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