Well Child Visit

Subjective

• 24-month well-child check and GI follow-up with mother present.

History of Present Illness

• Mother reports mild intermittent stool withholding over the past 2 weeks; stools are Bristol type 3-4 on current regimen. No hematochezia, emesis, or abdominal distension.

Past Medical History

• Infantile GERD, resolved at 12 months. Functional constipation diagnosed at 18 months, currently well-controlled. Full-term SVD, no NICU stay.

Medication History

• macrogol 3350 (polyethylene glycol 3350, Miralax®) 4 g PO daily; colecalciferol (vitamin D3) 400 IU PO daily.

Allergies

• NKDA. History of cow's milk protein intolerance in infancy, now resolved.

Immunizations

• Up to date per CDC schedule through 18 months. Due for Hepatitis A #2 today.

Growth and Development

• Passed M-CHAT-R (score 0) and ASQ-3.
• Uses 2-to-3-word phrases, follows 2-step commands, runs well, kicks a ball, stacks 6 blocks.
• Shows interest in the potty, sits clothed occasionally, not yet toilet-trained.

Diet and Nutrition

• Good appetite, eats 3 meals and 2 snacks daily.
• Varied diet including fruits, vegetables, whole grains, and lean proteins.
• Drinks 450 mL (15 oz) of whole cow's milk daily; 300 mL water daily.

Social History

• Lives in a single-family home with mother, father, and 5-year-old sister. Attends daycare 3 days/week.
• Smoke-free and vape-free home; smoke/CO detectors functioning; medications and cleaning supplies locked; no firearms in the home.

Family History

• Mother with celiac disease; father with mild intermittent asthma.

Objective

Vital Signs

• Weight: 12.6 kg (54th percentile)
• Height: 87.5 cm (60th percentile)
• BMI: 16.5 kg/m² (52nd percentile)

Physical Examination

• Alert, active, well-nourished toddler in NAD, interactive in exam room.
• Warm, dry, intact; no rashes, bruising, or lesions.
• HEENT: Normocephalic, atraumatic; PERRLA, EOMI, red reflex intact bilaterally:
• TMs pearly grey with normal landmarks bilaterally; canals clear.
• Moist mucous membranes; 16 deciduous teeth present without visible caries; oropharynx clear.
• Supple, full ROM, no lymphadenopathy or thyromegaly.
• CTA bilaterally, no wheezes, rales, or rhonchi; normal respiratory effort.
• RRR, normal S1/S2, no murmurs, rubs, or gallops; femoral pulses 2+ bilaterally.
• Soft, non-tender, non-distended; normoactive bowel sounds; no hepatosplenomegaly or palpable fecal masses; normal perianal exam without fissures.
• Normal gait, full ROM in all extremities, symmetric strength and muscle bulk.
• Cranial nerves II-XII grossly intact; normal tone and coordination.

Screenings

• Instrument-based photoscreening: Pass bilaterally.
• Behavioural audiometry / OAE: Pass bilaterally.
• Capillary blood lead level: < 1.0 µg/dL (normal).
• M-CHAT-R: Low risk (score 0); ASQ-3 normal across all domains.

Assessment

• Healthy 24-month-old male with resolved GERD and well-controlled functional constipation.
• Appropriate linear growth and weight gain tracking along the 50th-60th percentiles.
• Meeting all age-appropriate developmental milestones.

Plan

• Administer Hepatitis A vaccine (2nd dose) 0.5 mL IM today.
• Anticipatory guidance provided:
• Read together daily, narrate daily activities, and limit screen time to < 1 hour/day of high-quality programming.
• Encourage parallel play and supervised social interaction with peers; use positive reinforcement and redirection for tantrums.
• Keep in a rear-facing 5-point harness car seat in the back seat until reaching the maximum height or weight limit allowed by the manufacturer.
• Ensure constant supervision near water and streets; use a helmet when riding push-toys/tricycles; keep Poison Control number (1-800-222-1222) accessible.
• Brush teeth BID with a rice-grain-sized smear of fluoridated toothpaste; schedule first dental visit.
• Maintain a consistent bedtime routine, aiming for 11-14 hours of total sleep per 24 hours (including 1 nap).
• Transition from whole milk to 1% or skim milk; limit milk intake to 480 mL (16 oz) daily to prevent constipation and iron deficiency; maintain high-fibre diet and continue macrogol 3350 4 g PO daily.
• Return for 30-month well-child visit in 6 months, or sooner PRN for worsening constipation or red-flag GI symptoms.

Health Promotion

• Bright Futures 2-Year Visit handout and high-fibre toddler diet guide provided.
• Toilet training readiness, temper tantrum management, and dietary fibre maintenance.
• Drowning prevention, car seat safety, poison control, and fall prevention reviewed.