Session 1: History Flashcards
SHEEADSS I’M Very Good
Strengths: strengths or interests
Home: household relationship/family dynamics
Education/employment: school, grade, etc.
Activities
Disabilities/drugs
Sleep/safety/self image/sleep sexuality/suicide/self mutilation
Internet
Media
Violence
Gang
CAGE Questionnaire
Four-question screening tool that evaluates substance use
*Can also be used to identify patterns, consequences, and tolerance of alcohol and other drugs
Inventory History
Listed problems that the patient is asked and checks off if they have; used more in adult medicine
Problem-focused history
Taken for acute illness
Interim History
History of what has happened between last visits
Recapitulation
Useful when a long complicated history or unusual history is presented
*Summarize frequently, especially with unusual histories
Sentence Completion Game
Psychodiagnosis/type of communication tool
*Give the first part of the sentence, child completes the second half of the sentence
Ex: I feel bad when I…
Developmental Considerations when taking history of baby 0-8 Months (3) Overview…
- Examine the child in the mother’s lap
- Once child is able to grasp, give the tongue blade to the child and see what the infant does with it
- Show parents how to react to the child
Communication with Child 0-2 months old (3)
- Note child’s ability to self-quiet and observe tracking behaviors
- Engage the infant by being face-to-face
- Watch them coo
Communication with Child 3-7 months old (5)
- Note social responsiveness
- -Should be very social: smiling, peek-a-boo, etc. - Reaching out play
- Mother-child interactions
- While you watch interactions, note if they are using legs and hands equally - How does child use hands and mouth in exploration?
- How does the parent see the child?
Communication with Child 8-12 months old (5)
- At 8 months –> object permanence and infant hatching occurs (coming in to his or her own)
- Greater sense of self
- If you take off something, put it back on to make sure infant feels safe
- Put stethoscope on mom’s arm first, then infant’s chest
- Develops separation anxiety
Communication with Child 12-18 months old (3)
- Age of separation anxiety
- Observe the child’s social distance - the limit of proximity that the child allows you before showing signs of distress
- Does child appear depressed? baby’s reflect maternal depression
Communication with Child 18 months-2 years old
18 months-2 years old = Toddlerhood
- Communication by observation
- Look for interactions with toys and caretakers
- Look for aggressive behavior or hyperactivity - Look for maternal-child mismatch
Preschool age
2-5 years old
Interviewing the child 2-3 years old (2)
- Ask the child’s name and age, guess wrong and play game with child
- Play with puppets nurse-doctor games; have a medical kit in the office and have the child play with it and a doll
Interviewing the child 3-5 years old (3)
- Obtain initial history from child; by 2 years old you want to talk to the kid a lot
- Draw-a-person test
- gives idea of how they can handle a pencil and how developed they are - Has no concept of illness
Pre-Schoolers Development (4)
- Concept of illness is not clear, feel guilty when someone is sick around them
- Cannot judge size well
- Does not understand concept of time or people permanence
- Ask child what they think made them sick
- introduce germs, give band-aids, allow child to cry if upset
School-Aged Children
6-10 years old
Communication with School-Aged Child (6)
- Sense of mastery and privacy is very important
- Oriented toward peer-group
- Ask about school life
- Ask if child wants to stay home or go to school. If wanting to stay home, suspect learning disability, emotional difficulties, or separation difficulty - Very concrete thought processes; tend not to talk and keeps feelings inwards
- Can be very quiet or introverted - Ask about social life and obtain peer history
- Ask about home life (3 wishes)
Communication with Adolescents 11-? (3)
- It is now time to talk to the child on their own, without a parent present
- Confidentiality issues and explanation
- Set the scene, explain confidentiality and when confidentiality can be breached - Ask about sexuality in private after establishing boundaries
Non-consensual sex definition
4 years apart is considered not consensual (ex: 9 year old and 13 year old)
16 years old is age of consent with adults
The Five P’s in Sexual History
- Partners
- amount, type - Prevention of Pregnancy
- preventative measures? - Protections from STDs
- preventative measures? - Practices
- Vaginal, anal, oral?
- do you use condoms? - Past history of STDs
Edinburg Postnatal Depression Scale (EPDS)
Screening for post-natal depression should be done 2 weeks, 6-8 weeks
*Designed for use at 6-8 weeks
HITS Screening tOOL
HITS = hurt, insulted, threatened with harm, partner violence
How often does your partner:
- Physically hurt you?
- Insult or talk down to you?
- Threaten you with harm?
- Scream or curse at you?
Answers: 1=never, 5=frequently
Range is 4-20, and greater than 10 is positive
CRAFFT Questionnaire
For Alcohol use
CRAFFT –>
- CAR – have you ever been in car with someone under the influence?
- RELAX – do you use drugs or alc to relax?
- ALONE – do you use drugs or alc when you’re alone?
- FORGET – do you forget things while using drugs or alc?
- FRIENDS –do they ever tell you to cut down or quit?
- TROUBLE – do you ever get into trouble?
Patient Health Questionnaire-2 (PHQ-2)
Over past 2 weeks, how often have you been bothered by any of the following:
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
(range is 1-3 points per question)
A score of 3 or more means you need to do PHQ-9
History of Present Illness OPQRST
O = onset P = Promoting, preventing, precipitating, palliating factors Q= Quality or quantity R = Region or radiation S= severity, setting, simultaneous symptoms T= temporal factors
Pre-natal history cfDNA screening
10 week cell-free DNA screening; identifies trisomy, Down syndrome, fetal sex
15-20 weeks gestation prenatal Quad screen
Risk of down syndrome (trisomy 21), trisomy 18, and open neural tube defects such as spina bifida
High Grade Ultra Sound Pre-natal screen
Done at 16-18 weeks
Genogram (4)
- Male = square
- Female = circle
- Male is placed to the left of the female in the father/mother dyad
- Children are noted oldest to youngest, left to right
Genogram: Liason
Denotes a couple living together, unmarried
*Denoted by a dotted line between the male and the female, rather than a solid line
Genogram: Separtism
Marked with one slashed line
Genogram: Divorce
Marked by two slashed lines
Genogram: death
Indicated by an “x” through the shape. the birth date and death date are recorded
Genogram: remarriage
Remarriage is shown to the side with a smaller shape
Heritability
Measures the contribution of genetics (compared to environment) in development of a particular disorder
Recurrence risk
Likelihood that a trait or disorder present in one family member will occur again in other family members in the same or subsequent generations
NEEDSS in history taking
Nutrition Elimination Education, environment Development, daycare Sleep, sexuality (if adolescent) Safety
Environmental Health Anticipatory Guidance Topic at prenatal or first visit (5)
- Home,
- ETS,
- mold,
- occupational exposures,
- breast/bottle issues
Environmental Health Anticipatory Guidance Topic at 2 months (3)
- ETS,
- Sun exposure,
- mold
Environmental Health Anticipatory Guidance Topic at 6 months (3)
- poisons,
- household pesticides,
- lead
Environmental Health Anticipatory Guidance Topic at preschool
arts and crafts
Environmental Health Anticipatory Guidance Topic for seasons (4 summer/spring, 2 fall/winter)
Spring/Summer: lawn, garden products, services
Fall/winter: wood stoves/heating
Interval history must include… (6)
- Chief complaint
- HPI
- Brief significant past medical history
- All meds/confirm allergies
- Activities of daily living
- NEEDS
Interpretation
Move beyond clarification to an inference that can be made from the circumstances presented
Confrontation
Pointing out contradictions between actions and feelings
Perinatal history includes (7)
- Birth history (type of delivery, problems?, Apgar)
- Ease or difficulty of labor
- Duration of labor
- Type of anesthesia
- Attendance by other family members
- Birth order if multiple births
- If C-section, why?
