Pediatrics Case Hx Flashcards
What is the importance of a case history?
guides the direction of examination
The case history is…
never finished
What insight does a case history provide?
ocular and medical health, family Hx, socio-economic considerations, education, lifestyle, development
What is one additional goal of a case history?
build rapport with the patient and parent
Who is the most reliable observer?
grandmother– hyperaware
During the chief complaint what is the goal of your questions?
determine parent and child reliability, determine billing level of examination, make sure to solve the chief complaint with the exam
What are vision codes and what are medical codes?
vision 92000 for routine eye exams, medical 99000 ex: flashes of light, headaches
List the common chief complaints in peds
routine eye exam/1st eye exam/annual eye exam, failed vision screening, problems seeing the board or seeing up close, perceived eye turn, rubs/blinks eye excessively, FOHx, problems reading, pink eye, headaches
List the HPIs
frequency, location, onset, relief, intensity/severity, duration, associated signs and symptoms
What are the main ROS complaints for a peds exam?
attention deficit disorder/hyperactivity, asthma, allergies
What are additional ROS complaints for a peds exam?
autism, down syndrome, cerebral palsy, diabetes, hypertension, marfan’s, neurofibromatosis, juvenile idiopathic arthritis, sickle cell anemia
What do you need to make sure to include in PMHx?
current treatments, prior surgeries
What questions need to be asked about medications?
what is taken? why? how long? dose?
POHX questions?
LEE, previous Rx, previous Tx, disease, injuries, surgeries
FMHx questions?
conditions, ocular hx: refractive error, strabismus, amblyopia, color vision defects, congenital glaucoma/cataracts
What does lazy eye mean?
it depends, need parent to elaborate, could be strabismus or amblyopia
How do you determine if a child is an appropriate age for their grade?
age-5
What should you ask about academics?
favorite and least favorite subject, grades, IEP/504 plan
What is included in a developmental history?
length of pregnancy, birth weight, exposure to drugs, delivery, apgar, milestones