Date of Encounter: 09/01/2025 Age/Sex: 29-year-old Female Race: Hispanic Insurance: PPO Referral: No referral Reason for Visit: New Consult Chief Complaint: Shortness of breath, wheezing, and cough for 2 days Type of H&P: Focused Type of Decision-Making: Moderate Time with Patient: 35 minutes Consult with Preceptor: 10 minutes
Social Problems Addressed: Education/Language, Safety Medications: Albuterol 90 mcg inhaler PRN, Prednisone 40 mg daily x5 days Adherence Issues: None reported
ICD-10 Codes:
· J45.901 – Unspecified asthma with (acute) exacerbation
CPT® Billing Codes:
· 99213 – Office/outpatient visit, established patient
Clinical Notes: Patient presents with SOB, wheezing, and cough for 2 days. O₂ sat 94%, scattered expiratory wheezes. Nebulized albuterol given in office with improvement. Prescribed short course of oral steroids and advised inhaler use every 4–6 hrs as needed. Patient educated on trigger avoidance and follow-up in 1 week.