Well Child Check: 3 year old

SUBJECTIVE:

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

REVIEW OF SYSTEMS:

- Diet: No concerns.

- Voiding/stooling: No concerns. + toilet trained (during the day, at least).

- Sleeping: No concerns. Has regular bedtime routine.

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

- Behavior: No concerns.

- Activity: Screen/TV time is limited to < 2 hrs/day, gets time outside every day.

PM/SH:

Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.

DEVELOPMENT:

- Gross and fine motor: Can stack 6-8 blocks, stand on one foot, pedal a tricycle, throw a ball overhand, walk up stairs with alternating feet, copy a circle, draw a person with two body parts, dress self (may need some help).

- Cognitive: Knows name, age, sex. Counts to 3 or more.

- Social/Emotional: Joins other children in play. Asks questions. Able to name friends.

- Communication: Others can understand at least 3/4 of what is said. Speaks in 3-4 word sentences. MCHAT in chart.

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 3yo child

- The family was given a children’s book today (per “Reach Out and Read” program).

- CBC ordered.

- MCHAT was done at 18 and 24 months of age.

- Follow up at 4 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 (Poison Control number: 800-222-1222), gun safety, helmets and safety equipment.

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

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

- Discipline: Praising wanted behaviors, time outs, setting limits, routines, offering choices, +expect sharing, limiting screen time.

- Speech: Importance of reading, temporary stuttering

- Dental care and fluoride; dental visits

- Sleep: Nightmares, sleep hygiene

- Hazards of second hand smoke