The patient is now 3 years old. This visit is for her yearly well-child check. The patient is 3. She did very well this past year. There were no sick visits to the office. Last year, in the spring, she had two episodes of pneumonia.
Family Situation: Her mother is pregnant and is due in June.
Nutrition: She does not like meat. She eats some fruits, some sweet potato, but she likes fruits. She eats eggs and she drinks a lot of milk.
Elimination: She goes every day, no problem.
Toilet Training: Her mom will start toilet training. She tried months ago but the patient just did not have any idea of what she was being trained on.
Sleep: She sleeps in her own room now and sleeps through the night.
Behavior/Impairment: She is very good. She listens real well and follows rules. She attends mom’s group. Mum takes her to gymnastics.
Development:
Language: She has finished her intervention program already. She was referred there because of her speech. Her speech now is really quite well. She understands and follows directions. She appropriately answers questions.
Social Development: She interacts well with peers and plays nicely with other children. She does pretend play.
Motor Development: No concern about gross motor skills. Her fine motor skills are good. She is learning how to hold a pen.
Behavioral Screening: Mom answered the pediatric response form and she does not have any queries or questions but would like to know more about positive training and the best way to start. She wants to know how to go about with her new baby coming.
PHYSICAL EXAMINATION: The patient is active and playful and easy going. Height is 34 inches. She grew 2-1/4 inches in the past year, 24th percentile. Weight is 29 pounds, an increase of 5 pounds within the past year, 42nd percentile. Blood pressure is 90/56, 67th percentile. Body mass index is 16.30. HEENT: Both tympanic membranes are clear. Both conjunctivae are clear. Red-orange reflexes are positive in both eyes. Nose is clear. Mouth is clear and throat is clear. There is no neck mass. Chest and lungs are symmetric. Good air entry with clear breath sounds. Heart normal. Abdomen benign. No mass or hepatosplenomegaly. Extremities: Femoral pulses are easily palpable. There is full range of motion of all four extremities. Skin: Clear, except for some bruising on the shin. Back: Straight. Neurologic: Examination is normal.
ASSESSMENT: Well-child check. The patient is a well 3-year-old girl.
PLAN: Anticipatory guidance was given on nutrition, dental care, elimination, sleep, cognition and injury prevention. There will be no shots today, but she will go to the lab for CBC and blood.
Well-Child Check Sample #2
The patient presents for a 6-month well-child check. She is here with her mother. The patient has been growing and developing normally, achieving all developmental milestones on time or early. She has been healthy since her last well-child check.
Diet was discussed. The patient has essentially weaned herself from breast feeding; however, she does breast feed in the morning. Throughout the remainder of the day, she has Nestle Good Start formula, at least 18 ounces daily, sometimes more. Mother has introduced rice cereal, fruits, and some vegetables at this point as well as a little bit of hamburger. She has been using all organic foods. She eats 2 or 3 meals a day and is actually more interested in solid food than she is in her formula at this point.
Elimination patterns are normal. Stools are normal.
Sleeping was discussed. The patient has numerous relatives that take care of her during the day and so her schedule during the day is a bit chaotic. She does not have a strict daytime and nighttime routine at this point; however, she does have at least 1 or 2 naps a day, but they vary in terms of their timing and she goes to bed at night around 7:30 or 8:30, and typically sleeps through the night about 50% of the time, sometimes waking up around 3:00 a.m. Mother admits that she allows the baby to come into her bed in the middle of the night and she does wake up.
REVIEW OF SYSTEMS: Ten system review at this time is entirely negative except for mother’s observation that she has had a bit of clear rhinorrhea lately.
OBJECTIVE: Temperature 97.8, height 25-3/4 inches, weight 15 pounds 12 ounces, head circumference 16-1/2 inches. In general, this is a vigorous-appearing infant in no acute distress. HEENT: Head normocephalic, atraumatic. Her anterior fontanelle is open and flat. Posterior fontanelle is closed. Eyes: Positive red reflex bilaterally. Extraocular movements full. Good tracking. Good eye contact. Nares patent. No discharge currently. Oropharynx: Benign appearing. She has 2 lower incisors and her 2 upper incisors are also starting to come in. Ears: Hearing grossly normal. TMs normal. Neck: Supple. No rash. No pits. No adenopathy. Lungs: Clear bilaterally. Heart: Normal S1, S2. No murmur, rub or gallop. Abdomen: Soft and nontender. No palpable organomegaly or masses noted. Positive bowel sounds noted. Genitourinary exam: Reveals normal Tanner I female with no rashes. Normal introitus. Normal patent anus. Extremities: Reveal full range of motion. Normal hip exam, no click or clunk. No clonus noted. Skin exam reveals no suspicious lesions and no birthmarks. Neurological exam: Reveals symmetrical movements of all four extremities and excellent tone. Baby sits well without support and bears weight on her legs. Mother tells me she has also pulled to stand.
ASSESSMENT: Well-child check.
PLAN:
1. Six-month shots to be given, Pentacel, PCV, and Rotavirus.
2. Normal growth and development issues discussed.
3. Dietary issues discussed. Reminded mom to introduce new foods with a 2 or 3 days pacing between them and that she can gradually ramp up to adding more meats around 8 months of age, transitioning to three meals a day at around 9 months of age. Foods to avoid were discussed at length as well. Counseled on the importance of continuing infant formula at this point for the iron supplementation.
4. Discussed safety issues at length including car seat safety, burns, etc. and followup will be at 9 months of age.
