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

school.
    Psychosocial information should also be obtained to identify behavioral concerns and possible underlying factors contributing to the somatic concern. Screening for emotional problems should be a routine part of all health maintenance visits for children (McCarthy & Eisbach, 2006). An example of a screeninginstrument that may be appropriate for use in primary care settings is the Pediatric Symptom Checklist (PSC) (Jellinek et al., 1988, 1999). The PSC is one page, with 35 items, completed by parents or children, and designed to help clinicians in outpatient practice screen for school-age children with difficulties in psychosocial functioning. The PSC is included in Bright Futures in Practice: Mental Health and the Bright Futures Web site ( http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_
sympton_chklst.pdf ) along with information on reliability and validity, scoring, and cutoff scores for referral.
    The final area of history that requires review involves a history of the presenting symptom(s) by starting at the point the symptoms presented until the current time. This review of symptoms can be remembered using the PQRSTU mnemonic (Jarvis, 2007).
•    Provocative or palliative: What brings on symptoms? What makes them better or worse?
•    Quality or quantity: How intense are symptoms? What do the symptoms feel like?
•    Region or radiation: Where do they start? Do the symptoms spread?
•    Severity scale: Use an age-appropriate rating scale and ask what makes symptoms better or worse.
•    Timing: This includes onset, duration, and frequency of symptoms.
•    Understanding: Understand the child’s perception of the problem of concern.
Your review of Katie’s medical history shows that she does not have any chronic conditions and, except for otitis media as a preschooler, she has been seen only for routine preventive health care. As noted earlier, you last saw her for her 10-year-old health maintenance visit, and no physical or psychosocial problems were noted. She lives with her nuclear family—her father, who is an engineer; her stay-at-home mother; and an older brother who is in ninth grade. No other individuals live in the home. There have been no changes in the family health history. Her school screening questionnaire completed by her mother at the 10-year-old health visit indicated that she was receiving A’s and B’s in all subjects and enjoyed school. Her behavioral assessment with the PSC, also completed by her mother, fell within the normal range at that time, although Ms. Murphy reported that sometimes Katie worries, is afraid of new situations, and acts younger than her age.
Katie and her mom are present for the appointment. Katie sits close to her mom and seems distant with a flat affect. Upon questioning the reason for their visit today, initially Katie does not respond, and her mother answers your questions. Katie occasionally offers responses to direct questions but her responses are brief, single-word responses, usually yes or no, and with limited eye contact.
You then ask questions specific to the presenting complaint of stomachaches. Ms. Murphy reports that Katie has missed many days of school over the last 3 weeks due to stomachaches. The stomachaches begin in the morning but often appear to resolve bylate afternoon. Katie reports some nausea, but denies vomiting or diarrhea with the stomachaches. Her mother states she has not had any fevers over the last 3 weeks. Katie explains that her appetite is normal, yet her mother interrupts and reports that she does not seem to eat very much. You learn that Katie’s maternal grandmother passed away about 2 months ago from lung cancer but Ms. Murphy says that everyone seems to be coping well. No other recent family stressors were identified.
During the physical examination you ask Katie some more questions. Katie is hesitant to respond but states she started her menses 6 months ago and denies cramps that