Acute Bronchitis Patient Demographics Age: 34 years Sex: Female Race: Hispanic Insurance: PPO Referral: None Reason for Visit New consult

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