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chief complaint: “I need cold meds”
Patient is a 66 y/o female who came for consultation with acute upper respiratory infection, she complains of cough, nasal congestion, sore throat, chills, headache. On the physical examination there was erythema of the oropharynx, no added respiratory sounds. COVID-19 and flu test performed at office were negative. We started patient on Z-pack, cough syrup, continue with OTC medications. We also ordered a Dexamethasone+ Rocephin IM stat given at office. We will follow up if needed in 2 weeks.
ICD J06.9 – ACUTE UPPER RESPIRATORY INFECTION, UNSPECIFIED
4170-20241017-001
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