Well Child Check: 5 year old

5 YEARS

SUBJECTIVE:

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

REVIEW OF SYSTEMS:

- Diet: No concerns.

- Fast food, soda, juice intake: _

- Calcium intake: _

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

- Sleeping: No concerns. Has regular bedtime routine.

- Dental: + brushes teeth. Sees the dentist regularly.

- 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: Hops and skips, holds crayon or pencil well, rides a bike, able to tie a knot; copies squares and triangles.

- Cognitive: Draws a person with head, body, and limbs (6+ body parts); knows at least 4 colors; counts to 5 or 10; can explain the use of a ball or shoe.

- Social/Emotional: Plays cooperatively, plays board/card games, plays make-believe, listens and attends.

- Communication: Can speak in full sentences and tell a story, recognizes most letters, prints some letters and numbers.

SOCIAL:

- In kindergarten

- After-school activities:

- No smokers in the home.

- No major social stressors at home.

- No safety concerns in the home.

- 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 and nares normal. MMM. Normal gums, mucosa, palate, OP. 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: No deformities. Normal gait. No clubbing, cyanosis, or edema.

- NEURO: Normal muscle strength and tone. No focal deficits.

GROWTH CHART: Following growth curve well in all parameters. BMI at _ percentile.

LABS/STUDIES:

- Urine dip normal.

- Hearing screen normal.

- Snellen testing: _

ASSESSMENT/PLAN:

* Healthy 5 yo child

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

- CBC ordered. No indication for a lipid panel or DM screening.

- Follow up at 6 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, strangers, gun safety, helmets and safety equipment.

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

- Food and exercise: Limiting juice and junk/fast food, exercise.

- Memorize name, address, and phone number.

- Speech: Importance of reading, limiting screen time.

- Dental care and fluoride; dental visits

- Hazards of second hand smoke