3-Year-Old Routine Check-Up
Presents for a 3-year well-child check-up
Accompanied by:
Age: years, months
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
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
- 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:
Uses sentences with 5 or more words:
Walks up stairs using handrail:
Twists lids off jars or turns knobs:
Shares some of the time:
Plays make-believe games with actions and words (e.g. pretending to cook a meal, fix a car):
Turns pages one at a time:
Listens to music or stories for 5-10 minutes:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Metrics: length: cm - th perc, weight: kg - th perc, BMI: - 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, toilet training issues, sleep disturbances
PLAN:
Investigations:
- 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
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: