History of present illness

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Reference no: EM133728714

History of Present Illness: The patient is a 6-month-old male who has been sick for the past 3 days. His mother states he is congested with a cough and decreased appetite. He has had no fever. He has had no rhinorrhea. Nobody else at home is currently ill. He has no cigarette smoke exposure. She brought him to the emergency room this morning after a bad coughing spell. Past Medical History: Unremarkable. Up-to-date on all immunizations. Physical Examination: Unremarkable Diagnostic Studies: Chest X-ray performed is confirmed by radiologist and ER physician as unremarkable. Assessment: Upper respiratory infection. Treatment: Instructed mom how to use the bulb syringe to clear passages and start utilizing saline nose drops. Smaller but more frequent feeds. Asked mom to recheck if there is any fever or if he does not improve in three days. What is the code for this case? Hint 1: Emergency Department Services (99281-22985) Hint 2: MDM look at the physician ordering an x-ray and reviewing the x-ray

Reference no: EM133728714

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