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Week 1: Building a Comprehensive Health History Essay Discussion

26 Year Old Lebanese Grad Student

For the purpose of this discussion post, I was assigned to interview a 26 year old Lebanese female living in graduate student housing. Before any questioning happens, it is important to establish a connection. In order to do this, one strategy is to ask the patient what they are expecting by coming to visit you. This gives the practitioner an idea of how to proceed because a stiff and formal attitude may make the patient feel uncomfortable, but an over casual interview may fail as well (Ball et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Due to the younger age of this patient, there is a chance that a more informal interaction could be the best way to proceed, but I would bear in mind that this should change if the patient does not seem to respond well to it. Another factor to consider is the handling of silence during the interview process. A common misconception is that silence is awkward and needs to be broken. A practitioner who exhibits patience during silence can actually make the patient feel more comfortable, thus giving them time to summon courage to share information (Ball et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers).

Based on this patient’s age and the fact that she is a college student, she is more likely to abuse alcohol than any other age group. Six students a day die from alcohol poisoning in the United States and over 40% of college students drink heavily (Ward et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). With this information, I believe an alcohol abuse risk assessment instrument is appropriate for this patient. An appropriate tool is the TACE Model. This consists of asking the patient how many drinks it takes to feel the effects of alcohol, if they’ve ever been criticized for their drinking, if they’ve ever felt the need to cut down, and if they drink in the morning to alleviate the effects of a hangover (Ball et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). There are numerous risk assessment instruments available should the client provide any information that gives the practitioner reason for further questioning. These include, but are not limited to domestic violence, drugs, and competency to make medical decisions (Sullivan, 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers).

Assessments and interviews need to be performed thoroughly, but in a timely manner. There is not much time to waste. Knowing this, providers need to have quality questions ready to go for their patients. Ideally these question will provide new information that the provider does not already have access to. In the case of this patient these are five target questions I would likely ask:

“What brings you in to see me today?” This allows me to quickly get an idea as to why the patient came through my door. It also gives them the opportunity to provide the answer in their own words (Sullivan, 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers).
“What are your expectations for our visit today?” By asking this, she has the opportunity to tell me exactly what she’s looking for. Is she in pain and looking for relief? Is she depressed and doesn’t know where to turn? Does she need a prescription filled? Early in the interview process, it is entirely appropriate to check the patient’s agenda (Ball et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers).
“What can you tell me about your medical history?” What if anything do you think is important for me to know?” Once a connection is established and some sort of comfort level is reached, this information will help get the interview going where it needs to go. Even if the patient has something in their medical history that isn’t related to their current visit, the practitioner needs to be aware of this in order to provide the best care possible.
“Do you use alcohol or any drugs? If so, can you elaborate and give me an idea of how you use them and how frequently?” It was pointed out previously that this patient falls into a category where the use of drugs and alcohol is likely. Perhaps this patient doesn’t use either, or maybe she has a problem that could be a serious risk to her overall health. Knowing the risk factors is reason enough to ask this question.
“In the recent months have you battled depression or anxiety?” Assumedly most graduate level students would admit to some stress related to their coursework. However, a recent study found that over 19% of graduate level students admitted to feeling high levels of depression or anxiety (Barton & Bulmer, 2017). Knowing this, it is vital to screen for these issues.
After gathering all the information, organizing the patient’s health record in a SOAP note format is an efficient way to outline everything that happened. These notes consist of subjective data, objective data, assessment, and the plan going forward (Ball et al., 2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Any answers that the client provides to questioning can be considered subjective material where objective data is purely what is observed directly. This could be injuries or any other physical details on the patient’s body. The assessment portion of the note is where the provider lists his or her interpretation of the data. For example, if the patient is crying and stating that she has recently had thoughts of suicide, this would lead the provider to bring up the possibility of depression. Finally, the planning portion is where any additional testing or consults can be recommended. Providing rational for any further action is also the responsibility of the provider.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Barton, B. A. ., & Bulmer, S. M. 2. B. ed. (2017). Correlates and Predictors of Depression and Anxiety Disorders in Graduate Students. Health Educator, 49(2), 17–26. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=eue&AN=132912313&site=eds-live&scope=site

Sullivan, D. D. (2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Ward, R. M., McMurrary, M., Brinkman, C., Taylor, E. A., Witmer, K. A., Bonar, R. N., & Lewis, P. (2019: 2024 – Online Assignment Homework Writing Help Service By Expert Research Writers). Relationship Between College Student Intoxication Level and Their Recall of Alcohol Poisoning Symptoms. Journal of Alcohol & Drug Education, 63(2), 18–34. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=rzh&AN=138497829&site=eds-live&scope=site

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