Abstract
The art of taking a patient's case history is essential for a solid understanding of pertinent details before proceeding with an examination. While establishing rapport with the patient, the clinician should ask questions about birth history, developmental history, educational and social history. Active listening skills and flexibility of the provider are useful tools for an effective start to the examination. This chapter reviews categories of questions needed for optimization of case history for the pediatric patient. This includes questions focused on specific age categories, including infants and toddlers, preschoolers, elementary-aged children, and adolescents. The chapter author provides clinical pearls for a more efficient and effective exam, including a section on assisting children with special needs.
TopBackground
The case history, or medical interview, is an examination step that is universal to all healthcare professionals. While there are many technological advances and tools such as online or tablet-based case histories, the importance of interpersonal communication and connection cannot be replaced (Keifenheim et al., 2015). An effective clinician must be able to read both verbal and non-verbal cues, as well as be skilled to ask questions that can elicit quality information from the patient and caregiver (Keifenheim et al., 2015). Peterson and Holbrook (1992) studied 80 outpatients and the doctors who examined them and found that 76% of the doctors’ differential diagnoses after their history-taking led to the final diagnosis. In comparison, the physical examination led to 12% of the final diagnoses, and laboratory testing led to 11% of the final diagnoses (Peterson et al., 1992).
The definition of history-taking is a “way of eliciting relevant personal, psychosocial and symptom information from a patient with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient” (Keifenheim et al., 2015). While it may be necessary for technicians or other assistants to take a preliminary case history, the clinician should be the main interviewer to assess if further detail is necessary.
For complex medical and developmental histories, some eye care practices may prefer to have a questionnaire sent to their patients before the appointment, so that the bulk of the allotted time can be spent on examination and patient education. Alternatively, a complex case history form may be completed by the adult caregiver in the office while the clinician begins testing the child. This strategy is particularly helpful when the complexity of the child or case type is not known at the time of the appointment. The clinician may select the appropriate case history form after the chief complaint and meeting the child, if the child is able to sit independently in the exam chair.
Efficiency is key with a pediatric exam. At the same time, the clinician should maintain a positive, relaxed, and fun environment, especially for young children. Be fun and flexible! Young children typically have a short attention span and can be uncooperative with the examination. The clinician must prioritize the sequence of exams to maximize the amount of pertinent information obtained. Therefore, having a detailed history helps the clinician to formulate a differential diagnosis and a sequential list of exams to be performed. Each patient is unique and responds differently, so it is up to the clinician to strategically perform all the needed tests to formulate the correct assessment and management. Taking case history with a child differs from that of a typical adult exam due to factors such as the source of the information (caregiver versus the child), details sought by the clinician for the purpose of the examination, and how communication occurs between the clinician and the patient.
Key Terms in this Chapter
Toddler: This refers to the age group of a child about 12 to 36 months old.
Postnatal: The period from birth until a baby is 6 weeks old.
504 Plan: A tailored plan for a child whose disability does not qualify for an IEP, but still needs special supports and resources to help them to succeed in elementary or secondary education.
Preschooler: A child between 3-5 years of age who has not yet attended kindergarten.
Adolescent: A child approximately between the ages of 10-19 years of age, with 3 major stages during this time period--early, middle, and late adolescence ( World Health Organization, 2021 ).
Perinatal: The period immediately before and after birth; the definition can vary to include the time period starting at 154 days gestation and lasting through 7 days after birth.
Individualized Educational Program (IEP): A tailored plan for a child with an eligible disability to provide for specialized instruction, supports, and resources to help the child to thrive in elementary or secondary education.
Identity-First Language: Making reference to a person with their condition listed first, such as “Deaf person.”
Developmental Milestone: A skill or behavior that is generally expected by a certain age as part of normal development.
Person-First Language: Making reference to a person with the person first and then condition, such as “person with Down Syndrome.”
Infant: This refers to children anywhere from birth to 1-year-old.
Prenatal: The period between conception and birth.
Elementary-Aged Child: A child usually between 5 to 11 years of age and refers to grades kindergarten (K) through grade 5 or 6.