Paediatric Preventive Health Visit Note

Patient Details

Patient Name: Oliver Davies Date of Birth: 14/04/2020 Date of Consultation: 18/04/2024 Medical Record Number: 482-910-37

Well-child Check-up Documentation

Parent/Guardian Present

• Name: Sarah Davies (Mother)

Developmental History

• Milestones: Hops on one foot, catches bounced ball, speaks in 4–5 word sentences, uses scissors, dresses independently except for shoelaces.
• School/Daycare: Attends 4-year-old kinder 3 days/week; engages in cooperative play with peers.

Medical History

• Previous Illnesses: Acute otitis media (2022), mild viral croup (2023).
• Chronic Conditions: Mild infantile eczema (resolved).
• Allergies: NKDA. No food allergies.
• Immunizations: Up to date per National Immunisation Program (NIP) schedule up to 18 months. Due for 4-year-old vaccines today.
• Medications: Nil regular.

Physical Examination

• General Appearance: Well-nourished, alert, cooperative.
• Growth Measurements
  • Weight: 16.5 kg (50th centile)
  • Height: 103 cm (50th centile)
  • Head Circumference: N/A (not routinely measured at 4 years)
• Vital Signs
  • Temperature: 36.6 °C
  • Heart Rate: 95 bpm
  • Respiratory Rate: 22 bpm
  • Blood Pressure: 92/58 mmHg
• Systemic Examination
  • Head and Neck: Normocephalic, TMs clear bilaterally, pharynx NAD, no cervical lymphadenopathy. Red reflex present bilaterally, visual acuity 6/6 bilaterally (Sheridan Gardiner).
  • Chest: Clear to auscultation bilaterally, nil wheeze/crackles. HS dual, nil murmurs.
  • Abdomen: Soft, non-tender, no organomegaly, normal bowel sounds.
  • Musculoskeletal: Normal gait, full ROM all joints, spine straight.

Developmental and Behavioural Assessment

• Cognitive Development: Age-appropriate; counts to 10, names 4 colours, understands time concepts (e.g., morning, night).
• Social and Emotional Development: Separates easily from mother, shares toys, displays appropriate empathy and emotional regulation.
• Behavioural Concerns: Occasional frustration tantrums when tired; nil major concerns reported by mother.

Preventive Health Recommendations

• Nutrition: Encourage balanced diet with 5 serves vegetables and 2 serves fruit daily; water and plain milk for drinks, limit discretionary sugary snacks.
• Physical Activity: Aim for ≥ 3 hours of physical activity spread throughout the day, including ≥ 1 hour of energetic play. Limit screen time to ≤ 1 hour/day.
• Sleep: Recommend 10–13 hours of uninterrupted sleep per night, maintaining a consistent bedtime routine.
• Dental Care: Brush twice daily with pea-sized amount of low-fluoride toothpaste; schedule routine 6-monthly dental check-ups.

Immunizations

• Vaccinations Administered: Diphtheria, tetanus, acellular pertussis, and inactivated poliomyelitis (dTpa-IPV, Infanrix IPV®) 0.5 mL IM left deltoid.
• Next Due Vaccines: Year 7 school-based program (HPV and dTpa) at age 12–13 years, or annual influenza vaccine if desired.

Follow-up and Next Steps

• Next Well-Child Visit: PRN prior to school entry, or in 1 year (18/04/2025) at age 5 for general review.
• Referral: Nil required.
• Additional Testing: Nil required.

Patient and Parent/Guardian Education

• Discussed: Advice about staying active, eating well, and maintaining regular dental care. Discussed post-vaccination care (paracetamol (Panadol®) 240 mg PO QID PRN for fever/pain) and sun safety.
• Materials Provided: Raising Children Network 4-year-old development handout, NIP immunisation aftercare sheet.

Parent/Guardian Understanding

• Confirmed: Yes, the parent or guardian showed understanding of the health advice and planned follow-up.

Signature

Dr. Liam Vance General Practitioner Bayside Family Medical Centre, 124 Bay Rd, Sandringham VIC 3191 | Ph: (03) 9555 0192

Date: 18/04/2024