What Primary Diagnosis Assignment Help: How to Answer This Question
This type of question evaluates analytical and critical thinking skills.
What This Question Is About
This question relates to what primary diagnosis and requires a structured academic response.
How to Approach This Question
Use appropriate theories and support your answer with clear reasoning.
Key Explanation
This topic involves what primary diagnosis. A strong answer should include explanation, application, and examples.
Original Question
what is the primary diagnosis codes for this case study. There are 4 CPT codes here. 18 MONTHS SUBJECTIVE: 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: 90/62 GEN: 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 toddler The 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 2 Influenza quadrivalent (IIV4) 0.25 mL IM Anticipatory guidance (discussed & covered in a handout given to the family) Common immunization SE's Safety: 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 pounds Dental care and fluoride; dental visits Food: Picky eating, fortified whole milk, limiting juice and junk/fast food. Transitioning from bottle to cups; no bottle in bed Discipline: Praising wanted behaviors, distraction, time outs, setting limits, routines. Emerging independence (offer choices) Growing vocabulary (importance of reading and talking) Limiting screen time Sleep: Nightmares, sleep hygiene Hazards of second hand smoke
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