BUILDING A HEALTH HISTORY Discussion -4 year old African American male living in a rural community

BUILDING A HEALTH HISTORY Discussion -4 year old African American male living in a rural community

Introduction:
In this discussion, we will examine the process of gathering a comprehensive health history for a 4-year-old African American male residing in a rural community. We will explore effective communication techniques, risk assessment, and targeted questions that can be utilized for this specific patient scenario.

Components of a Comprehensive Health History and Physical:
When conducting a comprehensive health history and physical (H&P), it’s essential to address various aspects (Sullivan, 2019). These include the chief complaint, present illness history, medical and family history, social history, review of systems, physical examination, laboratory data, assessments, and treatment plans (Sullivan, 2019).

Tailored Communication Techniques:
There isn’t a universal approach to completing an H&P; each patient’s situation guides the conversation (Ball et al., 2019). Effective communication is crucial, with healthcare providers using non-medical language and clarifications to ensure understanding (Ball et al., 2019). If in an emergency setting, emergency care takes priority before conducting the H&P (Ball et al., 2019).

Communication with Pediatric Patients:
When dealing with children, it’s important to confirm if a consenting adult is present and authorized for medical decisions (Ball et al., 2019). Addressing the guardian’s relationship, introducing oneself at the child’s level, and respecting how they’d like to be addressed can establish rapport (Ball et al., 2019). Open-ended questions like “What prompted care today?” allow patients to share their narrative (Ball et al., 2019).

Incorporating Developmental Milestones:
Evaluating developmental milestones is vital, as delays may signify underlying issues (Zubler et al., 2022). Gross motor skills, for instance, impact physical, psychological, and social aspects (Amemiya et al., 2018). Monitoring these milestones can identify developmental delays or deficits (Amemiya et al., 2018).

Consideration of Socioeconomic Factors:
Assessing the affordability and understanding of prescribed medications is crucial (Rosenthal & Burchum, 2021). Lack of adherence often results from lack of understanding or cost (Kaiser Family Foundation, 2022). Addressing affordability and providing education on medication administration is essential for optimal patient outcomes (Rosenthal & Burchum, 2021).

Conclusion:
A comprehensive health history and physical are foundational to patient care (Sullivan, 2019). Effective communication, thorough assessment, and proper documentation contribute to accurate diagnoses and tailored treatment plans (Ball et al., 2019). This approach ensures optimal care delivery and sets the stage for a patient’s clinical journey (Sullivan, 2019).

References:
Amemiya, Y., Suzuki, S., & Satoh, M. (2018). A Support System for Gross Motor Assessment of Preschool Children. IECON 2018 – 44th Annual Conference of the IEEE Industrial Electronics Society, 4251–4256. https://doi.org/10.1109/IECON.2018.8591574

Ball, J.W., Dains, J.E., Flynn, J.A., Soloman, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, (9th ed.). Elsevier.

Kaiser Family Foundation. (2022, October 20). Public Opinion on Prescription Drugs and Their Prices. https://www.kff.org/health-costs/poll-finding/public-opinion-on-prescription-drugs-and-their-prices/

Rosenthal, L.D. & Burchum, J.R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants, (2nd ed.). Elsevier.

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

Zubler, J. M., Wiggins, L. D., Macias, M. M., Whitaker, T. M., Shaw, J. S., Squires, J. K., Pajek, J. A., Wolf, R. B., Slaughter, K. S., Broughton, A. S., Gerndt, K. L., Mlodoch, B. J., & Lipkin, P. H. (2022). Evidence-informed milestones for developmental surveillance tools. Pediatrics. https://doi.org/10.1542/peds.2021-052138