Well Child Note
Patient’s Name: XXXXXXX
Age: 25 months
Date: 11/12/12
Allergies: NKA
Subjective:
History of Present Illness: Patient is a 25 month old female who presents today for her 2 year old well
physical. No concerns at this time. The parents claim that the child is well behaved, other than the
occasional temper tantrum. She spends four hours a day at daycare where there have been no
problems. She is eating well, parents states she will eat anything. They say she enjoys fruits but is picky
with vegetables. Child is able to eat with spoon and drink from cup without help. Parents also state that
she gets along well with her 5 year old sister at home. Patient rides in car seat, sleeps well and rarely
gets up within an 8-9 hour period. Patient does not complain of difficulty with bowel movements or
urination, and mother claims that there have been no changes in texture or color of bowel movements
and that the child generally has 2 per day. Parents have not begun potty training at this time but plan to
begin shortly. Patients claim child has approximately 30 words in vocabulary, which she uses in several
word sentences.
Past Medical History:
1. Patient was hospitalized at age of 18 months for right sided pneumonia, was treated and
discharged 2 days later.
2. Birth complications: none, delivered full term
a. APGAR: 10 at birth
b. Prenatal care: yes, provided by Pocono Medical Center
c. Was breast fed for first 4 months of life
3. Accidents and Injuries: none
4. Past surgical history: none
Immunizations: current, no scheduled immunizations for today
Medications: none
Developmental History
Responds to voice by turning head: 3 months
Smiles with social stimuli: 3month
Making sounds: 3 months
Reaching for objects: 6months
Grasps objects: 6 months
Reaches for mother: 6 months
Pinches with thumb and forefinger: 9 months
Uncovers toy when covered with blanket: 9 months
Waves bye: 9 months
Plays back and forth with ball: 1 year
Build tower of 2 blocks: 1 year
Walking with assistance: 16 months
Objective
Physical exam:
VS: Weight: 29lbs(75%), height: 33 in. (50%) HC: 18.5 in. (60%) BP: 102/56, Pulse 88, RR: 22, O2: 99% RA
Vision 20/20 BL
Hearing: no defects noted
General: well developed, well nourished, 25 month old females
Head: norm cephalic and non-traumatic
Eyes: Red reflex present, pupils equal and reactive to light, clear conjunctive
Ears: wax present bilaterally, tympanic membrane pink with no bulging presents
Neck: no lymphadenopathy, no thyromegaly, trachea midline without masses
Cardiovascular: Regular rate and rhythm, no murmurs, extremities are warm with capillary refill less
than 3 seconds
Lungs: clear to auscultation bilaterally, symmetric chest expansion
Abdomen: positive bowel sounds, soft, nontender, no organomegaly
Skin: warm, without rashes, ecchymosis or lesions
External Genitalia: within normal limits, no deformities
Musculoskeletal: full range of motion, strength as expected and equal bilaterally
Extremities: no cyanosis, clubbing, without deformity
Back: straight, no deformities or masses
Neurology: Awake and active, no distress, DTRs: Biceps, triceps, brachioradialis, patellar, and achilles all
+2 and equal bilaterally
Developmental Screening:
Is able to walk up and down steps of exam table
Jumps on one foot
Builds tower with blocks
Able to copy drawing of circle
Able to touch toes
Assessment:
1. Height and weight growth appropriate for age (50% and 75%)
2. Hearing and vision within expected limits
3. Motor, speech, behavioral skills appropriate for age
Plan:
1. Educate patient/parents of anticipatory guidance for age 2-5 years
a. Communication and language: speak to her in terms that she will understand and read
to her every day
b. Discipline: make understandable rules, ignore tantrums, use time out (2 minutes), and
limit television to 2 hour per day
c. Health/nutrition: keep her away from cigarette smoke, do physical activities outside
with adult supervision, eat 3 healthy meals with snacks between, drink 1 or 2% milk, and
limit juices to 4-6 oz. per day
d. Safety: be aware of furniture that she climbs on and make fall, never leave her alone
near water (either indoors or out) and do not let either patient or older sister use
appliances in kitchen
e. Toilet training: do not force training
2. Return to clinic in 5 months for 2 ½ year well visit if no concerns prior
Anticipatory guidance
Age birth-1 year
1. Injury prevention: baby safe furniture, car seats, smoke alarms, fire extinguishers, water
thermostat below 120, don’t leave alone on bed, keep small objects out of reach , poison
control center number
2. Nutrition: breast vs. bottle feeding, introducing foods, colic
3. Daily care/activity: stool patterns, sleeping positions, bathing, skincare, hiccups, bedtime routine
4. Developmental/behavioral: normal reflexes, importance of close interaction, childcare
arrangements, separation anxiety,
5. Medical: Immunizations, care of umbilical cord and circumcision, jaundice, when to call doctor,
bulb syringe, dental care, lead screenings
1-2 Years
1. Injury prevention: Supervised play, sunburn protection, avoid hot stoves, irons, supervision
around water, gun safety
2. Nutrition: self-feeding, eat meals with family, phase out bottle, fluoride supplement, use of
spoon and cup, balanced diet
3. Daily care/activity: thumb sucking, masturbation, night routine, “yes” vs “no” messages
4. Developmental/behavioral: toilet training readiness, clinging behavior, time out
5. Medical: Immunizations, why antibiotics may be harmful
5-10
1.
2.
3.
4.
5.
Years
Injury prevention: bicycle and pedestrian safety, car seat, stranger, safety drills, avoidance of
tobacco use, drugs, alcohol, internet safety, hazards of guns and tools
Nutrition: balanced diet, avoid excess sugar, salt and fat, maintain healthy body weight
Daily care/activity: exercise daily, brush teeth, sleeping, school and sport, peer interactions
Developmental/behavioral: show interest in school, limit television, chores
Medical: Immunizations, dental visits
10-15 Years
1. Injury prevention: risk taking behaviors, avoidance of tobacco, drugs, alcohol, internet safety,
hazards of guns and tools, inhalation abuse
2. Nutrition: balanced diet, avoid excess sugar, salt and fat, maintain healthy body weight, social
meals, supplements if needed
3. Daily care/activity: exercise daily, brush teeth, sleeping, school and sport, peer interactions,
weekend jobs
4. Developmental/behavioral: rapid growth, sexual development, privacy, safe sexual practices
5. Medical: Immunizations, dental visits
15-18 Years
1. Injury prevention: avoidance of tobacco, drugs, alcohol, internet safety, hazards of . guns and
tools, inhalation abuse, driving safety, healthy decisions
2. Nutrition: balanced diet
3. Daily care/activity: exercise daily, adequate sleep
4. Developmental/behavioral: plans for college, peer pressure, communication, safe sexual
practices
5. Medical: Immunizations, dental visits
Christie E. Slottje PA-S
Christie E. Slottje PA-S
11/12/12 2:30pm