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Office Visit This patient has been a patient of mine for six years, and I saw him three months ago for his annual physical. Today, he presents with a cough, which he has had for the last two days, with a fever of 101 and is short of breath. Personal medical history is significant for appendicitis in 2003. This well-nourished, well-developed 25-year-old patient presents with a cough and fever. BP: 120/70. Height: 5 feet 9 inches. Weight: 175 lb. Ears: Auditory canals and tympanic membranes within normal limits. Oropharynx: No significant findings. Lungs: Bilaterally congested. Heart: Regular sinus rhythm. Abdomen: Soft. Liver and spleen: Not palpable. Assessment: Acute bronchitis. Plan: Patient was prescribed an antibiotic. See medication order for details. The total time for the visit was 22 minutes. CPT code(s):
Sagot :
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