View MR 099403 -
MR 099403 -
New Patient Office Visit -
Patient presents for initial 1-week well-child visit. Had jaundice since birth but now is resolved. Mother does not have any current concerns, but wants to talk about blood-work. Baby has home health nurse x 1 visit to date. Baby eating well: approximately 15 minutes each breast.
Having BM qd. Urination: Normal.
Patient accompanied by both parents and older sister; parents have no specific concerns.
Newborn screening is normal.
Diet: Breastfeeds q 2 to 3 hrs. Breastfeeding is going well overall. Patient is interested in nursing. Awakens to nursing regularly: left side 15 minutes, right side 15 minutes. Audible signs of milk transfer. Patient appears satisfied after breastfeeding; is alternating breasts. Mother does not use feeding supplement. Patient experiencing 6 to 8 wet diapers per day. Stools appear yellow glow and seedy. No difficulties with constipation or diarrhea. Sleeps on back and side. Wakes up to feed every 2 to 4 hours. Patient alert. Cries intermittently but is easily consoled. Infant able to lift head, turn head side to side and exhibit equal movements on extremities. Patient is able to startle to sound. Alert to voice. Discussed feeding schedule and feeding tips with parents. Advised no bottle propping. Discussed bathing tips. Discussed: Noisy breathing, burping, cool mist humidifier use, hiccups and immunizations. Discussed bonding and use of pacifier. Emphasized importance of proper usage of car seat. Also reminded importance of patient sleeping on back. Discussed animals in home and proper precautions.
Past Family Medical and Social History: Reviewed and updated.
Exam:
Weight: 7 lbs. 9 oz. Rectal Temp: 97.9. Height: 19 inches. Head Circ: 18.7
Healthy appearing infant. Well-nourished and alert. Weight: Within normal range for stated age. Mucus membranes: Moist and pink. Capillary refill: Brisk-less than two seconds. Respiratory pattern: Unremarkable. No grunting or nasal flaring. Umbilical cord: Not present.
Head proportion: Normal. Head: Normocephalic and symmetrical. Palpation reveals smooth, symmetric skull.
Anterior fontanelle: Slightly concave and soft. Posterior fontanelle is present.
PERRLA: EOMI ENMT: External ears: Inspection reveals ears normal in size, position and alignment. Auditory canals are patent. Tympanic membranes: Normal landmarks. No fluid or erythema. Nares: Bilaterally are patent.
Nasal mucosa: No discharge. Palate: Normal in appearance. Rooting reflex: Present. Sucking reflex: Present.
Neck: Supple, no masses.
Resp: Lungs clear bilaterally.
CV: PMI is not displaced. Rhythm: Regular. No heart murmur. Pulses: Femorals 2+ bilaterally.
GI: Abdomen: Non-distended, nontender and soft. Umbilicus: Inverted and absent.
Bowel sounds: Normal and active. No palpable hepatosplenomegaly.
Anus/Perineum: Normal -
Musculoskeletal:
Spine: Spinal contour: Normal. Gluteal fold: Normal. Upper Extremities: Normal to inspection and palpation.
Shoulders: Palpate smooth. Clavicles: Normal, stable.
Skin: No rash, lesions or petechiae. No jaundice.
Neurological: Babinski reflex: Present bilaterally. Moro reflex: Present.
Assessment: Routine infant child check: Patient doing well post-op with no obvious sign of jaundice.
What E/M code is reported?
mathunit1
1 month ago