Patient comes in today at 4 months of age for a checkup. she is growing and developing well. her mother is concerned because she seems to cry a lot when lying down but when she is picked up she is fine. she is on breast milk but her mother has returned to work and is using a breast pump but hasn’t seemed to produce enough milk.
physical exam: weight 12 lbs. 11 oz., height 25in., ofc 41.5 cm. heent: eye: red reflex normal. right eardrum is minimally pink, left eardrum is normal. nose: slight mucous throat with slight thrush on the inside of the cheeks and on the tongue. lungs: clear. heart: w/o murmur. abdomen: soft. hip exam normal. genitalia normal although her mother says there was a diaper rash earlier in the week.
assessment
four month-old well check
cold
mild thrush
diaper rash
plan:
okay to advance to baby foods
okay to supplement with similac
nystatin suspension for the thrush and creams for the diaper rash if it recurs
mother will bring child back after the cold symptoms resolve for her dpt, hib and polio
what e/m code(s) is/are reported?