Well Child Check: 2 year old

SUBJECTIVE:

2yo _ here for well child check. No parental concerns at this time.

REVIEW OF SYSTEMS:

- Diet: No concerns. Weaned from bottle.

- Voiding/stooling: No concerns. Working on toilet training.

- Sleeping: No concerns. Has regular bedtime routine.

- Dental: Weaned from the bottle. + brushes teeth with help. Has already been to the dentist.

- 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: Walks up/down steps, able to kick a ball, jumps in place, throws a ball overhand.

- Fine motor: Turns a page one at a time, removes clothes, stacks 5-6 blocks.

- Cognitive: Follows 2-step commands, scribbles, names items in pictures, uses spoon and cup well.

- Social/Emotional: Copies adults, plays pretend, plays well alongside other children.

- Communication: Able to put 2 words together, knows 20+ words.

- Autism Screening: MCHAT score: _. 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 _

- No TB or lead risk factors.

IMMUNIZATIONS:

- Up to date.

OBJECTIVE:

- VITALS: _

- 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. BMI at _ percentile.

ASSESSMENT/PLAN:

* Healthy 2yo toddler

- CBC and lead level ordered.

- 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 2.5 years of age, or sooner PRN.

- ER/return precautions discussed.

* Vaccines today:

- Influenza

- None

* Anticipatory guidance (discussed or covered in a handout given to the family)

- Safety: Street/car safety, water safety, toxins, gun safety.

- Booster seat required by law until 8 yrs old or 4’9”

- Food: Picky eating, fortified 2% milk, limiting juice and junk/fast food.

- Development: Toilet training, limiting screen time.

- Discipline: Praising wanted behaviors, tantrum management, time outs, setting limits, routines, offering choices, don’t expect sharing.

- Speech: Normal speech dysfluency, importance of reading to child.

- Dental care and fluoride; dental visits

- Sleep: Nightmares, sleep hygiene

- Hazards of second hand smoke