History-Taking Strategy Activity

Essay by sberriUniversity, Bachelor'sA+, March 2007

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Three year-old, white, female presents to office for general check-up. Client is accompanied by birth mother who has concerns regarding daughter's obesity. Mother appears warm and attentive to client. Client is somewhat clingy and whining. There is good eye contact between mother and client. Client appears in no apparent pain at this time. Vital statistics obtained for the client are: height, 39 ¼ inches; weight 52.5 pounds; temperature 97.8 axillary; blood pressure, 130/88; pulse, 92 and regular; respirations, 26, regular and silent.

Please, have a seat and we can start discussing Catherine's history. Feel free to hold Catherine in your lap or she can play with the toys on the blanket next to us.

To begin with I would like for you to tell me how your pregnancy and delivery were. Were there any complications such as high blood pressure, excessive weight gain, swelling of your hands or feet, falls, or nausea and vomiting? Did you smoke, drink or use drugs while you were pregnant?

At what hospital did you give birth to Catherine? Were you on labor for very long? Were you able to deliver normally or did you have a C-section? Were you given anesthesia or did you have a natural birth? What was Catherine's birth weight and what were her Apgar scores? Was there any special equipment or procedures used on Catherine when she was delivered?

Was Catherine able to go home with you when you were discharged? Did you bottle feed or breast feed Catherine? Did Catherine have any feeing problems such as colic, diarrhea, or constipation?

With what cultural groups are you and Catherine affiliated? Do you and Catherine associate with members of this group on a regular basis? What is your and Catherine's "reported racial affiliation (e.g.,

black, Native American, Asian)" (Jarvis, 2004,