Presents for a 3-year 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
Homigenized milk (500 ml or 16 oz): daily
Vitamin D 400 IU/day:
Appetite:
Vegeterian diet:
Food insecurity:
Counseling:
- Avoid foods high in sugar or salt
- Avoid small, hard pieces / choking prevention
- Avoid juice
- Gradual transition to lower fat diet
EDUCATION AND ADVICE:
Daycare: ,
Parenting/bonding:
Family conflict/stress:
Second hand smoke exposure:
Counseling:
- Healthy sleep habits (>10 hrs per day)
- Encourage reading
- Limit screen time
- Promote physical activity
- Choking / safe toys
- Car seat (child/booster)
- Burn pervention / matches
- Poison prevention (poison control center)
- Attend during baths
- Bike helmet
- Fall prevention (stairs, change table, unstable furniture/TV)
- No pacifier
- Limit sun exposure / sunscreens
- Dental cleaning twice a day
- Dentist visit
- Visual screening
DEVELOPMENT:
Understands 2 and 3 step directions:
Uses sentences with 5 or more words:
Walks up stairs using handrail:
Twists lids off jars or turns knobs:
Shares some of the time:
Plays make-believe games with actions and words (e.g. pretending to cook a meal, fix a car):
Turns pages one at a time:
Listens to music or stories for 5-10 minutes:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Measurements: height: cm - perc, weight: kg - perc, BMI:
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
ASSESSMENT:
DDx:
PLAN:
- Blood work: if at risk of anemia, if at risk, if at risk and not done yet
- Hearing screening if speech delay or doubt on hearing acuity
- Vision screening
- Caregiver questions answered
- Iron supplementation if not consuming iron-rich foods
- Vitamin D supplementation
- Referral to dentist
- Follow-up in