2-Year-Old Routine Check-Up
Presents for a 2-year well-child check-up
Accompanied by:
Age: , Gestational age:
Past medical history:
Medications:
Allergies:
Family history:
Known risk factors:
Current symptoms or caregiver concerns:
NUTRITION:
Breastfeeding: , feeds daily
Homigenized 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 small, hard pieces / choking prevention
- Avoid juice
- Gradual transition to lower fat diet
- No bottles
EDUCATION AND ADVICE:
Daycare: ,
Parenting/bonding:
Family conflict/stress:
Second hand smoke exposure:
Counseling:
- Healthy sleep habits (11-14 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
DEVELOPMENT:
Combines or more words
Understands 1 and 2 step directions:
Walks backward 2 steps without support:
Tries to run:
Puts objects into small container:
Uses toys for pretend play (e.g give doll a drink):
Continues to develop new skills:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Metrics: length: cm - th perc, weight: kg - th perc, head circ: cm - th perc
Head: fontanelles ,
Eyes: conjunctiva/sclera , lids/lashes , , extraocular movements , red reflex , corneal light reflex , fix and follow test
Ears: tympanic membranes , auditory canal on , hearing
Nose: , , discharge ,
Throat: , ,
Neck: , , , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , ,
Genitourinary: external genitalia , testes , penis , Tanner stage
Extremities: , , , , Barlow , Ortolani , , cap refill sec
Skin: on
Musculoskeletal: joints ,
Neurologic: cranial nerves , overall motricity , muscle tone , gait , reflexes
Mental status: , , reactive to
Developmental milestones: motor: , communication: , social/emotional: , cognitive: , adaptive:
ASSESSMENT:
DDx: developmental delay, autism spectrum disorder, hearing impairment, vision impairment, speech and language delay, motor skill delay, cognitive impairment, growth disorders, nutritional deficiencies, anemia, lead poisoning, genetic disorders, metabolic disorders, environmental exposure concerns, attachment issues, behavioral issues
PLAN:
Investigations:
- Blood work: if at risk of anemia, if at risk, if at risk
- Hearing screening if speech delay or doubt on hearing acuity
Treatments:
- Caregiver questions answered
- Iron supplementation if not consuming iron-rich foods
- Vitamin D supplementation
Further care:
- Referral to dentist
- Follow-up in
EXAM: ASSESSMENT: PLAN: