4-Year Well-Child
Presents for a 4-year well-child check-up
Accompanied by:
Past medical history:
Medications:
Allergies:
Family history:
Known risk factors:
Current symptoms or caregiver concerns:
NUTRITION:
Milk (500 ml or 16 oz): daily
Vitamin D 400 IU/day:
Appetite:
Vegeterian diet:
Food insecurity:
Counseling:
- Avoid foods high in sugar or salt
- Avoid juice
- Healthy diet
EDUCATION AND ADVICE:
Daycare: ,
Parenting/bonding:
Family conflict/stress:
Second hand smoke exposure:
Counseling:
- Healthy sleep habits (>10 hrs per day)
- Encourage reading
- Limit screen time
- Promote physical activity
- Car seat (child/booster)
- Burn pervention / matches
- Poison prevention (poison control center)
- Bike helmet
- No pacifier
- Limit sun exposure / sunscreens
- Dental cleaning
- Dentist visit
- Visual screening
DEVELOPMENT:
Understands 3-part directions:
Asks and answers lots of questions (e.g. "What are you doing?"):
Walks up/down stairs alternating feet:
Undoes buttons and zippers:
Tries to comfort someone who is upset:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Measurements: height: cm - perc, weight: kg - perc, BMI:
Head: fontanelles ,
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose: , , discharge ,
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Genital: , testicles , penis
Extremities: , , cap refill
Skin:
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , reactive to
ASSESSMENT:
DDx:
PLAN:
- Blood work: if at risk of anemia, if at risk, 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
- Immunizations:
- Tdap-IPV (preschool booster)
- 2nd dose of varicella vaccine if not yet received
- Meningococcal vaccine booster if needed
- Referral to dentist
- Follow-up in