Well Child Check: 3 year old
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.
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
- 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.
- 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.
- Up to date.
- 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.
* 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:
* 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