Pediatric Preventive Visit Note

Chief Complaint

4-year well-child examination

History of Present Illness

Lucas Miller (DOB: 14/05/2020, MRN: 849-204-11) is a 4-year-old male presenting for a routine well-child check accompanied by his mother. Birth and past medical history are unremarkable.

Parental Concerns: Mother notes mild dry skin on the bilateral antecubital fossae and popliteal areas over the past two weeks, associated with occasional pruritus in the evenings. No history of secondary skin infection, weeping, or bleeding. Currently applying unscented emollient cream intermittently.

Mother also reports occasional resistance at bedtime over the past month, taking approximately 30 minutes to settle after lights out.

Nutrition/Elimination: Consumes a varied diet including meats, dairy, grains, fruits, and vegetables; drinks 450 mL of low-fat milk and 600 mL of water daily. Normal bowel and bladder function; fully toilet trained during the day with one soft bowel movement daily and rare nocturnal enuresis.

Dental: Brushes teeth twice daily with fluoridated toothpaste under parental supervision; last dental evaluation 4 months ago with no caries identified.

Sleep: Sleeps in own toddler bed in a private bedroom. Sleeps 10 to 11 hours nightly from 20:00 to 06:30 with no nocturnal awakenings or snoring.

Development/Behavior: SWYC developmental screening completed and scored within normal limits across all domains. Speaks in full sentences understood by strangers, hops on one foot, draws a person with three parts, dresses self with minimal assistance, and engages in cooperative play with peers.

Safety: Rides in a forward-facing 5-point harness car seat in the rear vehicle seat, wears a helmet when riding a tricycle. Smoke and carbon monoxide detectors are functional in the home, medications and cleaning supplies are locked, and no firearms are kept on the premises.

Health Risks: No exposure to secondhand smoke; no signs of anxiety or depression noted by parent.

Childcare/School: Attends preschool 3 days per week and adjusts well to classroom routines and peers.

Mother inquired about readiness for community swimming lessons this coming summer.

REVIEW OF SYMPTOMS

All other systems negative except as documented in the HPI.

---

Physical Assessment

General: Alert, active, well-nourished, well-developed male in NAD; BMI at the 65th percentile.

Head: Normocephalic and atraumatic.

Eyes: Conjunctiva and lids: Conjunctivae clear, lids normal without erythema or exudate. Pupils and irises: PERRLA. Symmetric corneal light reflex bilaterally.

Ears, Nose, Mouth and Throat: External inspection of ears and nose: Pinnae and external nose normal; nares patent with clear mucosa. Otoscopic examination: Tympanic membranes pearly grey with normal landmarks and mobility bilaterally. External auditory canals clear without erythema or cerumen impaction. Oropharynx: Mucous membranes moist; posterior pharynx clear without erythema or tonsillar hypertrophy; dentition intact without visible caries.

Neck: Examination of neck: Supple with full range of motion and no masses or thyromegaly.

Pulmonary: Respiratory effort: Eupneic at 22 breaths/min with regular rhythm and no retractions or nasal flaring. Auscultation of lungs: Clear to auscultation bilaterally throughout all lung fields without wheezes, rales, or rhonchi.

Cardiovascular: Auscultation of heart: RRR, HR 95 bpm, normal S1 and S2 without murmurs, rubs, or gallops; femoral pulses 2+ and symmetric.

Abdomen: Examination of abdomen: Soft, non-tender, non-distended with normoactive bowel sounds and no palpable masses. Examination of liver and spleen: No hepatosplenomegaly.

Lymphatic: Palpation of lymph nodes in neck: No cervical or supraclavicular lymphadenopathy.

Musculoskeletal: Normal muscle tone, bulk, and 5/5 strength throughout; full range of motion in all extremities with normal gait and spine alignment.

Skin: Skin and subcutaneous tissue: Warm and well-perfused; mild erythematous, xerotic patches noted in the bilateral antecubital fossae without excoriation or crusting.

Neurologic: Sensation: Grossly intact to light touch. Alert, cooperative, and developmentally appropriate mood and affect.

Genitourinary: Normal circumcised male external genitalia; testes descended bilaterally without hernia or hydrocele.

Vision screening via LEA symbols is 20/25 bilaterally; pure-tone audiometry screening passed at 1000, 2000, and 4000 Hz in both ears.

Assessment

1. 4-year well-child examination
2. Mild atopic dermatitis

Plan/Recommendations

1. Return for 5-year well-child examination in 1 year.
2. Immunizations: Administered DTaP-IPV (Kinrix) 0.5 mL IM and MMR-Varicella (ProQuad) 0.5 mL SC today. Influenza vaccine declined by mother today. Discussed required vaccines as indicated by the CDC immunization schedule. Immunizations given today as above after informed consent discussion during which all parent's questions were answered, concerns were reviewed at length, and I have personally provided face to face counseling on all vaccine components.
3. For mild atopic dermatitis, apply plain fragrance-free emollient ointment twice daily and immediately after lukewarm baths. Apply hydrocortisone 1% ointment topically BID PRN to antecubital flares for up to 7 days.
4. For bedtime resistance, maintain a consistent, structured 20-minute wind-down routine without screens for 1 hour prior to sleep.

Counseling: Discussed age-appropriate nutrition, limiting sugary beverages, daily physical activity, water safety and formal swimming lessons, street safety, and limiting recreational screen time to less than 1 hour daily.

Mother verbalizes understanding of the care plan and was instructed to return to clinic or call if rash worsens, signs of secondary skin infection develop, or persistent vaccine side effects occur.