Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 1

Obtaining an Initial History

Beth Richardson

I. INTRODUCTION

A. The complete health history taken at the first visit is an opportunity for the practitioner to establish a relationship with the child and family, gain insight into family relationships, and obtain pertinent health information.

II. INITIAL INFORMATION

A. Parent(s).

1. Name(s).

2. Age(s).

3. Health status.

B. Sibling(s).

1. Age(s).

2. Health status.

III. REASON FOR CURRENT VISIT

A. Current problem or illness.

1. Background information.

a. When did it start?

b. What are the symptoms?

c. Are others in family ill with similar symptoms?

d. What has been done to treat symptoms?

IV. PAST HISTORY

A. Prenatal history and care if child younger than 5 years.

1. Was pregnancy planned?

2. Did the mother smoke? Drink alcohol? Take any medications or drugs?

3. Any problems such as:

a. Vaginal infection?

b. Kidney infection?

c. High blood pressure?

d. Diabetes?

e. Edema?

f. Bleeding?

g. Any accidents during pregnancy?

B. Natal history and care.

1. Labor and delivery.

a. Where was infant born?

b. Type of delivery?

c. Length of labor?

d. Anesthesia used during labor?

e. Any problems with mother or infant after birth?

f. Infant's birth weight? Length? Head circumference? Gestational age?

g. Did infant go home with the mother?

2. Feeding.

a. Baby fed by bottle or breast?

b. Type of formula used?

c. Frequency of feedings?

d. Pattern of weight gain?

3. Childhood illness.

a. Rheumatic fever, chickenpox, number of ear infections, strep throat, respiratory syncytial virus (RSV), whooping cough, mononucleosis, sexually transmitted infections (STIs).

4. Hospitalizations.

a. Dates, names of hospitals, diagnoses.

5. Surgeries.

a. Dates, names of hospitals, diagnoses, complications.

6. Immunizations (see Appendix A).

a. Dates, reactions.

7. Screening tests.

a. Vision, hearing, speech, hemoglobin, urine, tuberculosis skin test, X-rays, other laboratory tests.

8. Allergies.

a. Medications, environment, foods.

9. Transfusions.

a. Dates, number of units transfused, reactions.

10. Medications.

a. Prescription; over the counter; herbal; current/recent medications including dosage, length of time taking medication, adverse reactions/ side effects.

V. REVIEW OF SYSTEMS

A. History.

1. Head, eyes, ears, nose, throat.

a. Head: Headaches or head injuries?

b. Eyes: Tearing, strabismus? Has child had vision test? Does child wear glasses/contacts?

c. Ears: Ear infections? Drainage? Has child had a hearing test?

d. Nose: Allergies? Frequency of colds? Does child snore, have nosebleeds, or postnasal drip?

e. Throat: Sore throat, dental hygiene, lymph glands, hoarseness?

2. Cardiovascular.

a. Heart murmur.

b. Congenital heart disease.

c. Cyanosis.

d. Edema.

e. Activity tolerance, shortness of breath, syncope.

3. Respiratory.

a. Pneumonia, bronchitis.

b. Asthma.

c. Cystic fibrosis.

d. Croup, cough.

4. Gastrointestinal.

a. Diarrhea, constipation.

b. Vomiting, reflux, upset stomach, abdominal pain.

c. Bloody stools, rectal bleeding.

d. Fissures, ulcer.

e. Jaundice.

5. Genitourinary.

a. When did child achieve night dryness?

b. Frequency of urination, urinary tract infections, dysuria, polyuria.

c. Hematuria.

d. Menstrual history (pain, flow), vaginal drainage.

e. Penis or testes abnormalities, STIs, sexual activity.

6. Musculoskeletal.

a. Painful joints, swelling, strains, sprains, fractures.

b. Deformities.

c. Activity tolerance.

7. Neurologic.

a. Headaches.

b. Seizures, epilepsy.

c. Fainting, dizziness, tremors.

d. Clumsy, uncoordinated.

e. ADD/ADHD, learning disability, developmental delay.

8. Endocrine.

a. Sexual maturation.

b. Diabetes.

c. Thyroid or adrenal diseases.

9. Skin.

a. Rashes, birth marks.

VI. FAMILY HISTORY

A. History of any of following in family members:

1. High blood pressure.

2. Heart disease, stroke.

3. Diabetes.

4. Cataracts, glaucoma.

5. Anemia.

6. High cholesterol levels.

7. Asthma, allergies.

8. Kidney infections.

9. Colitis, ulcers.

10. Cancer.

11. Thyroid problems.

12. Epilepsy.

13. Dysplasia of hip.

14. Mental retardation.

15. Alcoholism or substance abuse.

VII. DISEASE HISTORY

A. Disease/problem.

1. When was patient diagnosed?

2. How was patient treated? Response to treatment?

3. How have symptoms changed? How is patient doing now?

4. Is patient taking medications to treat problem?

VIII. SOCIAL HISTORY

A. Parents'/guardians' employment site(s) and hours worked.

B. Child care.

1. Daycare or sitter?

2. Preschool or after-school programs?

C. Family relationships: How do family members get along?

D. Home life.

1. Does home have a yard where child can play?

2. Stairs in house?

3. City, well, or bottled water?

4. Is home in safe neighborhood?

E. School life.

1. How is child's progress?

a. What are child's grades?

b. What are child's strengths and weaknesses in learning? Does child need extra help in learning?

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.


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