The Comprehensive History and Physical

When gathering a comprehensive history and physical (H&P), several areas need to be addressed (Sullivan, 2019). Components of an H&P include the chief complaint with history of present illness, past medical history, family history, social history, review of systems, physical examination, laboratory data, problem list with assessments and differential diagnoses, and the treatment plan (Sullivan, 2019) BUILDING A HEALTH HISTORY Discussion -4 year old African American male living in a rural community. There is not a one size fits all technique to completing a H&P meaning that the patient’s situation should lead the conversation (Ball et al., 2019). Communication is paramount; therefore, healthcare providers need to make sure they are being understood by using non-medical jargon as well as clarifying what the patient states (Ball et al., 2019). If the patient is presenting in an emergency setting, the emergency care is provided prior to the H&P as needed (Ball et al., 2019). This paper will address working with a 4-year-old male African American child.

One of the first things to address when working with children is if a consenting adult is present with the patient (Ball et al., 2019). It cannot be assumed that the person in the room with the child has guardianship (Ball et al., 2019). Asking a direct question such as their name and their relation to the child, plus if they have the right to consent to care should be asked upon initial meeting (Ball et al., 2019). The child should be a part of the introductions as well and can be included by getting down to their level to be able to look into their eyes and speak to them (Ball et al., 2019). Asking the guardian and child how they would like to be addressed helps establish a respectful relationship while clarifying the relationship between the patient and person in the room (Ball et al., 2019). The 4-year-old child should be able to answer some questions with the guardian being able to expand on the answers (Ball et al., 2019). The patient is best able to answer what something feels like to them (Ball et al., 2019). Letting the guardian expand on their observations helps to clarify the symptoms and situation that is beyond the understanding of a 4-year-old (McCance & Huether, 2019). Asking direct open-ended questions such as “what prompted you to seek care today” or “when was the child’s last know well day” can allow for the person to tell the narrative of the condition without being prompted by the health care professional (Ball et al., 2019). Also, by asking last know well day rather than first sick day, it opens up the idea of really when the symptoms started (Ball et al., 2019). Allowing for a narrative enables many questions to be answered without having to ask them and they will be in the patient or guardian’s own words (Ball et al., 2019). The healthcare provider can listen to the narrative without interrupting, getting a sense of the chief complaint, then ask directed follow up questions (Ball et al., 2019).

Children may be anxious or nervous about being in the office so they should be allowed to sit where they are comfortable when able (Ball et al., 2019). For example, in the lap of a parent (Ball et al., 2019). Having a sick child can be stressful so emotions maybe running high (Ball et al., 2019). The health care professional should use respectful candor to gain trust of the patient and guardian (Ball et al., 2019). It is also important to run a risk assessment for maltreatment when a vulnerable population, such as a child, is being seen (van der put et al., 2017) BUILDING A HEALTH HISTORY Discussion -4 year old African American male living in a rural community. van der put et al. (2017) found that ancillary staff assessments, such as social work, had a better risk assessment tool than clinical tools being used. Van der put et al. (2017) suggest combining aspects of both type of assessments to limit patients falling through the cracks. Healthcare providers are assessing the guardian in the room as well, looking for signs of stress from caregiving (van der put et al., 2017). Ball et al. (2019) also highlights that witnessing violence as a child can hinder appropriate growth and development. Asking a direct question like “has something scared you” or “do you ever have bad dreams about something that you have seen” can help to open a discussion on the situation that occurred (Ball et al., 2019). Getting feedback from the guardian on how they addressed the situation can also assist in gathering information on how this is affecting the child (Ball et al., 2019).

Asking what a typical day looks like for the child can help gather information (Ball et al., 2019). For example, when asked if there are pets in the home the answer may be no, but there may be pets in the home of a babysitter which could trigger allergies (Ball et al., 2019). Running through a typical day can help determine the patient’s social determinants of health from the environments that the child is exposed to (Ball et al., 2019). Some information can be gathered based on where the patient lives (Ball et al., 2019). For example, if the patient lives in an area with high known child asthma cases due to air quality, then the child should be checked for signs and symptoms of asthma and the guardian educated on the risks and what signs to look for (Ball et al., 2019).

Part of a child’s H&P should include if the child is hitting developmental milestones (Ball et al., 2019). A four-year-old child could be in preschool in which case the information could be gathered as to how the child in doing in a social school environment (Ball et al., 2019). History of milestone development is important as well; did the child hit developmental markers up to this age (Ball et al., 2019)? In preschool aged children, gross motor skills can be especially meaningful for other developmental functions (Amemiya et al., 2018). Gross motor skills can affect physical and psychological functions, but also social participation for children (Amemiya et al., 2018).  Monitoring the gross motor skills in the preschool years can help to see developmental delays or deficits (Amemiya et al., 2018) BUILDING A HEALTH HISTORY Discussion -4 year old African American male living in a rural community.

Gathering a family history is especially important for children as many genetic diseases can be seen by tracing the family (Ball et al., 2019). The child is African American. Some diseases are more prevalent in populations with ancestors from Africa (McCance & Huether, 2019). For example, if the family has a history of sickle cell disease, the child may need to be checked for the disease (McCance & Huether, 2019). Gathering cultural and religious practices that may affect care is also imperative as it may guide the direction of care in a different route (Ball et al., 2019).

If medications are being prescribed two key factors need to be addressed. Can the patient’s guardian afford the medication and do they understand how the medication is to be taken (Rosenthal & Burchum, 2021)? Practitioners throw around the word noncompliance easily but what is behind the noncompliance (Rosenthal & Burchum, 2021)? If the patient’s guardian does not understand the importance of the medication or they cannot afford the medication, it is the job of the healthcare professional to remedy these situations (Rosenthal & Burchum, 2021). If they cannot afford the top tier medication, can they afford a second-tier medication? These medications may not have as high of efficacy but it may be better than the patient being without anything (Rosenthal & Burchum, 2021). Guardians also need to understand that children process medications differently than adults due to immature organ systems and that many medications are not studied in children so they are being written off label (Rosenthal & Burchum, 2021). Teaching the importance of monitoring the child after medication doses should be part of the education in the visit (Rosenthal & Burchum, 2021).

In conclusion, a comprehensive history and physical is just that, comprehensive. Obtaining the history and physical is just as important as the physical exam (Sullivan, 2019). Documentation is also key as the record is often used as a base throughout the patient’s entire clinical course (Sullivan, 2019). As a healthcare provider it is our goal to provide above adequate care to our patients, which all begins with the initial H&P (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, (9^th ed.). Elsevier.

McCance, K.L. & Huether, S.E. (2019). Pathophysiology: The biologic basis for disease in adults and children, (8^th ed.). Elsevier BUILDING A HEALTH HISTORY Discussion -4 year old African American male living in a rural community.

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

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

van der put, C.E., Assink, M., & Boekhout van Solinge, N.F. (2017). Predicting child maltreatment: A meta-analysis of the predictive

validity of risk assessment instruments. Child Abuse and Neglect, 73, 71-88. https://doi.org/10.1016/j.chiabu.2017.09.016

Focused Exam: Depression Abigail Harris Shadow health Objective data

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

You bring up a valid point about the affordability and understanding of medications prescribed.  Obtaining and assessing the patient is indeed a crucial step in diagnosing a patient.  However, as you mentioned, a diagnosis is only as good as the treatment provided if it is executed and adhered to.  About three in ten adults report not taking their medicines as prescribed at some point in the past year because of the cost. This includes about one in six (16%) who report they have not filled a prescription, about one in five (22%) who took an over-the counter drug instead, and 13% who say they have cut pills in half or skipped a dose (Kaiser Family Foundation, 2022).  As a practitioner, it is not only important to educate the patient/family, but also to discuss the feasibility in obtaining such prescriptions.   In doing so, the practitioner can address the issue of cost and find alternate means to access the necessary medications.   “Noncompliance” happens more often than we think because patients do not understand the need for the medicine, the nature of side effects or the time it takes to see results (American Medical Association, 2023).  Communication is of utmost importance in order to properly diagnose and provide effective treatment.

References

American Medical Association. (2023, February 22). 8 reasons patients don’t take their medications. https://www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medications

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

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/

response 2

Thank you for your kind words! I appreciate your agreement regarding the importance of adapting communication techniques to each patient’s unique situation. Establishing trust through effective communication indeed plays a vital role in the clinician-patient relationship.

Pediatric assessments should encompass not only physical health but also factors like basic needs, psychosocial risks, and behavioral issues. Recognizing and addressing these aspects can significantly impact the care plan, especially considering the long-term consequences of childhood stress, trauma, or neglect on mental and physical health.

I’m glad you found the mention of developmental milestones screening relevant. Monitoring these milestones helps in identifying any potential delays or disabilities early, enabling timely interventions and support for the child.

Thorough health assessments and accurate documentation are indeed fundamental for establishing a baseline and tracking changes in the patient’s health over time. This comprehensive approach ensures continuity of care and facilitates collaboration among healthcare providers.

Thank you again for your feedback! If you have any further questions or insights, feel free to share.

I enjoyed reading your post. It was well-written and informative. I completely agree with you about there “not being a one size fits all technique.” Being able to relate and communicate with our patients can allow us to establish trust that fosters a good clinician-patient relationship. With minimal prompting, the patient can carry the conversation and provide much of the needed information necessary to complete a good H & P (Ball et al., 2019). When working with the pediatric population, conducting a good assessment of basic needs being met, psychosocial risks, and behavioral risks can help providers to tailor their care plan to address these issues. Pediatric patients that experience childhood stress, trauma, or neglect are more likely to have mental and physical health issues later in life (Oh et al., 2018). I love that you mentioned meeting childhood developmental milestones as a screening tool to be utilized for your assigned case scenario. Assessing if a child is meeting their developmental milestones can help clinicians to assess for delays or disabilities and intervene accordingly (Zubler et al., 2022). It is important to conduct a thorough health assessment and ensure accurate documentation in the patient’s chart. This will establish a health baseline that other clinicians can refer to and identify changes in the patient’s health (Ball et al., 2019). Great Post!

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.

Oh, D., Jerman, P., Silvério Marques, S., Koita, K., Purewal Boparai, S., Burke Harris, N., & Bucci, M. (2018). Systematic review of pediatric health outcomes associated with childhood adversity. BMC Pediatrics, 18(1). https://doi.org/10.1186/s12887-018-1037-7Links to an external site.

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