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

Introduction: In this discussion, we explore the process of building a health history for an adolescent white male without health insurance seeking medical care for a sexually transmitted infection (STI). We will cover interview techniques, assessments, risk assessment tools, and targeted questions tailored to his situation.

Table of Contents

Interview Techniques:
Creating a health history involves establishing a connection with the patient to identify their concerns and priorities (Ball et al., 2019). For this adolescent, who is Hispanic/Latino and lives in a middle-class suburb, confidentiality and effective communication are crucial. Using open-ended questions and ensuring language comprehension through an interpreter, if needed, would facilitate the interview process.

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Assessment:
While adolescents are generally physically healthy, they might be dealing with psychosocial issues. The provider should begin by introducing themselves and engaging in a casual conversation to build rapport. Gathering information about complaints, present illness, medical and family history, and conducting a complete physical examination is essential. Emphasizing psychosocial history is vital.

Social History and Risk Assessment:
Assessing social history helps uncover behaviors that could lead to medical conditions (Sullivan, 2019). The chosen risk assessment tool is the HEEADSSS assessment. It evaluates the adolescent’s Home environment, Education and employment, Eating habits, Activities (peer-related), Affect (emotions), Ambitions, Anger, Drug use, Sexual activity, Suicide/depression, and Safety (Doukrou & Segal, 2018). This assessment provides a comprehensive view of the patient’s experiences and concerns.

Targeted Questions:
The interview should start by asking the patient about their concerns, followed by questions like “Who do you live with?” to understand their living situation and support network. Inquiring about school/work, friends, and activities (“Tell me about school/work” and “Who are your closest friends?”) helps gather valuable information about their life and interests.

Conclusion:
Healthcare providers play a crucial role in creating a safe environment for adolescents to share sensitive concerns and receive support (Ball et al., 2019). Through privacy, attentive listening, and patience, a thorough health history can be obtained, aiding in providing appropriate care to the adolescent.

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.

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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.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis

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