Chapter 9: Ambulatory & Office Pediatrics

INTRODUCTION

Pediatric ambulatory outpatient services provide children and adolescents with preventive health care and acute and chronic care management services and consultations. In this chapter, special attention is given to the pediatric history and physical examination, normal developmental stages, screening laboratories, and common pediatric issues.

The development of a physician-patient-parent relationship is crucially important if the patient and parent are to effectively confide their concerns. This relationship develops over time, with regular visits, and is facilitated by the continuity of clinicians and other staff members. This clinical relationship is based on trust that develops as a result of several experiences in the context of the office visit. Perhaps the greatest factor facilitating the relationship is for patients or parents to experience advice as valid and effective. Anticipatory guidance should be age-appropriate and timely in order to be most helpful. Important skills include choosing vocabulary that communicates understanding and competence, demonstrating commitment of time and attention to the concern, and showing respect for areas that the patient or parent does not wish to address (assuming that there are no concerns relating to physical or sexual abuse or neglect). Parents and patients expect that their concerns will be managed confidentially and that the clinician understands and sympathizes with those concerns. The effective physician-patient-parent relationship is one of the most satisfying aspects of ambulatory pediatrics.

PEDIATRIC HISTORY

A unique feature of pediatrics is that the history represents an amalgam of parents’ objective reporting of facts (eg, fever for 4 days), parents’ subjective interpretation of their child’s symptoms (eg, infant crying interpreted by parents as abdominal pain), and for older children their own history of events. Parents and patients may provide a specific and detailed history, or a vague history that necessitates more focused probing. Parents may or may not be able to distinguish whether symptoms are caused by organic illness or a psychological concern. Understanding the family and its hopes for and concerns about the child can help in the process of distinguishing organic, emotional, and/or behavioral conditions, thus minimizing unnecessary testing and intervention.

Although the parents’ concerns need to be understood, it is essential also to obtain as much of the history as possible directly from the patient. Direct histories not only provide firsthand information but also give the child a sense of agency over a potentially threatening situation and may reveal important information about the family.

Obtaining a comprehensive pediatric history is time consuming. Many offices provide questionnaires for parents to complete before the clinician sees the child. Data from questionnaires can make an outpatient visit more productive, allowing the physician to address problems in detail while more quickly reviewing areas ...