Patient presents with symptoms consistent with a respiratory infection.  Presenting complaints include cough, shortness of breath, and chest congestion.  Onset of symptoms began approximately three days prior to presentation.  Patient reports productive cough with white sputum, denies hemoptysis.  Associated symptoms include fever, chills, myalgia, and rhinorrhea.  Patient denies recent travel history or known exposure to individuals with similar symptoms.  Vital signs reveal elevated temperature of 100.4 degrees Fahrenheit, heart rate of 92 beats per minute, respiratory rate of 20 breaths per minute, and blood pressure of 12080 mmHg.  Oxygen saturation is 98% on room air.  Lung auscultation reveals bilateral rhonchi.  Diagnosis of acute respiratory infection is made.  Differential diagnoses considered include pneumonia, bronchitis, and influenza.  Rapid influenza test performed and resulted negative.  Chest X-ray ordered to rule out pneumonia.  Treatment plan includes symptomatic management with over-the-counter medications such as acetaminophen for fever and ibuprofen for pain.  Patient advised to increase fluid intake and rest.  Patient education provided regarding cough etiquette and hand hygiene.  Follow-up recommended in one week if symptoms do not improve.  ICD-10 code J06.9, Acute upper respiratory infection, unspecified, is assigned.  Medical billing codes for evaluation and management services will be determined based on the complexity of the visit.