Pediatrician's note

PATIENT'S NAME: **JAMES SMITH** DOS: **1 November 2024** DOB: **03/15/20** AGE: **4 years, 7 months, 17 days** SEX: **Male** ACCOMPANIED by: **Mother, Sarah Smith** **SUBJECTIVE**: James was brought in by his mother, Sarah Smith, for a routine check-up and concerns about a persistent cough. The cough started two weeks ago, is dry in nature, and occurs mostly at night. James denies any fever or shortness of breath. Denies any other issues other than the mentioned above. Past Medical History: Noted in chart. Medication History: Not currently on any medications. Allergies: NKA Immunizations: Up-to-date Growth and Development: Development appropriate for age Diet and Nutrition: No loss of appetite, Eating well Family History: No Changes **OBJECTIVE**: Growth Parameters: - Wt: 40 lbs, Ht: 42 inches - Vital Signs: Temperature: 98.6°F, Pulse: 90 bpm, Respiratory rate: 20 breaths/min - PHYSICAL EXAMINATION: - General Appearance: Active, Alert, Pink, and Nontoxic - Eyes: Normal eyes, No redness - Nose: Mucus present in both nostrils - Ears: Normal TM with good LR - Throat: No redness or ulcers - Chest/Lungs: No distress, No wheezing or rales - Cardiovascular: Normal S1 and S2, No Murmur heard - Abdomen: Soft, Non tender, No HSM - Skin: No rashes - Musculoskeletal: Moving all Extremities well - CNS: Normal tone and reflexes **INVESTIGATIONS**: - None **ASSESSMENT and PLAN** 1. Persistent Cough - Investigations planned for Issue 1: Chest X-ray - Treatment planned for Issue 1: Prescribe cough syrup 2. Routine Check-up - No additional investigations or treatments required -Signed: Dr. Emily Johnson MD_________________________________________________________________________ BILLING: - ICD-10 Codes: · R05 - Cough - CPT Code for New and Established patient for above visit: · 99213 - Established patient office visit