Building a Health History

Patient Profile: 14-year-old biracial male living with his grandmother in a high-density public housing complex

When treating a patient, information gathered can be crucial to guiding and directing the plan of care (Nelson, Nichol, & Sundjaja, 2021). The primary goal when obtaining a medical history from a patient is to understand their current state of health and any factors that may influence the plan of care (Nelson, Nichol, & Sundjaja, 2021). The purpose of this discussion post is to analyze the significance of interview questions, communication techniques, risk assessment instruments, and the five target questions for the patient.

The patient is a biracial 4-year-old male accompanied by his grandmother. It is important to initially assess if the grandmother can speak and understand English. If not, there should be a medical interpreter present during the interview. These initial assessments are significant because the grandmother will be the primary source of information regarding the patient’s medical history and chief complaint. In the best circumstances, at 4-years-old, the patient should be able to answer simple questions if he has reached appropriate milestones. A medical relationship in pediatrics involves three members which are the physician, the parent, and the patient (child) (Lang, 2012). Although there is a susceptible difficulty regarding communication, the parent can show trust in the physician, therefore the child can mirror and take after their guardian.

A communication technique often used in pediatrics is time management. Physicians tend to use closed interview techniques by asking yes or no questions, which will hinder the patient’s need to express their feelings and beliefs (Marginean, et al., 2017). Children at that age should be able to form short sentences and ask follow-up questions. The healthcare provider should solicit the child and family to express their concerns to gain their trust (Marginean, et al., 2017).

Screening tools are useful for identifying patients with complex needs at risk of becoming high users of healthcare services (Marcoux, et al., 2017). A helpful screening tool to use when obtaining a health history and determining social risks is HEEADSSS. This acronym stands for: home, education or employment, eating, activities, drugs, sexuality, suicide, and safety (Sullivan, 2019, p.102). Socioeconomic status is a common health risk in children, and this can easily be identified when using this screening tool. Although these aspects may not apply to this patient, they will apply to the family and environment that he is surrounded by. Interventions will vary based on the information gathered from the patient and his grandmother.

Five Target Questions:

1. Who lives with you at home? Whom do you play with at home?
2. What is your favorite game to play?
3. What are some of your favorite foods or snacks?
4. Do mom and dad go to work (or in this case, maybe grandmother if she is primary guardian)? What do they do when they go to work?
5. Who is your teacher at school? What are your friend’s names? What is your favorite thing to do at school?

References

Lang E. V. (2012). A Better Patient Experience Through Better Communication. Journal of radiology nursing, 31(4), 114–119. https://doi.org/10.1016/j.jradnu.2012.08.001

Marcoux, V., Chouinard, M. C., Diadiou, F., Dufour, I., & Hudon, C. (2017). Screening tools to identify patients with complex health needs at risk of high use of health care services: A scoping review. PloS one, 12(11), e0188663. https://doi.org/10.1371/journal.pone.0188663

Mărginean, C. O., Meliţ, L. E., Chinceşan, M., Mureşan, S., Georgescu, A. M., Suciu, N., Pop, A., & Azamfirei, L. (2017). Communication skills in pediatrics – the relationship between pediatrician and child. Medicine, 96(43), e8399. https://doi.org/10.1097/MD.0000000000008399

Nelson, G., Nichol, J. R., & Sundjaja, J. (2020). Medical History. In StatPearls. StatPearls Publishing.

response

Negative Effects of Growing up with Grandparents

Thank you for your highly educative post. I agree with you that the primary goal when obtaining a medical history from a patient is to understand their current state of health and any factors that may influence the plan of care. Based on the patient’s profile, a 14-year-old living with his grandmother in a high-density public housing complex put him at risk of waywardness.  According to Keller et al. (2019), children raised by their grandparents are at an increased risk for emotional and behavioral problems in adulthood. Early in their lives, these children have experienced divided loyalties, rejection, loss, guilt, and anger. Many children feel disappointed and hurt by their parent’s actions and lack of time spent together. In corroborating previous authors’ assertion, Ball et al. (2019) stressed further that Adolescents whose parents do not monitor are more likely to smoke, use alcohol and marijuana, be depressed, and initiate sexual activity than are those who are monitored. Based on this, my targeted question may be worded in the following way:

1. Can you tell me how things are going in your home? Like, how do the people in your family get along?
2. How is your performance in school? Do you participate in any sports activities?
3. What do you and your friends do for fun? Do you drink or use any illegal drugs alone or with your friends?
4. Do you have any concerns about your physical/sexual development? Are you sexually active now?
5. Do you feel down or depressed most of the time?
6. Have you ever been in trouble with the law?

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.

Keller, P. S., Bi, S., & Schoenberg, N. (2019). Children being Reared by their Grandparents in Rural Appalachia: A Pilot Study of Relations Between Psychosocial Stress and Changes in Salivary Markers of Inflammation Over Time. Journal of Child & Adolescent Trauma, 12(2), 269–277. https://doi-org.ezp.waldenulibrary.org/10.1007/s40653-018-0214-z

My patient is a 38-year-old pregnant Native American female residing on a reservation.  According to research by Danielson et al. (2018), Native Americans experience a vast array of health disparities compared to all other Americans, specifically, they are more likely to die due to liver disease, diabetes, accidental injuries, heart disease, infectious diseases, suicide, and homicide. The researchers looked specifically at birth outcomes among the Native American population and found that the rate of infant mortality is 2-3 times greater than for white Americans and found high rates of fetal alcohol syndrome and preterm delivery. Some factors that the researchers uncovered that would lead to these outcomes are poor prenatal care and higher levels of smoking while pregnant. Another factor that the researchers found was high levels of adverse childhood experiences (ACEs) that are linked to behaviors such as drug and alcohol use, risky sexual practices, depression, and higher levels of chronic diseases. Goodkind et al. (2015) discuss the mental health disparities that American Indians experience in regard to the rest of the population. High levels of depression can lead to chronic illnesses, substance abuse, and suicidal ideation and behavior. These authors found that traditional treatment modalities for mental health may not be effective for this population as they put more emphasis on the family and community and what Western medicine refers to as “alternative” methods of treatment.

With that background in mind, I would first want to greet my patient and put her at ease by sitting level with her and making eye contact. I would assure her of her privacy and confidentiality.  I would like to ascertain a health history regarding any chronic illnesses either she or her immediate family experience and what, if any, treatment they have received. Since she is pregnant, I would ask about 1). any previous pregnancies and what were the outcomes, 2). her marital status, 3). the date of her last menstrual period, and 4). her and her partner’s (if there is one) occupations. I will ask about any sexually transmitted infections directly assuring her that this is a “no judgment” zone. Since Native Americans have a statistically higher rate of drug and alcohol use, I will ask her if she has or currently uses alcohol, drugs, or tobacco products. If she answers affirmatively, I will utilize the CAGE questionnaire or the TACE Model screening tool (Ball et al., 2019). I will also educate her and provide literature that is easily understood regarding the dangers of substance use on an unborn child during pregnancy. Since it is apparent that she has been sexually active, I will question her as to whether she has been the victim of intimate partner violence via the Partner Violence Screen (PVS) (Bell et al., 2019). As Goodkind et al. (2015) pointed out, American Indians may rely on their spirituality and practices associated with it for wellness as opposed to Western medicine. I will, therefore, inquire as to whether she would like to share with me any spiritual beliefs or practices that she utilizes for wellness. As mental illness is more prevalent in this population, I would inquire as to whether she feels depressed or sad and whether she has or has had any suicidal/homicidal ideations. I would make a note that after her pregnancy, she should be followed up for post-partum depression screening. At the conclusion of the interview, I would make any recommendations for follow-up care such as smoking cessation programs and a prenatal care schedule. I would also provide easily understandable literature regarding follow-up care and education discussed in her preferred language.

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 (9^th ed.). Elsevier.

Danielson, R.A., Wallenborn, J.T., Warne, D.K., & Masho, S.W. (2018). Disparities in

risk factors and birth outcomes among American Indians in North Dakota. Maternal

            and Child Health Journal, 22(10), 1519-1525.

https://doi.org/10.1007/s10995-018-2551-9

Goodkind, J.R., Gorman, B., Hess, J.M., Parker, D.P., & Hough, R.L. (2015). Reconsidering

culturally competent approaches to American Indian healing and well-being. Qualitative

            Health Research, 25(4), 486-499.

https://doi.org/10.1177/1049732314551056

response

According to Hanson (2012), Native Americans that drink enter prenatal care later and subsequently experience more sudden infant deaths than all other races in the nation. They have more children that suffer from Fetal Alcohol Syndrome. This saddens me because I have seen FAS up close. I tried to adopt a set of twins, a boy and a girl, once. I had them in my home for almost two years. Two days before the final custody court date the mother flew up to Alaska and claimed them back with the State of Alaska’s help. Still, these children were behind in almost every area. I took them into town weekly to participate in an infant learning program. Within the first nine months, we had made up 50% of what they were behind. By the time they left me, we were within 10% of where they should have been. It was a lot of work for them and all the adults involved.

I like that your interview communication techniques show open-ended questions and listening. According to Ball et al. (2010), interviewers should seek to understand when communicating. When I first received the twins to care for, I tried to understand what they had been through. Of course, they could not tell me, but I tried to picture their life from the parts I was told. The first four days were horrible. They were completely silent during the day, holding onto each other, and at night, they screamed their heads off all night. It was unreal. But I felt their emotion and waited. I also liked your question of intimate partner abuse because when a risk factor is identified, it should be included in the problem list (Sullivan, 2019). I saw a lot of this firsthand while living in Alaska among the Native Americans there. It seemed the village changed after 6 pm when everyone started drinking. Intimate partner violence is disproportionately found among indigenous people (Kozhimannil, 2020).

Ideas for additional interview questions would be “what do you see as benefits of prenatal health care?” and “how would you describe your tribe’s view on prenatal care?” as suggested by Hanson (2012). The reason I would ask these are to gain insight on her personal thoughts and perhaps how her family influences her thoughts. If she does not have her own way of getting to prenatal care and no one around her thinks it is important, then she will struggle to make those appointments even if she feels they are worthwhile.

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 (9^th ed.). St Louis, MO: Elsevier Mosby.

Hanson J. D. (2012). Understanding prenatal health care for American Indian women in a Northern Plains tribe. Journal of transcultural nursing : official journal of the Transcultural Nursing Society, 23(1), 29–37. https://doi.org/10.1177/1043659611423826

Kozhimannil KB. Indigenous Maternal Health—A Crisis Demanding Attention. JAMA Health Forum. 2020;1(5):e200517. doi:10.1001/jamahealthforum.2020.0517

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