What is the recommended structure for an interview and physical exam during a new-patient well-child visit for a 5-year-old female?

Structured Interview and Physical Exam for a 5-Year-Old Female Well-Child Visit

A comprehensive well-child visit for a 5-year-old female should include separate interviews with both the child and parents, a complete physical examination, appropriate screenings, and targeted anticipatory guidance focused on development, safety, and health promotion.

Interview Structure

Initial Approach

• Create a comfortable environment with age-appropriate toys/activities
• Address the child directly in developmentally appropriate language
• Establish rapport by asking about interests, friends, and activities 1
• Include both parents/caregivers when possible 2

Parent Interview Components

1. Medical History:

   • Birth history and previous health concerns
   • Current medications and allergies
   • Recent illnesses or injuries
   • Family medical history (genetic conditions, chronic diseases) 3
   • Previous screenings and immunization status 4

2. Developmental Assessment:

   • School readiness and academic progress
   • Language development and communication skills
   • Social interactions with peers and adults
   • Fine and gross motor skill development
   • Behavioral concerns or changes

3. Nutrition and Sleep:

   • Typical daily diet and eating patterns
   • Sleep duration, quality, and bedtime routines
   • Screen time habits and limits

4. Family Functioning:

   • Family structure and dynamics
   • Recent major life changes or stressors
   • Parental mental health (screen for depression) 1
   • Social determinants of health (housing, food security, transportation) 5

Child Interview Components

• Conduct a separate, brief interview with the child when appropriate 1
• Ask about:
  • School experiences and friends
  • Activities they enjoy
  • What makes them happy/sad/scared
  • Any worries or concerns they have

Physical Examination

Growth Assessment

• Measure and plot height, weight, BMI on appropriate growth charts
• Compare with previous measurements to assess growth trajectory

Complete Physical Examination

1. General appearance:

   • Overall development and nutritional status
   • Behavior, attention span, and interaction style

2. Vital signs:

   • Blood pressure, heart rate, respiratory rate, temperature

3. Head-to-toe examination:

   • Head/neck: Fontanelles (if still open), lymph nodes, thyroid
   • Eyes: Visual acuity screening, eye alignment, extraocular movements
   • Ears: Otoscopic examination, hearing assessment
   • Mouth/throat: Dentition, tonsils, palate
   • Chest: Breath sounds, heart sounds, murmurs
   • Abdomen: Organomegaly, tenderness, masses
   • Genitalia: Normal development, signs of abuse/neglect
   • Skin: Rashes, lesions, birthmarks
   • Musculoskeletal: Gait, spine alignment, joint range of motion
   • Neurological: Gross and fine motor skills, reflexes, coordination

Screenings

1. Vision screening:

   • Formal vision screening (USPSTF recommends one-time screening between ages 3-5) 4

2. Developmental screening:

   • Formal developmental screening using standardized tool 4
   • Autism-specific screening if not previously completed 4

3. Behavioral/emotional screening:

   • Age-appropriate behavioral assessment

4. Social determinants of health:

   • Screen for food insecurity, housing stability, transportation needs 5

5. Parental depression screening:

   • Using validated tool like PHQ-2 or Edinburgh Postnatal Depression Scale 1

Anticipatory Guidance

1. Safety:

   • Car seat use (transition to booster seat if appropriate)
   • Water safety and swimming lessons
   • Fire safety and emergency plans
   • Stranger awareness and personal boundaries

2. Nutrition and physical activity:

   • Balanced diet recommendations
   • Limiting sugar-sweetened beverages
   • Physical activity requirements (60 minutes daily)
   • Screen time limits (1 hour per day of high-quality content) 4

3. School readiness:

   • Reading together daily
   • Fine motor skill development
   • Social skills and emotional regulation
   • Establishing routines for school success

4. Dental health:

   • Brushing twice daily with fluoride toothpaste
   • Regular dental visits
   • Limiting sugary snacks and drinks 4

5. Family dynamics:

   • Positive discipline strategies
   • Sibling relationships
   • Family activities and communication

Communication Approach

• Direct questions to the child first, then supplement with parental input 1
• Use clear, non-medical language when explaining findings
• Validate parents' concerns and observations
• Provide written materials to reinforce education 1
• Ensure time for questions from both child and parents

Common Pitfalls to Avoid

1. Focusing exclusively on parents and ignoring the child
2. Rushing through developmental or behavioral concerns
3. Missing signs of trauma or adverse childhood experiences 1
4. Neglecting to screen for parental mental health issues 1
5. Failing to address family dynamics and social determinants of health

By following this structured approach, clinicians can conduct a comprehensive well-child visit that addresses physical health, development, safety, and family functioning while building rapport with both the child and parents.