Presents for a 18-month well-child check-up
Accompanied by:
Past medical history:
Medications:
Allergies:
Family history:
Known risk factors:
Current symptoms or caregiver concerns:
NUTRITION:
Breastfeeding: , feeds daily
Homogenized milk (500–750 ml or 16-24 oz): daily
Vitamin D 400 IU/day:
Vegeterian diet:
Appetite:
Food insecurity:
Counseling:
- Avoid foods high in sugar or salt
- Avoid small, hard pieces / choking prevention
- Avoid juice
- Promote independent/self-feeding
- No bottles
EDUCATION AND ADVICE:
Daycare: ,
Parenting/bonding:
Family conflict/stress:
Second hand smoke exposure:
Counseling:
- Healthy sleep habits (11-14 hrs per day)
- Encourage reading
- Avoid screens
- Promote physical activity
- Wean from pacifier
- Choking / safe toys
- Fall prevention (stairs, change table, unstable furniture/TV)
- Poison prevention (poison control center)
- Car seat (child/booster)
- Burn pervention
- Protect electric plugs/cords
- Attend during baths
- Limit sun exposure / sunscreens
- Dental cleaning twice a day
DEVELOPMENT:
Interested in other children:
Usually casy to soothe:
Child's behaviour is usually manageable:
Comes for comfort when distressed:
Points to several different body parts:
Tries to get your attention to show you something:
Turns/responds when name is called:
Points to what helshe wants:
Looks for toy when asked or pointed in direction:
Imitates speech sounds and gestures:
Says 15 or more words (do not have to be clear):
Produces 4 consonants (e.g. BDGHNW):
Feeds self with spoon with little spilling:
Walks alone:
Removes hat/socks without help:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Measurements: length: cm - perc, weight: kg - perc, head circ: cm - perc
Head: fontanelles ,
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose: , , discharge ,
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Genital: , testicles , penis
Extremities: , , cap refill
Skin:
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , reactive to
Developmental milestones: motor: , communication: , social/emotional: , cognitive: , adaptive:
ASSESSMENT:
DDx:
PLAN:
- Blood work: if at risk of anemia, if at risk
- Hearing screening if speech delay or doubt on hearing acuity
- Caregiver questions answered
- Iron supplementation if not consuming iron-rich foods
- Vitamin D supplementation
- Immunizations:
- DTaP-IPV-Hib vaccine
- MMR-varicella vaccine
- Referral to dentist
- Follow-up in