Peds Acute Visit

**Subjective:** Lily, 6 months old, female, accompanied by mother for a cough and runny nose. Lily's mother reports that Lily has had a cough for the past 3 days, which is worse at night. She also has a runny nose and has been a little more irritable than usual. She has no fever, but her appetite is slightly decreased. The mother denies any difficulty breathing, wheezing, or chest pain. She reports that Lily has been drinking fluids well and has had normal wet diapers. There is no known sick contacts. Past Medical History: No prior hospitalizations or surgeries. Medications: None. Allergies: NKDA. **ROS:** * **Constitutional:** No fever, chills, or night sweats. * **Respiratory:** Cough productive of clear mucus, runny nose. * **Gastrointestinal:** Appetite slightly decreased, normal bowel movements. **Examination:** * **General:** Alert, active infant in no acute distress. * **Head:** Normocephalic, atraumatic. * **Ears:** External Ear grossly normal. No tenderness with movement. * **Eyes:** Pupils equal, round, and reactive to light. No conjunctival injection or discharge. * **Nose:** Mild clear rhinorrhea. * **Throat:** Moist mucous membranes. No tonsillar exudates or erythema. * **Lungs:** Respiratory effort comfortable, without use of accessory muscles. Vesicular breath sounds appreciated equally throughout lung fields. No wheezing, consolidation, or rhonchi appreciated. * **Cardiovascular:** Good perfusion. Brisk Capillary Refill. Auscultation of Regular Rate and Rhythm for age. No murmur appreciated upon auscultation. * **Gastrointestinal:** Soft, non-tender, non-distended. No organomegaly. Normoactive bowel sounds. * **Musculoskeletal:** No joint swelling, erythema, or tenderness. * **Skin:** Warm and dry. No rashes or lesions. **Impression and Plan:** 1. **Upper Respiratory Infection** * Impression: Viral upper respiratory infection. * Treatment planned: Supportive care with saline nasal drops, bulb suctioning, and increased fluids. Advised to monitor for worsening symptoms. * Prevention: Hand hygiene, avoid contact with sick individuals. ICD-10: J06.9 (Acute upper respiratory infection, unspecified) CPT: 99213 (Established patient office visit, level 3) [15 minutes]