispanic
- Insurance: PPO
- Referral: None
Reason for Visit
- New consult
Chief Complaint
- Cough, chest congestion, and fatigue x5 days
Type of H&P
- Expanded problem-focused
Decision-Making Type
- Low complexity
Clinical Notes
Patient presents with productive cough, mild wheezing, sore throat, afebrile. Lungs: scattered rhonchi, good air entry. No respiratory distress. Diagnosed with acute bronchitis. Encouraged hydration, OTC antitussives, albuterol PRN. No red-flag symptoms. Return precautions given.
ICD-10 Codes
- J20.9 — Acute bronchitis, unspecified
- R05.1 — Acute cough
- R09.81 — Nasal congestion
CPT Codes
- 99213 — Established patient visit, low complexity
