Building a Health History Discussion Case – Adolescent white male without health insurance seeking medical care for STI
Building a health history is a crucial part of taking care of a patient. It’s like creating a story with the patient to understand their problems and priorities together (Ball et al., 2019).
In this case, we need to build a health history for an adolescent Hispanic/Latino boy living in a middle-class neighborhood.
Adolescents can be tricky to get information from because they might not want to share personal stuff.
To help this patient, it’s important to make sure they understand the provider. If the patient’s first language isn’t English, we should offer an interpreter.
Interview Techniques
Being an adolescent is a sensitive time with lots of changes and trying out new things. The first thing to do is make sure that everything they share is kept secret. If they came with a parent, we should give them privacy to get honest answers (Ball et al., 2019). We should also ask questions that can’t be answered with a simple “yes” or “no.” Starting with open-ended questions can make the patient share more during the interview. Talking about home, school, friends, and activities can uncover concerns (Ball et al., 2019).
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Assessment
Even though most teenagers are physically healthy, they could have emotional issues. To start, we introduce ourselves and have a casual conversation with the patient. They should talk about their complaints and their current health issues. We also need to know about their past and family health history. Then, we check their whole body and ask them about their emotional well-being.
We need to find out about the patient’s behaviors that might put them at risk for health problems (Sullivan, 2019). The tool we can use for this is the HEEADSSS assessment. It checks things like their home, school or job, eating, friends, feelings, ambitions, anger, drug use, sexuality, mental health, and safety (Doukrou & Segal, 2018). The HEEADSSS assessment helps us get a good view of the teenager’s life and any worries they might have (Doukrou & Segal, 2018).
Targeted Questions
At the start of the interview, we should ask the patient, “What’s on your mind today?” This gives them a chance to talk about what’s bothering them. Next, we can ask, “Who do you live with?” This tells us about their living situation and support system. We should also ask about school or work by saying, “Tell me about school (or work).” Finding out if they have close friends and what they like to do with them is important, so we can ask, “Who are your closest friends?” and “What kind of activities do you enjoy doing together?” It’s good to use these open-ended questions and not interrupt the patient. If they have more to say, we should let them explain.
Conclusion
Healthcare providers can be a safe place for teenagers to share their worries and get help with tough issues (Ball et al., 2019). By giving them privacy, paying attention, and letting them talk without interruption, we can build a complete health history for the patient.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Doukrou, M., & Segal, T. Y. (2018). Fifteen-minute consultation: Communicating with young people—how to use HEEADSSS, a psychosocial interview for adolescents. Archives of Disease in Childhood Education and Practice Edition, 103(1), 15. https://doi.org/10.1136/archdischild-2016-311553
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Week 1 Discussion Main Post
Building a Health History
Building a health history is an essential component of patient care. “You build the history to establish a relationship with the patient, so that you jointly discover the issues and problems that need attention and priority” (Ball et al., 2019). In this scenario the provider is tasked with building a health history on an adolescent Hispanic/Latino boy who lives in a middle-class suburb. Adolescents can prove to be challenging to obtain a history from due to their hesitation to share personal information. It is crucial that the patient understands the provider. Due to this patient’s Hispanic ethnicity, I would ensure they are fluent in English or offer an interpreter if needed.
Interview Techniques
Adolescence is a sensitive time due to changes and experimentation occurring in the patient’s life. The first interview technique I would use is to ensure confidentiality. If the patient is accompanied by their parent or guardian, privacy should be offered to promote complete and honest answers and establish confidentiality. Another communication technique I would use is asking open-ended questions. Starting with open ended questions can result in the patient offering more details throughout the interview (Ball et al., 2019). Additionally, open-ended discussion about home, work, school, friends, and activities may reveal areas of concern (Ball et al., 2019) BUILDING A HEALTH HISTORY Discussion Case – Adolescent white male without health insurance seeking medical care for STI.
Assessment
Although adolescents are generally physically healthy, they may be struggling with psychosocial issues. To begin the interview the provider should introduce themselves and establish rapport through easy conversation. Initially the patient should be given the opportunity to voice any complaints and their history of present illness. Past medical history and family history should also be obtained. Then a complete review of systems and physical examination should be performed to ensure the patient’s physical health with an emphasis on psychosocial history.
Obtaining a social history determines behaviors that may put the patient at risk for certain medical conditions (Sullivan, 2019). The risk assessment tool I would use in this scenario is the HEEADSSS assessment. The HEEADSSS assessment is a useful tool for evaluating an adolescent’s psychosocial circumstances. HEEADSSS stands for: Home environment, Education and employment, Eating, Activities (peer-related), Affect, Ambitions, Anger, Drugs, Sexuality, Suicide/depression, and Safety from injury and violence (Doukrou & Segal, 2018). The HEEADSSS assessment is an important tool because it gives the provider a comprehensive view of the adolescent patient’s experiences and any areas of concern through a simple, easy to use assessment (Doukrou & Segal, 2018).
Targeted Questions
I would begin the interview by asking the patient “what would you like to discuss today?” giving them the opportunity to raise any concerns or worries. Next I would ask “Who do you live with?” This question would reveal the patient’s living situation as well as shed light on their support system. Then I would inquire about work/school asking the patient “tell me about school (or work).” I would also ask if the patient has close friends and what activities they like to participate in by saying “Who are your closest friends?” and “What kind of activities do you enjoy doing together?” I would begin with the open-ended questions above, being careful not to interrupt the patient and asking for elaboration when required.
Conclusion
Healthcare providers can provide a safe space for adolescents to share concerns and receive support regarding sensitive issues (Ball et al., 2019). By providing privacy, showing attentiveness, and allowing the patient time to voice their complaints without interruptions, a complete and thorough health history can be obtained by the ARNP BUILDING A HEALTH HISTORY Discussion Case – Adolescent white male without health insurance seeking medical care for STI.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s
guide to physical examination: An interprofessional approach (9th ed.). St. Louis,
MO: Elsevier Mosby.
Doukrou, M., & Segal, T. Y. (2018). Fifteen-minute consultation: Communicating with young people—how to use HEEADSSS, a psychosocial interview for adolescents. Archives of Disease in Childhood Education and Practice Edition, 103(1), 15. https://doi.org/10.1136/archdischild-2016-311553Links to an external site.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis
Building a Health History Discussion Case – Adolescent White Male Without Health Insurance Seeking Medical Care for STI
Building a health history is an essential component of patient care, acting as a foundation for understanding the patient’s unique health landscape. It serves as a collaborative process where the healthcare provider and patient work together to explore and identify health issues, concerns, and priorities (Ball et al., 2019). In this case, we focus on developing a health history for an adolescent Hispanic/Latino boy living in a middle-class neighborhood who is seeking medical care for a sexually transmitted infection (STI). Engaging adolescents can be particularly challenging, as they may be hesitant to share personal information due to fears of judgment or breaches of confidentiality. To facilitate open communication and ensure effective care, it is crucial that the patient feels comfortable and understood by the healthcare provider. If the patient’s primary language is not English, offering an interpreter is imperative to eliminate language barriers and enhance the quality of the interaction.
Interview Techniques
Adolescence is a sensitive period in life characterized by significant physical, emotional, and social changes. One of the first steps in the interview process is to establish a trusting environment through confidentiality. If the patient is accompanied by a parent or guardian, it is vital to provide privacy to foster an environment where the adolescent feels safe to express themselves honestly (Ball et al., 2019). Ensuring that the adolescent understands that their disclosures will be kept confidential can alleviate fears and encourage them to share sensitive information, which is especially important when discussing issues like STIs.
Utilizing open-ended questions is another effective technique that can significantly enhance the depth of the conversation. Open-ended questions invite elaboration and detail rather than eliciting simple “yes” or “no” responses. For example, asking questions such as, “Can you tell me more about what brings you here today?” or “What concerns do you have about your health?” encourages the patient to elaborate on their feelings and experiences. Additionally, engaging in discussions about various aspects of their life—such as home, school, friendships, and extracurricular activities—can uncover underlying areas of concern and emotional distress that may impact their health (Ball et al., 2019).
Assessment
While many adolescents may appear physically healthy, they often grapple with various psychosocial challenges that can significantly affect their overall well-being. Therefore, the assessment process should begin with the healthcare provider introducing themselves and engaging in light, informal conversation to build rapport. This initial interaction is crucial as it sets the tone for the rest of the consultation. The adolescent should be encouraged to voice any concerns, health complaints, or symptoms they are experiencing. Gathering detailed information about their medical history—including past medical events, family health history, and any previous treatments—provides essential context for understanding their current health status.
Following the history-taking, a thorough review of systems and a physical examination should be conducted, focusing on both physical health and emotional well-being. Adolescents may not always recognize the connection between emotional distress and physical symptoms, so it’s important to explore both aspects during the assessment.
Understanding the patient’s social history is vital in identifying behaviors that could pose health risks, particularly in the context of STIs (Sullivan, 2019). In this scenario, the HEEADSSS assessment tool proves particularly beneficial. HEEADSSS, which stands for Home environment, Education and Employment, Eating, Activities (peer-related), Affect, Ambitions, Anger, Drugs, Sexuality, Suicide/Depression, and Safety from injury and violence, provides a structured framework for evaluating the psychosocial circumstances surrounding the adolescent (Doukrou & Segal, 2018). This comprehensive approach allows the provider to gain insight into the adolescent’s life, including potential risk factors, lifestyle choices, and emotional challenges that may need to be addressed.
Targeted Questions
To initiate the interview effectively, I would ask the patient, “What would you like to discuss today?” This question empowers them to voice their concerns, setting a collaborative tone for the discussion. Following this, I would inquire, “Who do you live with?” This question is essential for understanding the patient’s living situation and support system, which can greatly influence their health outcomes.
Next, exploring their school or work life by asking, “Tell me about school (or work),” helps contextualize their daily experiences and any associated stressors. It is equally important to learn about their social connections. Questions such as, “Who are your closest friends?” and “What kind of activities do you enjoy doing together?” can provide insights into their support network and social engagement.
Throughout the interview, it’s crucial to encourage open dialogue and to be attentive to the patient’s responses. I would practice active listening, giving them the space to elaborate on their thoughts without interruption. If they seem hesitant or if there are pauses in the conversation, I would gently prompt them with follow-up questions like, “Can you tell me more about that?” or “What do you feel about that situation?”
Conclusion
Healthcare providers play a crucial role in creating a safe and supportive environment for adolescents to share their concerns and receive guidance on sensitive issues (Ball et al., 2019). By ensuring confidentiality, actively listening, and allowing the adolescent to speak freely, a thorough and accurate health history can be constructed. This holistic approach not only enhances the quality of care provided but also fosters a trusting relationship between the patient and provider, which is essential for effective healthcare outcomes, particularly in addressing sensitive health concerns like STIs.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Doukrou, M., & Segal, T. Y. (2018). Fifteen-minute consultation: Communicating with young people—how to use HEEADSSS, a psychosocial interview for adolescents. Archives of Disease in Childhood Education and Practice Edition, 103(1), 15. https://doi.org/10.1136/archdischild-2016-311553
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
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