PMH: Jennifer: Full-term gestation, born cesarean section, weight. 7lb 4 oz. There were no complications in pregnancy, but the mother did smoke 1 PPD throughout pregnancy. There were no hospitalizations—NKDA. The daily medication was chewable children’s multivitamin with iron. Rey: Born at 34 weeks gestation via cesarean section, weight. 5lb 1 oz. The mother developed preeclampsia and gestational diabetes. The mother quit smoking when she found out she was pregnant. Rey has allergies per mother and sometimes takes Cetrizine syrup half a teaspoon once daily, PRN congestion, and a children’s chewable multivitamin daily.
Immunizations: The mother has no immunization records with her at this timeon either child. She reports some immunizations given, but cannot remember last date.
Social History:Both children currently live with their mother and maternal grandparents for the last 8 weeks. Their father is involved but lives 2 hours away in the state capital where he works. Jennifer will be starting kindergarten this fall in the community’s elementary school.
Family History: They are maternal and paternal smokers. The mother has been one since age 16 at 1PPD until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Mother has a history with gestational diabetes and preeclampsia. MGM has a history of hyperlipidemia, Type 2 DM, and Hypertension. They are Latin American in descent, emigrated from Cuba in the 1970s. MGF has a history of hypertension, hyperlipidemia, and an MI with stenting 2 years ago. The mother has two siblings; one who died in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 32 and lives in a large urban city in the Midwest with her family, and she is in good health. Other family members died of old age. She is unaware of paternal familial health history.
Please answer the following questions):
1.- What would you like to focus on during your visit today?
2.- Would a family assessment tool be appropriate?
3.- What other historical information would you like to have at this visit?
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