Free Pediatric Primary Care Case Studies by Catherine E. Burns, Beth Richardson, Cpnp Rn Dns Beth Richardson, Margaret Brady

supervision visits and other minor acute illnesses. To date, Katie has never been diagnosed with any chronic health concerns. Katie’s last examination was for her 10-year-old well child visit. She was healthy and her development was progressing normally.
Ms. Murphy calls the health clinic concerned about Katie and tells the receptionist that Katie has been absent from school sporadically during the last 3 weeks. According to Ms. Murphy, Katie has complained of stomachaches intermittently during that time. Over the last week Katie’s absences from school have increased, all related to the stomachaches. Ms. Murphy states that Katie has not had a fever or any other signs of gastrointestinal distress such as nausea, vomiting, or diarrhea. Her stomachaches occur primarily in the morning and subside later in the day. The receptionist schedules a next day appointment for Katie to be evaluated by you. When you review Katie’s record prior to seeing her, your plan is to evaluate her first for an underlying physical cause for her stomachaches. If there isn’t a physical etiology, you then will evaluate her for school refusal related to a psychosocial problem.
What information do you need to rule out a physical etiology for Katie’s stomachaches?
    When primary care providers see a child or adolescent who has missed a number of days of school, accompanied by a physical complaint, it is important to rule out any potential underlying physical problems. Thus, an assessment of a child with somatic complaints that may be psychosocial in etiology first requires a thorough assessment of potential physical etiologies, including a complete medical history and physical exam. The history plus a physical examination with medical tests, if indicated, should provide the data needed to rule out a physical etiology in children, like Katie, who present with somatic complaints and increasing school absences.
    The child’s medical history should involve a prenatal to current age review of body systems, including any associated illnesses, hospitalizations, or surgeries related to a body system, accidents or injuries, current medications (prescription and nonprescription), and any alternative therapies used. Further exploration of any areas that may pertain to presenting health issues should be completed as necessary. In addition, the medical history should include a functional assessment of the child’s self-esteem, nutritional habits, sleep habits, involvement in activities, and screening for any type of abuse. The next step after completing a thorough medical history is to review the family medical and social history. A family medical history includes physical and psychological health concerns such as premature death, heart disease, stroke, diabetes, cancer, mental illness, or other inheritable conditions of siblings, parents, and one prior generation of family members (Jarvis, 2007).
    Information on school performance should be routinely obtained on all school-aged children. Primary care providers typically screen children before the age of 5 years for developmental and behavioral problems; however, many healthcare providers no longer do this type of screening once children enter school. Recent recommendations suggest that primary care providers should transition from routine developmental screening to screening school performance for school-age children and adolescents. This approach will help with early identification of problems and interventions to improve the child’s success in school (Kelly & Aylward, 2005). If concerns are identified, contact with school personnel and review of school attendance and achievement records may be warranted (Fremont, 2003). For example, in evaluating school absence, in addition to the documented school absences, discussion with the school nurse may reveal a student who is frequently seen in the school nurse’s office for somatic complaints, essentially being absent from class while still in