3-Year Well-Child

Presents for a 3-year well-child check-up

Accompanied by: ‍both parentsmotherfather





Past medical history: ‍ ‍none

Medications: ‍ ‍none

Allergies: ‍ ‍none

Family history: ‍ ‍unremarkable

Known risk factors: ‍ ‍none



Current symptoms or caregiver concerns:

‍ ‍none



NUTRITION:

Breastfeeding: ‍yesno, ‍ feeds daily

Homigenized milk (500 ml or 16 oz): ‍ ‍mloz daily

Vitamin D 400 IU/day: ‍yesno

Appetite: ‍goodaveragepoor

Vegeterian diet: ‍yesno

Food insecurity: ‍yesno

Counseling:

- Avoid foods high in sugar or salt

- Avoid small, hard pieces / choking prevention

- Avoid juice

- Gradual transition to lower fat diet



EDUCATION AND ADVICE:

Daycare: ‍yesno, ‍

Parenting/bonding: ‍goodaveragepoor

Family conflict/stress: ‍yesno

Second hand smoke exposure: ‍yesno

Counseling:

- Healthy sleep habits (>10 hrs per day)

- Encourage reading

- Limit screen time

- Promote physical activity

- Choking / safe toys

- Car seat (child/booster)

- Burn pervention / matches

- Poison prevention (poison control center)

- Attend during baths

- Bike helmet

- Fall prevention (stairs, change table, unstable furniture/TV)

- No pacifier

- Limit sun exposure / sunscreens

- Dental cleaning twice a day

- Dentist visit

- Visual screening



DEVELOPMENT:

Understands 2 and 3 step directions: ‍ACHIEVEDNOT ACHIEVED

Uses sentences with 5 or more words: ‍ACHIEVEDNOT ACHIEVED

Walks up stairs using handrail: ‍ACHIEVEDNOT ACHIEVED

Twists lids off jars or turns knobs: ‍ACHIEVEDNOT ACHIEVED

Shares some of the time: ‍ACHIEVEDNOT ACHIEVED

Plays make-believe games with actions and words (e.g. pretending to cook a meal, fix a car): ‍ACHIEVEDNOT ACHIEVED

Turns pages one at a time: ‍ACHIEVEDNOT ACHIEVED

Listens to music or stories for 5-10 minutes: ‍ACHIEVEDNOT ACHIEVED



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Measurements: height: ‍ cm - ‍ perc, weight: ‍ kg - ‍ perc, BMI: ‍

Head: fontanelles ‍soft, ‍normocephalic

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍clear, ‍nasal flaring, discharge ‍clear, ‍

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Genital: ‍normal, testicles ‍normal, penis ‍normal

Extremities: ‍normal, ‍normal pulses, cap refill ‍< 3 sec> 3 sec

Skin: ‍no rash

Musculoskeletal: joints ‍ ‍normal, ‍no limited ROM

Neurologic: cranial nerves ‍normal, strength ‍5/5 throughout, sensation ‍normal, reflexes ‍2+ throughout, cerebellar function ‍normal, gait ‍stable

Mental status: ‍alert, ‍, reactive to ‍



ASSESSMENT:

‍Normal growth and development ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC if at risk of anemia, ‍lead screening if at risk, ‍lipid profile if at risk and not done yet

- Hearing screening if speech delay or doubt on hearing acuity

- Vision screening

- Caregiver questions answered

- Iron supplementation if not consuming iron-rich foods

- Vitamin D supplementation

- Referral to dentist

- Follow-up in ‍ ‍weeksmonthsat 4 years