Sec.

A Batch 2015

The Pediatric History

Date: June 4, 2012 Lecturer: Dr. Ana Marie Morelos THE INTERVIEW Goals: Discovery: to glean the information that leads to appropriate assessment and care Sharing: to provide the patient/family the information so that patient can react, ask questions, offer opinions Negotiation: to arrive at a joint course that respects the patients feelings, needs and life situation Union: to establish a joint effort regarding all aspects of care Support: to define with the patient your availability to bolster emotional and spiritual needs inherent in the disease/illness Partnership with the Patient The ethical context Autonomy: the pts need for self-determination. A well-informed patient is better able to exercise autonomy knowing that choices (alternatives) are available . Utilitarianism: the need to consider the appropriate use of resources for Beneficence: the clinician needs to do good for the patient; the need to do whats best for the patient. Nonmaleficence: clinician must do no harm to the patient. Utilitarianism: the need to consider the appropriate use of resources for the greater good of the larger community. Fairness and justice: recognition of the balance between autonomy and the competing interests of the family and community. (managed care vs. Limited resources) Deontological imperatives: duties of care providers established by tradition and in cultural contexts. Ethics does not provide answers, rather, it offers a disciplined approach to understanding and determining ultimate behavior. S.G.de Ocampo

Communicating with the Patient The patient-centered communication Informative Encourages patient participation Includes questions about social and emotional issues Non-verbal attitude complements words Utilizes active-listening skills Constantly maintains eye contact Healthy communication Flexibility: early in the interview, let it flow, ask open-ended questions, then later as information accumulates, be more specific. Set a tone that will allow you to uncover hidden concerns. Specificity: phrase questions carefully to avoid inaccurate or misleading patient responses. Clarity: be clear, explicit, avoid technical jargon, use the patients idiom, avoid leading questions. Subtlety: during questioning, learn to go far enough but not too far. Choose words carefully and dont overload patient with information and questioning. Some apparent irrelevancies may actually be important background information. Empathy: show understanding and acceptance. The Pediatric Patient Children are people: Who want attention Who do not want to be patronized Who love it when you get down on floor to talk to and play with them Who have anxieties and fears that must be anticipated and eased
Talk with them, hold them, reassure them, include them Patronizing: condescending, going down to the same level as someone who is perceived to be inferior. Use language that is not above the child but do not patronize, do not use baby talk For older kids: allow them to be heard fully, ask questions directly, give information directly

Older child/ Adolescent: Requires sensitivity May prefer to be alone with physician Look for clues regarding family interaction that may suggest a problem with the family, significant others, friends.

If the child is hesitant or passive, silent, or vaguely hostile: this may suggest that child prefers to be alone with the interviewer, free of the parent : needs separation and privacy

Adolescents: -Risky behaviors

-Reluctance to talk

Interviewer must give a clear evidence of respect for confidentiality and for their impending adulthood. Do not force conversation (this may be construed as confrontational).
Adolescents are at a vulnerable time: involving a tendency to experiment with risky behaviors that lead to a high incidence of mortality and morbidity. At the start of the visit: (if a parent is present, also acknowledge the patient, talk to both patient and parent)

greet others in the room; inquire about persons name and relationship with the patient; maintain confidentiality; give the patient your undivided attention. 2. Invite the pts story: begin with an open-ended question: How can I help you What made you decide to come in for health care now? Use verbal and non-verbal cues that prompt patients to recount stories spontaneously. Listen actively, use continuers: tapos go on I see Uh-huh 3. Agenda for the interview: identify the specific goals, identify specific issues: questions and concerns that are of greatest concern. 4. Expand and clarify the health history: elaborate significant health issues. SYMPTOM : felt and experienced by the pt. Expand and elaborate: see 7 attributes of a symptom, establish the sequence and time course (chronology) Use continuers: what then, what happened next? Expanding & Clarifying The Health History 7 Attributes of a symptom: Location (where is it, does it radiate?) Quality (what is it like?) Quantity (severity, how bad is it?) Timing (onset, duration, how often?) Setting in which it occurs Remitting/exacerbating factors (what makes it better/worse?) Associated manifestations The Process of Interviewing

Issues for Adolescents HEEADSSS Home environment Education/Employment Eating Activities Drugs Sexuality Suicide/Depression Safety from injury and violence

The Approach to the Interview Take time for self-reflection. Review the chart. Set goals for the interview Review clinician behavior and appearance. Improve the environment. Take notes. The Process of Interviewing 1. Greet & establish rapport: Introduce self and greet pt (except for children or adolescents, avoid first names, unless with permission from the patient or the family); acknowledge and S.G.de Ocampo

1. Generate and test hypothesis: What disease process might be the cause? Use items from the review of systems to build evidence for or against the diagnostic possibilities. 2. Create a shared understanding of the problem 2 views of reality The patients view: the illness how the patient experiences symptoms: shaped by personal or family health, the effect of symptoms on everyday life, individual outlook and style of coping, expectations about medical care. The clinicians view: the disease the explanation that the clinicians brings to the symptoms: the way that the

clinician organizes what is learned from the patient into a coherent picture that leads to a clinical diagnosis and treatment plan. 3. Negotiate a plan After learning about the disease & conceptualizing the illness: you get a complete picture of the problem: this is now the basis for planning further evaluation:PE, laboratory tests, consultations and negotiating a treatment plan. 4. Plan for follow up and closing Give notice that the interview is about to end and this allows the patient to ask questions, then clinician can review future evaluation, treatments and follow ups The Techniques of Skilled Interviewing Active Listening fully attending to what the patient is communication, being aware of the patients emotional state, using verbal and non verbal skills to encourage the speaker to continue and expand. Adaptive questioning learn to adapt your questioning to your patients verbal and nonverbal cues Options for clarifying the patients story Directed questioning (general to specific) Questioning to elicit a graded response Asking a series of questions, one at a time Offering multiple choices for answers Clarifying what the patient means 1. Nonverbal communication occurs continuously and provides important clues to feelings and emotions. - Pay close attention to: eye contact, facial expression, posture, head position and movements (head nodding, shaking), interpersonal distance, placement of arms and legs (crossed, neutral, open) - Match your position to the patients - can be a sign of increasing rapport - Moving closer or engaging in physical contact (place hand on patients arm) can convey empathy or help the patient gain control of his feelings. - Mirroring patients quality of speech: pacing, tone, volume : will increase rapport 2. Facilitation: when you encourage the patient to say more but do not specify the topic: how by posturing, by words & actions, pausing with a nod of the head, S.G.de Ocampo

remaining silent yet attentive and relaxed a cue for the patient to continue, leaning forward, making eye contact, using continuers maintain flow of the patients story. 3. Echoing: simple repetition of the patients words encourages patient to express factual details and feelings. 4. Emphatic responses: To empathize with your patient, you must first identify his or her feelings. Once you sense important but unexpressed feelings fr the patients face, voice, words or behavior, inquire about them, do not assume how the pt feels. Let the pt know that you are interested in feelings as well as in facts. Responses may be:I understand, that sounds upsetting You seem sad or empathy is non-verbal: touching patients arm. 5. Validation of the patients emotional experience. Helps patient feel that such emotions are legitimate and understandable. 6. Reassurance: The first step to effective reassurance is identifying and accepting the patients feelings without offering reassurance at that moment. The actual reassurance comes after you have completed the interview,PE and some laboratory studies. At that point, you can interpret for the patient what you think is happening and deal openly with the real concerns. 7. Summarization: Giving a capsule summary of the patients story in the course of the interview indicates that you have been listening carefully. It also indicates what you know and what you dont know. Then you ask the patient anything else? To let the patient add information and confirms that you have heard the story correctly. This also allows the clinician to organize your clinical reasoning and to convey your thinking to the patient, making the relationship more collaborative. 8. Highlighting transitions: to put pts at ease, tell them when you are changing direction during the interview. Gives patient a greater sense of control. As you move fr one part of the history to another and on to the physical exam, orient the patient with brief phrases: Now Id like to ask some questions about your past health.

Interviewing Children - Children are usually accompanied by a parent or caregiver - You need to consider the needs and perspective of both the child and the caregivers Working with families Start with the child if he or she can talk : as early as age 3yrs. Ask simple open-ended questions, follow with more specific questions. Ask parents to verify the information, to add details and to identify other issues. Provides a rich opportunity to observe how they interact with the child. Interviewing the Adolescent Adolescents respond positively to anyone who demonstrates a genuine interest in them. Adolescents are more likely to open up when the interview is focused on them rather than on their problems. Start with specific directed questions to build trust and rapport and start the conversation. Use summarization and transitional statements Explain to both parents and adolescent that the best health care allows adolescents some degree of independence and confidentiality. Before the parent leaves the room, get relevant medical history to clarify the parents agenda for the visit. Your goal is to help adolescents bring their concerns or questions to their parents and to promote more open dialogue History of the Pediatric Patient - The history may be taken from a parent or other responsible adult. However, the child must be included as much as possible and appropriate for his or her age. General Patient Information (General Data) Name Date of Birth, age Gender Address

Source and Reliability of Information document the historians identity; the patient or the persons relationship to the patient. State your judgment about the reliability of the historians information Chief Complaint/ Presenting Problem/Reason for Seeking Care State the information verbatim in quotation marks, and include the duration of the problem. History of Present Illness Onset: when the problem started; chronologic order of events; setting and circumstances Location Duration: length of problem or episode Character: nature Aggravating and associated factors Relieving factors and effect on the problem Temporal factors Severity of symptoms Pertinent negatives- those details that designate the absence of sx relevant to your differential dx: ex. Pain, specifically abdominal pain: on theperiumbilical region, progressive becoming severe, radiating to the RLQ, (-) associated vomiting (-) diarrhea (-)fever Past Medical History General health and strength: reserve detailed questioning for those aspects most pertinent to the age of the child Past Illnesses Include dates and complications Medical illnesses Communicable diseases Surgeries Injuries/Accidents Drug reactions Hospitalizations Maternal History - Important items include the mother's age at delivery of each child, GP: gravidity/parity and history of spontaneous abortions (miscarriages) list all pregnancies(GP, FPAL) dates and duration of pregnancies(include miscarriages),

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ages of parents at the time of birth of other children and this child Mothers health during pregnancies Mothers attitude toward pregnancies
FPAL: Full term, Premature, Abortions, Live births past medical history (including diabetes or eclampsia/preeclampsia; presence of oligo- or polyhydramnios; known fetal abnormalities; results of amnioscentesis

Growth and Development Mention the month or year when the following were performed: Up to age of 1 yr.
Smiled Held head Rolled over Sat with support Crawled Stood with support Spoke single words (be specific) First tooth

Mothers health during this pregnancy General health as related by the mother/age of parents Attitude toward this pregnancy Specific diseases or conditions Birth History Pregnancy Labor and Delivery Condition of infant at birth Feeding History Breastfeeding:duration, frequency, associated problems, reasons for stopping Bottle feeding : reason for changes, type of formula used, amounts offered and consumed; frequency of feeding and weight gain, vitamin intake Present diet and appetite: age of introduction of solids age when 3 feedings achieved present feeding patterns age weaned from bottle/breast type of milk and daily intake food preferences & cultural variations ability to feed self Developmental History Development: age when able to do the ff: Hold head erect while in sitting position Roll over from front to back and back to front Sit alone and sit unsupported Stand with support and stand alone Walk with support and walk alone Use words Talk in sentences Dress self S.G.de Ocampo

Mention the month or year when the following were performed: From 1-3 yrs.
Walked with support Walked alone Handedness Used sentences Toilet training began and completed Daily routine: sleep and play Relationship to family Behavior disturbances

Mention the month or year when the following were performed: From 4-12 yrs School placement and adjustments Specific aptitudes Specific disabilities Daily routine play and sleep Age when toilet trained, approaches and attitudes regarding toilet training School age: grade, performance, problems Dentition: age of first teeth, eruption of first permanent teeth Growth: height and weight in sequence of ages; changes in rates of growth or weight gain Sexual dev: present status - females: breast development, nipples, sexual hair, menstruation, acne - males: development of sexual hair, voice changes, acne nocturnal emissions Immunizations - dates given & any reactions
BCG; Tuberculin and other skin tests Poliomyelitis Diphtheria, Pertussis,Tetanus Hepatitis B, Hepatitis A Hemophilusinfluenzae type B Measles, MMR Chicken pox Influenza Others

Family History Health status of parents & children Are parents alive and healthy? Size of the family Health and problems of other children deceased children: date, age, cause of death Important diseases in the family: including ailments relevant to the patients present condition
Construct a family tree that includes the last two generations (prior to the generation of the proband). Ask specifically about childhood diseases or adult diseases with childhood onset; history of consanguinity; unexplained recurrent miscarriages or SIDS. Also ask specific questions about family history that is related to the patients chief complaint.

Suicide Sexuality Safety

Personal and Social History Personal Status: School adjustment masturbation, nail biting, thumb sucking, breath holding, temper tantrums pica, tics, rituals bed wetting, constipation or fecal soiling of pants playing with fire reactions to prior illnesses, injuries or hospitalizations An account of the a day in the life of the patient is helpful in providing insights. Home Conditions: Fathers and mothers occupations Principal caretakers of the child Parents together or separated? Spiritual orientation & Cultural heritage Food preparation and by whom Adequacy of clothing Dependence on relief or social agency Number of rooms in the house Number of persons in the household Sleep habits, sleeping arrangements available to the child For the Adolescent: HEADDSS Home Environment Employment and Education Activities Drugs Depression S.G.de Ocampo

Review of Systems General: fever, weight change, overall appearance to the parent, appetite, elimination habits, activity level, ability to keep up with peers,insertion of foreign objects, heat/cold intolerance Skin : eczema, seborrhea,rashes, itching, color change, hair/nail problems, bruising/bleeding Head: headache, injuries Eyes: visual changes, discharge, redness, injuries Ears: discharge, hearing difficulties, tinnitus Nose: allergies, injury, discharge, bleeding Mouth: injury, sore throat, swallowing difficulties, dental abnormalities, teething, snoring, mouth breathing Neck: pain, swollen nodes, masses, stiffness, asymmetry Lungs: shortness of breath, chest tightness, cough, wheeze, hemoptysis, chest pain Heart:cyanosis, edema, heart murmurs Breast: masses, pain, nipple discharge Gastrointestinal: emesis (bilious or bloody), abdominal pain, frequency of bowel movements, diarrhea (bloody/non-bloody), encopresis, colic, jaundice Genitourinary: dysuria, frequency, urgency, nocturia, enuresis, hematuria, vaginal/penile discharge, pain, injury, menarche Extremities: deformities, joint pain/swelling/warmth/erythema, muscle pain, cramps Neurologic/Psychiatric: mental status changes, agitation, disorientation, mood change, weakness, paresthesias, fainting, incoordination, tremors