Pediatric Primary Care (7 page)
c. What type of classroom (advanced, regular, learning disability)?
2. Behavior.
a. Does this child bully others or is child a victim of bullying?
b. What is child's behavior in learning situations?
c. History of absenteeism or truancy?
3. Classmates/friends.
a. How does child relate to and play with those in classroom, daycare, or preschool?
b. Does child have a best friend?
c. What does child like to play?
IX. DEVELOPMENT
A. For child younger than 2 years ask when first:
1. Smiled.
2. Rolled.
3. Sat without assistance.
4. Crawled.
5. Walked without assistance.
6. Said 2 words.
7. Fed self.
8. Said 10 words.
B. Behavior.
1. Temper tantrums, whining.
2. Thumb sucking.
3. Sleep patterns.
4. Temperament.
BIBLIOGRAPHY
Bickley L.
Bates' Physical Examination and History Taking.
10th ed. Philadelphia, Lippincott; 2008.
Duderstadt K.
Pediatric Physical Examination.
Philadelphia, Elsevier; 2006.
CHAPTER 2
Obtaining an Interval History
Donna Hallas
I. THE INTERVAL HISTORY
A. Definition.
1. Interval history: data collection that occurs at subsequent visits to one in which comprehensive history and physical examination were completed.
2. Amount of information reviewed and collected for interval history depends on child's age and length of time since either comprehensive history was obtained and/or prior appointments in which interval history was updated.
3. General guideline for obtaining interval history: review and update data every 6 months for infants, toddlers, preschool-age children and every year for school-age children, adolescents.
B. Significance of interval history.
1. Although comprehensive history is used to establish initial health promotion plan, analysis of data collected during interval history is often used in one of four ways:
a. To continue established health promotion plan.
b. To identify new healthcare problems.
c. To make changes to health promotion plan based on new data.
d. To establish new health promotion plan.
C. Preparation for obtaining interval history.
1. Prior to beginning data collection for interval history, review comprehensive history and any prior interval histories available on medical record.
a. Helps nurse practitioner focus questions that will elicit data needed to complete interval history.
b. Sample data contained in comprehensive history that may need further exploration during interval history are listed in
Table 2-1
.
Table 2-1
Focusing the Interval History from Details in the Comprehensive History
| Comprehensive history | Interval history |
| Past medical history | Any data in past medical history that is significant and requires further clarification. |
| | Consider previous acute illnesses including hospitalizations, injuries, accidents, surgeries, chronic illnesses. |
| | Review problem list. |
| | If all prior problems are listed as resolved, then no further data should be elicited at this visit. |
| | If problems still exist, then ask questions specific to identified problem. |
| Allergies | Always obtain update on allergies to foods, medications, environmental pollutants. |
| Developmental history | Review results of prior DDST or the Ages and Stages Questionnaires. |
| | Note achievement of developmental milestones at each interval visit. |
| | If delays are noted, question status of intervention services (early intervention for children 5 years old, OT, PT, speech, special education services for all children). |
| Social history | Exercise and activity. |
| | Wellness behaviors. |
| | Behavior issues at home or at school. |
| Family history | Review family structure and family support systems. |
| | If data contained in comprehensive history suggest dysfunctional family, ask about present family structure and function. |
| | Review genogram. |
| | Review significant family history prior to interview. |
| | Pay particular attention to strong family history of conditions in which family lifestyle modifications can have significant impact (e.g., cardiovascular conditions, hypertension, diabetes, obesity). |
| | Implementing lifestyle modifications in early childhood years may significantly affect health throughout lifetime. |
| Medication history | Prescription. |
| | Over the counter. |
| | Homeopathic remedies. |
| Nutritional history | Timing and frequency of meals. |
| | Ethnic and cultural considerations in food choices. |
| Immunization history | Immunization records should be reviewed at each visit. |
| Mental health | Assess mental health status for school age and adolescence at each interval visit. |
| | Anxiety and depression frequently occur in these populations. |
D. Elements of an interval history.
1. Elements included in interval history should be related to the age of the child.
2. Major focus for interval history for each age child and adolescent should include questions concerning eating, sleeping, bladder and bowel patterns, and any unusual behaviors or changes in behaviors. Additional questions are then age related.
3. Infant, toddler, and preschool-age children.
a. Ask questions related to achievement of developmental milestones.
b. Denver Developmental Screening Test (DDST) may be used as a guide for questioning patterns concerning achievement of developmental milestones.
c. Toddlers and preschoolers: Assess information regarding speech and language development and development of social skills.
d. Use the Surveillance and Screening Algorithm: Autistic Spectrum Disorders for toddlers at the 18, 21, and/or 24 month old episodic visit if it had not been completed at a maintenance health visit.
Table 2-2
Review of System (ROS) in an Interval History
| System | ROS—gathering the interval history * |
| On a regular basis, do you have problems with: | |
| Head and neck | Headaches |
| | Blurred vision or any vision problems |
| | Earaches |
| | Nosebleeds |
| | Sore throats |
| | Diffi culty swallowing |
| | Any lumps in head or neck area |
| Chest and lungs | Chest pain |
| | Heart beating fast in chest (palpitations) |
| | Shortness of breath |
| | Fainting |
| | Frequent cough |
| Abdomen | Nausea |
| | Vomiting |
| | Diarrhea |
| | Urinating or bowels |
| | Menstruation |
| | Testicular pain |
| Musculoskeletal | Leg pain or cramps |
| | Stiffness, swelling, bone deformities |
| Skin, hair, and nails | Rashes |
| | Moles |
| | Darkened or discolored areas |
| | Abnormal hair growth |
| | Clubbing of nails |
| | Bruising easily |
| Sexual history | History of sexually transmitted infections |
*
This information is gathered in addition to the details related to eating, sleeping, bladder, and bowel patterns.
4. School-age children.
a. Should also include questions related to sociobehavioral development with peers and progress in school.
b. If female school-age child has secondary sex characteristics, then ask about menstrual cycle: Age of onset, frequency, length of cycle, any discomfort prior to or during menstruations.
c. Children older than10 years of age should be asked: Have they or their friends tried alcohol or drugs? Use a brief alcohol/drug screening tool at each episodic visit.
• What is their diet?
• Happy with appearance/weight?
• Thought about harming themselves or others?
• Sexually active?
5. Adolescents.
a. Use the HEADSSS assessment (home, education/employment, activity, drugs/alcohol, sexuality, suicide/depression, safety and exposure to violence).
b. Adolescent female: Ask questions related to menstrual cycle.
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