4-Year-Old Routine Check-Up

Presents for a 4-year well-child check-up

Accompanied by: ‍both parentsmotherfather



Age: ‍ years, ‍ months



Past medical history: ‍ ‍none

Medications: ‍ ‍none

Allergies: ‍ ‍none

Family history: ‍ ‍unremarkable

Known risk factors: ‍ ‍none



Current symptoms or caregiver concerns:

‍ ‍none



NUTRITION:

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 juice

- Healthy 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

- 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: ‍✓NOT ACHIEVED

Asks and answers lots of questions (e.g. "What are you doing?"): ‍✓NOT ACHIEVED

Walks up/down stairs alternating feet: ‍✓NOT ACHIEVED

Undoes buttons and zippers: ‍✓NOT ACHIEVED

Tries to comfort someone who is upset: ‍✓NOT ACHIEVED





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Metrics: length: ‍ cm - ‍th perc, weight: ‍ kg - ‍th perc, BMI: ‍ - ‍th perc

Head: fontanelles ‍soft, ‍normocephalic

Eyes: conjunctiva/sclera ‍normalinjection, lids/lashes ‍normalerythema, ‍PERRL, extraocular movements ‍intact, red reflex ‍present, corneal light reflex ‍symmetrical, fix and follow test ‍intact

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, ‍nasal flaring, discharge ‍clear, ‍

Throat: ‍normal, ‍palate intact, ‍redness

Neck: ‍normal, ‍lymphadenopathy, ‍nuchal rigidity, ‍torticollis, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Genitourinary: external genitalia ‍normal, testes ‍descended, penis ‍normal, Tanner stage ‍

Extremities: ‍normal inspection, ‍joints ‍normal, ‍limited ROM, ‍normal spine, Barlow ‍negative, Ortolani ‍negative, ‍normal pulses, cap refill ‍< 3> 3 sec

Skin: ‍rashlesions on ‍

Musculoskeletal: joints ‍ ‍normal, ‍limited ROM

Neurologic: cranial nerves ‍grossly intact, overall motricity ‍normal for agelimb weakness, muscle tone ‍normal for age, gait ‍appropriate for age, reflexes ‍intact 2+

Mental status: ‍alert, ‍, reactive to ‍

Developmental milestones: motor: ‍, communication: ‍, social/emotional: ‍, cognitive: ‍, adaptive: ‍





ASSESSMENT:

‍Normal growth and development ‍likelysuspectedpossible

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, attention-deficit/hyperactivity disorder (ADHD), learning disabilities





PLAN:

Investigations:

- 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

Treatments:

- 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

Further care:

- Referral to dentist

- Follow-up in ‍ ‍weeksmonthsat 5 years