Patient
4-year-old male, well-child examination
Visit Reason
Routine 4-year well-child check. Annual health supervision visit. Last well visit at 3 years of age.
Growth Parameters
Weight: 16.0 kg (75th percentile) — up 2.2 kg from last year (+1.1 kg/year, appropriate velocity)
Height: 102 cm (50th percentile) — grew 7 cm since last visit (+7 cm/year, normal for age)
BMI: 15.4 (50th percentile) — appropriate, stable
Head Circumference: 51 cm (45th percentile) — growth curve stable along same percentile
Growth velocity: Appropriate. Crosses no percentile lines. No concerns.
Vital Signs
BP: 94/58 (normal for age/height percentile)
HR: 92 regular
RR: 20
Temp: 98.4 F (tympanic)
Developmental Surveillance (PEDS + ASQ)
GROSS MOTOR: Hops on one foot 3+ times. Catches bounced ball with hands. Runs smoothly, can stop and turn without falling. Climbs stairs alternating feet. Pedals tricycle. ✓ AGE-APPROPRIATE
FINE MOTOR: Copies cross and square (4/6 directions correct). Draws person with 4+ body parts. Uses scissors to cut along line. Dresses self with minimal assistance (buttons, zipper). Stacks 10+ blocks. ✓ AGE-APPROPRIATE
LANGUAGE: Speaks in 4-5 word sentences. Tells simple story with beginning/middle/end. Follows 2-3 step commands. Asks "what" and "why" questions frequently. Names 4+ colors. Speech intelligible to strangers ~90% of time. ✓ AGE-APPROPRIATE
PERSONAL-SOCIAL: Plays cooperatively with peers (takes turns with minimal prompting). Knows full name, age, gender. Engages in imaginative play. Separates easily from caregiver. Toilet trained (day and night dry). ✓ AGE-APPROPRIATE
ASQ-3 scores: All domains within monitoring or above-cut-off range. No delays detected.
Physical Examination
General: Active, playful, cooperative with exam. Well-nourished, well-developed.
HEENT: Normocephalic, atraumatic. TM clear bilaterally. Eyes: red reflex present bilaterally, tracks normally. Nose: patent, no discharge. Mouth: 20 teeth present, no caries visible. Tonsils 1+, no exudate.
Neck: Supple, no lymphadenopathy, full ROM.
Cardiovascular: RRR, no murmur, normal S1/S2. Peripheral pulses 2+.
Respiratory: Clear to auscultation bilaterally. No wheeze, crackles, or retractions.
Abdomen: Soft, non-tender, non-distended. No hepatosplenomegaly.
Genitourinary: Circumcised male, Tanner stage 1. Testes descended bilaterally.
Extremities/Skin: Full ROM. No clubbing, cyanosis, or edema. Skin: clear, no rashes, a few scattered benign nevi.
Neurological: Gait normal. Reflexes 2+ symmetric. Tone appropriate.
Immunizations Due Today
DTaP #5 (DTaP-IPV-Hib-HepB combo) — ADMINISTERED TODAY
Influenza (seasonal) — ADMINISTERED TODAY
COVID-19 booster (if eligible per schedule) — discussed, deferred to next visit per parent preference
Screening
Vision: Passed (picture chart 20/30 OU)
Hearing: Passed (otoacoustic emissions bilaterally)
Autism (M-CHAT-R/F): Score 0/20 — LOW RISK. No follow-up needed.
Lead level: Not due (screened at 12 and 24 months, both < 3.5 mcg/dL)
Hemoglobin/Hematocrit: Not due (screened at 12 months, was normal)
Anticipatory Guidance Discussed
- Nutrition: balanced meals, limit juice to 4 oz/day, avoid sugary drinks, water as primary beverage
- Sleep: 10-12 hours recommended (currently sleeping 10h, on track)
- Screen time: limit to 1 hour/day of high-quality programming; co-view with parents
- Dental: brushing twice daily with fluoride toothpaste (pea-sized amount); dentist visit every 6 months
- Safety: car seat forward-facing (transition to booster when outgrows height/weight limits); helmet for bike/scooter; pool safety; gun safety (locked, unloaded, separate ammunition)
- School readiness: kindergarten registration discussion — child eligible for fall enrollment; readiness appears excellent based on developmental profile
- Behavior: age-appropriate limit-setting, positive reinforcement, time-out technique reviewed
Assessment & Plan
Healthy 4-year-old male. Growth and development appropriate for age. All screenings passed. Immunizations updated.
- Return for 5-year well-child visit in 12 months (or sooner if concerns arise)
- Vision and hearing screening at 5-year visit
- Kindergarten health form provided for school registration
- Parent handouts: nutrition, screen time, dental health, car seat safety
- Open access for any acute concerns