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USE THE 1995 DOCUMENTATION GUIDELINES CHIEF COMPLAINT RESPIRATORY DISTRESS AND FEVER X 12 HOURS HISTORY OF PRESENT ILLNESS THIS 20-MONTH-OLD CAUCASIAN MALE PRESENTS TO THE EMERGENCY DEPARTMENT DUE TO COUGHING WHICH BEGAN YESTERDAY LATE AFTERNOON. FEVER AND COUGHING WERE AGGRAVATED IN THE EVENING. PATIENT WAS GIVEN TYLENOL AND SLEPT WELL. TODAY AT 8:00 A.M. THE PATIENT SHOWED RESPIRATORY DISTRESS AND INCREASED MUCOUS SECRETION. PAST HISTORY ILLNESSES: THE PATIENT HAS HAD SIMILIAR SYMPTOMS 4 MONTHS AGO, BUT WAS RELIEVED SPONTANEOUSLY. THE PATIENT IS THE PRODUCT OF A NORMAL SPONTANEOUS VAGINAL DELIVERY. BIRTH WEIGHT 6 POUNDS 1 OUNCE. ALLERGIES: NONE FAMILY HISTORY: NO FAMILY HISTORY OF MATERNAL OR PATERNAL DIABETES, HYPERTENSIOPN OR TUBERCULOSIS. REVIEW OF SYSTEMS NONCONTRIBUTORY PHYSICAL EXAMANATION VITAL SIGNS: PULSE 168/MIN-RESPIRATORY RATE: 38 MIN AND LABORED. TEMPERATURE: 104.04 F. HEENT: INCREASED NASAL DISCHARGE. TRACHEA MIDLINE. TMs CLEAR. PHARYNX NOT EXAMINED. HEART: SINUS RHYTHM WITH TACHYCARDIA. NO MURMURS. LUNGS: THERE IS NO INSPIRATORY WHEEZING AND RESPIRATORY RETRACTION BILATERALLY. TACHYPNEA IS PRESENT. THERE ARE BILATERAL RHONCHI. NO AREAS OF CONSOLITDATION IMPRESSION: CROUP. RULE OUT EPIGLOTTITIS PLAN NPO. LATERAL NECK FILMS TO RULE OUT SYGLOTTIC EDEMA. THIRTY PERCENT OXYGEN MIST TENT. RACEMIC EPINEPHRINE 2 ML. DACADRON 5 MG. TYLENOL p.r.n. FOR FEVER. INTUBATION PRECAUTIONS UNTIL RADIOGRAPHIC EVIDENCE OF SUBLOTTIC EDEMA IS EXCLUDED PLEASE PROVIDE THE ICD-10 CM CODE AND THE E/M CODE

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