Obtaining an Interval History

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l C H A P T E R 2 Obtaining an Interval History T FOR SALE Donna Hallas ett Learning, OR DISTRIB I. THE INTERVAL HISTORY A. Definition. 1. Interval history: data collection that occurs at subsequent visits to one in which comprehensive history and physical examination were completed. 2. Amount of information reviewed and collected for interval history depends on child s age and length of time since either comprehensive NOT FOR history SALE was obtained and/or prior appointments in which interval NOT history FOR SALE was updated. 3. General guideline for obtaining interval history: review and update data every 6 months for infants, toddlers, preschool-age children and every ones & Bartlett Learning, year for school-age LLC children, adolescents. ett Learning, T FOR SALE B. OR Significance DISTRIBUTION of interval history. OR DISTRIB 1. Although comprehensive history is used to establish initial health promotion plan, analysis of data collected during interval history is often used in one of four ways: a. To continue established health promotion plan. b. To identify new healthcare Jones problems. & Bartl c. To make changes to health NOT promotion FOR SALE plan based on new data. d. To establish new health promotion plan. C. Preparation for obtaining interval history. 1. Prior to beginning data collection for interval history, review comprehensive & Bartlett history Learning, and any prior LLC interval histories available on Jones medical & Bartl Jones NOT FOR record. SALE a. Helps nurse practitioner focus questions that will elicit data needed to complete interval history. b. Sample data contained in comprehensive history that may need further exploration during interval history are listed in Table 2-1. ett Learning, T FOR SALE OR DISTRIB 9..

l 10 CHAPTER 2 Obtaining an Interval History Table 2-1 Focusing the Interval History from Details in the Comprehensive History Comprehensive ones & Bartlett history Learning, Interval LLC history ett Learning, T FOR SALE Past medical OR history DISTRIBUTION Any data in past medical history that NOT is significant FOR and SALE OR DISTRIB requires further clarification. Allergies Developmental history Consider previous acute illnesses including hospitalizations, injuries, accidents, surgeries, chronic illnesses. Review problem list. If all prior problems are listed as resolved, then no further data should be elicited at this visit. If problems still exist, then ask questions specific to identified problem. T FOR SALE Always obtain update on allergies to foods, medications, environmental pollutants. Review results of prior DDST or the Ages and Stages Questionnaires. Note achievement of developmental milestones at each interval visit. If delays are noted, question status of intervention services (early intervention for children 5 years old, OT, PT, speech, special education services for all children). ett Learning, OR DISTRIB Social history Exercise and activity. Wellness behaviors. Behavior issues at home or at school. Family history Review family structure and family support systems. If data contained in comprehensive history suggest dysfunctional family, ask about present family structure and function. Review genogram. T FOR SALE Review significant family history prior to interview. Pay particular attention to strong family history of conditions in which family lifestyle modifications can have significant impact (e.g., cardiovascular conditions, hypertension, diabetes, obesity). ett Learning, OR DISTRIB..

l I. The Interval History 11 Table 2-1 (Continued) Comprehensive history Interval history Implementing lifestyle modifications Jones in early childhood & Bartlett years Learning, T FOR SALE may significantly affect health throughout NOT FOR lifetime. SALE OR DISTRIB Medication history Nutritional history Prescription. Over the counter. Homeopathic remedies. Timing and frequency of meals. Ethnic and cultural considerations in food choices. Immunization history Immunization records should be reviewed at each visit. Mental Jones health& Bartlett Assess Learning, mental health LLC status for school age and adolescence at each interval visit. Anxiety and depression frequently occur in these populations. ones & Bartlett D. Elements Learning, of an interval LLC history. ett Learning, 1. Elements included in interval history should be related to the age of the T FOR SALE OR DISTRIB child. 2. Major focus for interval history for each age child and adolescent should include questions concerning eating, sleeping, bladder and bowel patterns, and any unusual behaviors or changes in behaviors. Additional questions are then age related. 3. Infant, toddler, and preschool-age NOT FOR children. SALE a. Ask questions related to achievement of developmental milestones. b. Denver Developmental Screening Test (DDST) may be used as a guide for questioning patterns concerning achievement of developmental milestones. c. Toddlers and preschoolers: Assess information regarding speech and language development and development of social skills. d. Use the Surveillance and Screening Algorithm: Autistic Spectrum Disorders for toddlers at the 18, 21, and/or 24 month old episodic visit if it had not been completed at a maintenance health visit. ett Learning, T FOR SALE OR DISTRIB..

l 12 CHAPTER 2 Obtaining an Interval History Table 2-2 Review of System (ROS) in an Interval History System On a regular basis, do you have problems with: ones & Bartlett Head and neck Learning, LLC T FOR SALE Chest and lungs Abdomen Musculoskeletal Skin, hair, and nails ROS gathering the interval h istory* Headaches Blurred vision or any vision problems Earaches Nosebleeds Difficulty swallowing Any lumps in head or neck area Chest pain T FOR SALE Heart beating fast in chest (palpitations) Shortness of breath Fainting Frequent cough Nausea Vomiting Diarrhea Urinating or bowels Menstruation Testicular pain Leg pain or cramps Stiffness, swelling, bone deformities Rashes Moles Sexual history T FOR SALE Darkened or discolored areas Abnormal hair growth Clubbing of nails ett Learning, OR DISTRIB Sore Jones throats & Bartl Bruising easily History of sexually transmitted infections *This information is gathered in addition to the details related to eating, sleeping, bladder, and bowel patterns. ett Learning, OR DISTRIB ett Learning, OR DISTRIB..

l II. Interval History for Athletic Child or Adolescent 13 NOT 4. FOR School-age SALE children. a. Should also include questions related to sociobehavioral development with peers and progress in school. b. If female school-age child has secondary sex characteristics, then ask about menstrual cycle: Age of onset, frequency, length of cycle, any ett Learning, discomfort prior to or during menstruations. T FOR SALE c. Children older than10 years of age should NOT be asked: FOR Have SALE they or OR their DISTRIB friends tried alcohol or drugs? Use a brief alcohol/drug screening tool at each episodic visit. What is their diet? Happy with appearance/weight? Thought about harming NOT themselves FOR SALE or others? Sexually active? 5. Adolescents. a. Use the HEADSSS assessment (home, education/employment, activity, drugs/alcohol, sexuality, suicide/depression, safety and exposure to violence). NOT FOR b. SALE Adolescent OR female: DISTRIBUTION Ask questions related to menstrual cycle. c. Ask about high-risk social behaviors (smoking; alcohol/drug use; sexual activity, including diagnosis and treatment of sexually transmitted infections [STIs]; driving motor vehicle in reckless manner; use of ones & Bartlett Learning, guns; etc.). LLC ett Learning, T FOR SALE E. OR Review DISTRIBUTION of systems (ROS). OR DISTRIB 1. Age-appropriate ROS: Conduct in head-to-toe manner as identified in comprehensive physical examination (Table 2-2). II. INTERVAL HISTORY FOR ATHLETIC CHILD OR ADOLESCENT A. Pre-participation sports history and physical have well-established guidelines; follow explicitly. B. Jones Interval & history Bartlett is integral Learning, part of assessment. LLC 1. Question parent and child about significant family history changes (e.g., sudden death of relative who was 50 years old from cardiovascular condition). Include questions that elicit information about significant episodes (red flags) of chest pain, dyspnea, syncope, palpitations, loss of consciousness, history of concussions (Table 2-3). T FOR SALE ett Learning, OR DISTRIB..

l 14 CHAPTER 2 Obtaining an Interval History Table 2-3 Red Flags: The Interval History for the Athletic Child or Adolescent Interval history questions that ones & Bartlett may elicit red Learning, flag data LLC System Red Jones flag data& Bartlett Learning, T FOR SALE Any relatives OR < DISTRIBUTION 50 years of age die Cardiovascular NOT Change FOR in family SALE history OR DISTRIB as result of sudden unexpected Sudden death of relative cardiac death? < 50 years of age Child report chest pain or Chief complaint from child: palpitations, syncope during or ett Learning, after exercise? LLC Chest pain Palpitations Syncope Child report any breathing problems during or after exercise? Respiratory Chief complaint from child: Dyspnea Wheezing Child had any episodes of dizziness, syncope, fainting, concussion? T FOR SALE Neurologic Chief complaint from child: Syncope Loss Jones of consciousness & Bartlett Learning, OR DISTRIB III. FOCUSED HISTORY ett Learning, A. Focused LLC history: Used to collect data Jones about & a specific Bartlett problem, Learning, usually chief LLC complaint identified by parent/child (Tables 2-4 and 2-5). B. Focus all questions on eliciting data about chief complaint. C. Focused history usually limited to one or two systems. IV. APPLYING Jones & Bartlett DATA Learning, OBTAINED LLC IN INTERVAL NOT HISTORY FOR SALE TO CLINICAL PRACTICE A. After completing interval history and physical examination, compare findings in comprehensive history to data obtained in interval history. ones & Bartlett 1. Learning, If no significant LLC changes found in interval history, Jones advise & parent, Bartlett infant/ Learning, child to continue to follow established health promotion plan. T FOR SALE OR DISTRIB..

l IV. Applying Data Obtained in Interval History to Clinical Practice 15 Table 2-4 Sample Focused History: Medical Subjective data My child has a chronic cough. T FOR SALE My child begins coughing each night. I cannot remember the last time he didn t cough at night. Questions to focus the history What do you mean by a chronic cough? Does child cough during day or just at night? What time of night does child begin coughing? Describe the cough. Is cough productive or nonproductive? Does cough affect child s sleeping pattern? Any products currently being used in household that weren t being used before child began having this chronic cough? Pets in your household? T FOR SALE Did you change pillow your child uses? Use any over-the-counter or prescription medications to treat this cough? Has child been evaluated for asthma or allergies? Anything make cough better or worse? Table 2-5 Sample Focused History: Mental Health Subjective ett Learning, My child s LLCbehavior has become so difficult at home. Questions to focus the history Describe what you Jones mean by & difficult Bartlett behavior. Learning, LLC Does anything trigger these behaviors? What do you do when this behavior becomes so difficult? What is your child s response? T FOR SALE Does this behavior pattern occur at school or outside the home, such as at a friend s house or relative s home? Has there been a change in your family lifestyle such as parents arguing at home, parental separation, new family member living in the home? Has there been any change in your child s physical abilities such as change in cognitive or psychomotor skills? Does your child complain of headaches? ett Learning, OR DISTRIB ett Learning, OR DISTRIB ett Learning, OR DISTRIB..

l 16 CHAPTER 2 Obtaining an Interval History NOT 2. FOR If significant SALE changes are found in interval history, revise health NOT promotion plan. FOR SALE a. Example: If interval family history reveals family members have diabetes mellitus, evaluate and modify family/child exercise and dietary patterns. ett Learning, 3. If significant changes are found in interval history in relation to child s T FOR SALE OR health, DISTRIBUTION establish new health promotion plan NOT with parent FOR and SALE child/adolescent active participation. OR DISTRIB a. Example: If interval history reveals significant change in frequency of coughing and upper respiratory symptoms, complete a detailed focused history and establish Jones a new health & Bartlett promotion Learning, plan. LLC BIBLIOGRAPHY Bickley LS, Hoekelman RA. Bates Guide to Physical Assessment. 10th ed. Philadelphia, PA: Lippincott; 2008. Burns CE, Jones Dunn AM, & Brady Bartlett MA, al. Pediatric Learning, Primary Care. LLC4th ed. St. Louis, MO: Saunders; 2009. Duderstadt NOT KG. FOR Pediatric SALE Physical Examination: An Illustrated Handbook. St. Louis, MO: Mosby; 2006. Johnson CP, Myers SA, and the Council on Children with Disabilities. Identification and evaluation of children with autistic spectrum disorders. Pediatrics. 2007;120:1183-1215. American Academy of Pediatrics website: http://www.aap.org/pressroom/autismid.pdf. Accessed June 1, 2011. T FOR SALE ett Learning, OR DISTRIB T FOR SALE ett Learning, OR DISTRIB..

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