Adolescent white male without health insurance seeking medical care for STI
Building a Health History
Developing a medical background is really important when taking care of patients. “You create the background to make a connection with the patient, so that together you find out what problems need attention first” (Ball et al., 2019). In this situation, the healthcare provider has to gather medical information about a teenage Hispanic/Latino boy who lives in a middle-class neighborhood. It can be tough to get information from teenagers because they might not want to share personal stuff. It’s really important that the patient can understand the healthcare provider. Because this patient is Hispanic, I would make sure they can speak English well or provide a translator if needed.
WAYS TO TALK WITH THE PATIENT
Being a teenager can be hard because there are lots of changes and trying new things. The first thing I would do is make sure the patient knows their information will be kept private. If the patient is with a parent or guardian, I would offer privacy so they can give honest answers and know their information is safe. Another way to talk with the patient is by asking open-ended questions. Starting with open-ended questions might make the patient share more during the conversation (Ball et al., 2019). Also, talking openly about their home, school, work, friends, and activities might show areas that need attention (Ball et al., 2019).
BUILDING A MEDICAL BACKGROUND – SCENARIO: A teenage white male without health insurance needs medical care for an STI.
CHECKING
Even though teenagers are usually healthy physically, they might have problems with feelings and social stuff. At the beginning of the talk, the healthcare provider should introduce themselves and have an easy chat to build trust. First, the patient should be able to talk about any problems and their medical history. Then, the healthcare provider should ask about past medical issues and family history. After that, a full check-up and physical exam should be done to make sure the patient is physically okay, with a focus on their feelings and social life.
Knowing about their social life helps figure out behaviors that might cause health problems (Sullivan, 2019). The tool I would use in this situation is called HEEADSSS. This tool helps understand what’s happening in a teenager’s life. HEEADSSS stands for: Home, Education and work, Eating, Activities (with friends), Feelings, Goals, Anger, Drugs, Sex, Sadness, Safety from harm (Doukrou & Segal, 2018). Using HEEADSSS is important because it helps the healthcare provider understand everything about the teenager and any problems they might have in an easy way (Doukrou & Segal, 2018).
SPECIFIC QUESTIONS
I would start by asking the patient, “What’s bothering you today?” so they can talk about any worries they have. Then, I would ask, “Who do you live with?” to know about their home and who supports them. After that, I would ask about school or work, saying “Tell me about school (or work).” Also, I would ask if they have close friends and what they like doing together by saying “Who are your best friends?” and “What activities do you enjoy with them?” I would begin with these open questions, making sure not to interrupt the patient and asking for more details when needed.
ENDING
Healthcare providers can be a safe place for teenagers to talk about worries and get help with hard stuff (Ball et al., 2019). By giving privacy, being attentive, and letting the patient talk without interruptions, the healthcare provider can get all the information needed for a complete medical background.
Alcohol Use Disorder Rachel Adler shadow health Documentation
Adolescent white male without health insurance seeking medical care for STI
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
