BUILDING A HEALTH HISTORY Discussion Case – Adolescent white male without health insurance seeking medical care for STI
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.
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.
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).
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.
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.
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