what is the primary diagnosis codes for this case study. The

what is the primary diagnosis codes for this case study. There are… what is the primary diagnosis codes for this case study. There are 4 CPT codes here.18 MONTHSSUBJECTIVE:18 month old female here for well child check. No parental concerns at this time.REVIEW OF SYSTEMS:Diet: No concerns. Weaned from bottle.Voiding/stooling: No concerns. + showing interest in potty.Sleeping: Has regular bedtime routine, and sleeps through the night without feeding.Behavior: No concerns.Activity: Screen/TV time is limited to < 2 hrs/day.PM/SH:Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.DEVELOPMENT:Gross motor: Runs, walks up steps, able to kick a ball.Fine motor: Feeds self with a spoon, removes clothes, stacks 2 blocks, uses spoon and cup without spilling most of the time.Cognitive: Follows simple directions, scribbles, knows name of favorite book.Social/Emotional: Helps in the house, laughs in response to others, points out things of interest.Communication: Knows at least 4-10 words, points to at least one body part.Autism Screening: MCHAT score: 0. Seems to interact with others well. Makes eye contact. Enjoys pretend play. Orients to name. Points and gestures socially. Using 2-word phrases.SOCIAL:No smokers in the home.No major social stressors at home. No safety concerns in the home.Daytime child care is with Grandma.No TB or lead risk factors.IMMUNIZATIONS:Up to date.OBJECTIVE:VITALS: 90/62GEN: Normal general appearance. NAD.HEAD: NCAT.EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.ENMT: TMs, nares, and OP normal. MMM. Normal gums, mucosa, palate. Good dentition.NECK: Supple, with no masses.CV: RRR, no m/r/g.LUNGS: CTAB, no w/r/c.ABD: Soft, NT/ND, NBS, no masses or organomegaly.GU: Normal _male genitalia. Testes descended bilaterally.SKIN: WWP. No skin rashes or abnormal lesions.MSK: Normal extremities & spine.NEURO: Normal muscle strength and tone. No focal deficits.GROWTH CHART: Following growth curve well in all parameters.ASSESSMENT/PLAN: Healthy 18-month old toddlerThe family was given a children's book today (per "Reach Out and Read" program).MCHAT done today - No concerns.The family was given a list of dentists in the county who take MediCal.Follow up at 2 years of age, or sooner PRN.ER/return precautions discussed.Vaccines today:HepA #2 of 2Influenza quadrivalent (IIV4) 0.25 mL IMAnticipatory guidance (discussed & covered in a handout given to the family)Common immunization SE'sSafety: Child-proofed home, burn prevention, kitchen safety, water safety, firearms, sunscreen, Poison Control number (800-222-1222)Car seat facing backward until 2 years of age (ideally 2) and 20 poundsDental care and fluoride; dental visitsFood: Picky eating, fortified whole milk, limiting juice and junk/fast food.Transitioning from bottle to cups; no bottle in bedDiscipline: Praising wanted behaviors, distraction, time outs, setting limits, routines.Emerging independence (offer choices)Growing vocabulary (importance of reading and talking)Limiting screen timeSleep: Nightmares, sleep hygieneHazards of second hand smoke Health Science Science Nursing HITM 2224

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