Medical Report

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  • Published : January 17, 2013
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Learning Objectives:
1. To understand the content differences in obtaining a medical history on a pediatric patient compared to an adult. a. To understand how the age of the child has an impact on obtaining an appropriate medical history. 2. To understand all the ramifications of the parent as historian in obtaining a medical history in a pediatric patient. 3. To understand the appropriate wording of open-ended and directed questions, and appropriate use of each type of question. 4. To develop an awareness of which clinical settings it is appropriate to obtain a complete medical history compared to a more limited, focused history. Competencies:

1. To obtain an accurate and complete history of a pediatric patient in different age groups ( 5 years). Differences of a Pediatric History Compared to an Adult History: I. Content Differences A. Prenatal and birth history

B. Developmental history
C. Social history of family - environmental risks D. Immunization history II. Parent as Historian
A. Parent’s interpretation of signs, symptoms
1. Children above the age of 4 may be able to provide some of their own history 2. Reliability of parents’ observations varies
3. Adjust wording of questions - “When did you first notice Johnny was limping”? instead of “When did Johnny’s hip pain start”? B. Observation of parent-child interactions
1. Distractions to parents may interfere with history taking 2. Quality of relationship C. Parental behaviors/emotions are important
1. Parental guilt - nonjudgmental/reassurance 2. The irate parent: causes
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