Case study

38-year-old Native American pregnant female living on a reservation

To prepare:

With the information presented in Chapter 2 of Ball et al. in mind, consider the following:

• By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. 
• How would your communication and interview techniques for building a health history differ with each patient?
• How might you target your questions for building a health history based on the patient’s social determinants of health?
• What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
• Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
• Select one of the risk assessment instruments presented in Chapter 2 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
• Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history. 

Peer response 1

• 40-year-old black recent immigrant from Africa without health insurance.Communication and Interview TechniquesTo start a health history with any patient I would initially start with developing a rapport and establishing effective communication. With this patient being a recent immigrant of African descent, I do not have much in common with them. I am not necessarily familiar with their customs, or comfort level with medical practitioners especially a practitioner of opposite gender as I have experienced, some cultures value modesty very highly even in the medical setting (Ball et al., 2023). I would start by introducing myself, including my title and responsibilities of my position and assure the patient of the confidentiality of their visit with me. I would then ask if they were comfortable with having a male as their provider, for this discussion I will assume the answer is yes. If not I would attempt to find them another provider they are comfortable with to ensure they are fully disclosing their history so we can better address their needs.Social Determinants of HealthWhen considering this patient’s social determinants of health, the glaring issue is the lack of health care. This could lead to a financial burden when considering health care. I would give this patient access to resources such as a financial counselor and social worker, in addition I would be very direct in what is entailed in suggested treatments and medications so that the patient is fully aware of what they are agreeing to (Ball et al., 2023). I would ask questions about access to nutrition and living situations. If the patient seems uneasy with medical professionals, I would speak softly and attempt to foster a welcoming and trusting environment. I would clarify what I am saying and ask follow-up questions to ensure understanding. There may be a language barrier in this case. I would attempt to reiterate my words in a way they understand and avoid medical jargon that may be confusing. If an interpreter is needed, Then the proper steps would be taken to get a private interpreter for this patient (Ball et al., 2023).Assessment Instruments Since this patient is a younger adult, I would consider screening for intimate partner violence. Intimate partner violence is more often committed against women and should be screened for in all patients of the appropriate age range. I would start by asking simply if the patient is in a relationship, married, or has an intimate partner. The Partner Violence Screen (PVS) would be applicable in this case. I would ask questions such as: Have you been physically hurt by someone within the last year? Do you feel safe in your relationship? Did a previous partner physically hurt you or are they currently making you feel unsafe? I would be very direct and respectful of their answers (Ball et al., 2023). Unfortunately, it has been shown that there is an increased barrier to admission of intimate partner violence in some minorities and immigrant notably from Africa. Some of these countries do not have the same view of partner violence as the United States does and some of this violence is seen as the norm (Hulley et al., 2023). Other targeted health risk assessments could focus on asking if the patient had access to health care before coming to this country, if they had access to vaccines, and general knowledge about the healthcare system in America.Potential Health-Related Risks As previously stated, based on this patient, I would ask about knowledge deficits in our healthcare system. This is to ensure the patient can ask the correct questions to get the treatment they need. I would ask them about their living conditions, access to nutrition and access to healthcare in general. This could be related to lack of transportation and financial difficulties. I would ask about their diet, as African Americans are at higher risk for hypertension (McCance & Huether, 2019). I would give them information on low sodium diets if appropriate. I would ask about sexual activity and potential plans to get pregnant since they are of child-bearing age. I would ask about medical history to see if they had been exposed to diseases not common in the United States such as malaria. I would ask about smoking and alcohol use as well as family-history of breast and colon cancer specifically since they are at the age they should begin to be screened if appropriate.Risk Assessment Tool I would use the PVS to assess for intimate partner violence. This assesses current and previous exposure to intimate partner violence. If the patient reports there was violence I would be able to provide resources for them accordingly. Resources include social workers, psychiatrists, and general information on the topic.Patient Specific Questions
  • What is the reason for your visit today? Is this a new problem or an existing problem?
  • What is your current access to healthcare? Is there a potential for this to change in the near future?
  • What questions do you have about healthcare in this country?
  • Can you tell me about your sexual history? Are you currently in an intimate relationship?
  • Have you ever been physically or emotionally hurt in your current or past relationship?
  • Are you planning on getting pregnant?
  • What is your access to nutrition?
  • What was your access to healthcare in your home country?
  • Do you have a personal or family history of any medical conditions? 

Peer response 2

The patient being interviewed is a 14-year-old biracial male living with his grandmother in a high-density public housing complex. The interview process is especially important when treating adolescents to aid a provider in properly identifying and addressing present and potential health issues, and health-related risky behaviors. The patient should be clear that all information obtained during the interview will remain confidential. This will lead the adolescent to provide accurate information and actual answers to the provider’s questions. The provider should focus on building a comfortable relationship with the patient and ask questions in a developmentally appropriate manner. In this case, the provider should also take the patient’s race and living conditions into consideration to address patient specific health risks. Questions should be addressed at multiple angles to give the patient a greater opportunity to disclose important information. For example, when asking about drug use, a question may be asked about general drug use, followed by a question about a specific drug. Simple, and easy to understand language should be used when conducting the interview, as well. This ensures that the individual understands the questions being asked, leading to more accurate answers, and an effective interview (Nass & Pasternak, 2012).

There are many social determinants of health that will affect the outline of the interview for this patient. The main ones are socioeconomic status and education. Being that the patient lives in public housing, he is living in a low-income home. This, together with the fact that he lives with his grandmother, can contribute to poor access to healthcare. Additionally, his knowledge regarding safe and healthy behaviors may be limited. Therefore, the interview must be carefully crafted to gain as much information as possible to help this individual. Due to his low-income status, the patient may also not have proper education. This would prompt the provider to simplify the interview questions in an easy-to-understand way. Since this patient is biracial, he is at greater risk of emotional, physical, and behavioral health issues. Being of mixed race can lead to increased stress and poor self-esteem and family dynamics. Questions that target emotional health and identifying support systems are important to include in the health assessment interview (Udry et al., 2003).

Since the basis of a health assessment interview with an adolescent is addressing risky behaviors that relate to one’s health, the risk assessment instrument HEEADSSS should be used with this patient. This tool addresses various issues that are present in an adolescent’s life, providing the provider with a solid health history. HEEADSSS addresses issues surrounding home, education, eating, activities, drugs, suicidality, sex, and safety. Although these factors affect almost all adolescents, this patient is especially at risk of the issues that arise with each of these topics (Katzenellenbogen, 2005). This instrument will address the health issues discussed above that arise from being a biracial adolescent, living in a low-income household and neighborhood.

Potential health-related risks that apply to this patient are malnutrition, or poor eating habits, poor self-esteem, self-harm, chronic stress, alcohol or drug use, and smoking. These risks are mainly based upon the patient’s race, age, and environmental setting. In addition, living in high-density public housing can lead to health issues due to the likelihood of poor air quality, excess mold and moisture, and allergens (Jacobs, 2011).

The following are some of the questions I would ask this patient to assess his health risks and begin building a health history. Do you feel safe at home? Can you please tell me about the school you attend? Have you ever used drugs such as marijuana, or weed, cocaine, or heroin? Do you have any thoughts of hurting yourself? What foods are available in your home? The patient’s characteristics are complex and require a lot of forethought prior to conducting the interview. Proper identification of risk factors, and knowledge of patient specific interview techniques is necessary for building a health history.