Module 1 Assignment: Taking a Health History: Building a Health History: Asking Difficult Questions

Module 1 Assignment: Taking a Health History: Building a Health History: Asking Difficult Questions

Much of an archeologist’s work is done under the mantra “proceed with caution.” Archeologists must dutifully secure permissions to access sites. They also must exercise extreme caution when excavating or analyzing in a lab to avoid potential damage to historical artifacts.

Likewise, nurse practitioners must proceed with caution when building a patient’s health history. Important questions can be difficult for both nurse and patient. Care must be taken to approach such questions with dignity, tact, and respect to create an environment conducive to productive conversations.

For this Assignment, you will develop a script to be used to interview a volunteer serving in the role of patient.

To prepare:

• Review the Ewing (2004) questionnaire found in this week’s Learning Resources and consider the difficult questions you might have to ask when you take a patient’s health history.
• Review the screening tools found in the Learning Resources and consider how you might use an app or tool to assist in screening.
• Review the media programs related to a vaginal exam, pap test, and breast exam.
• Review the health history guide presented in Chapter 6 of the Schuiling & Likis (2017) text and consider how you would create your own script for building a health history. (Note: You will also find the Health History Form in Chapter 6)
• Describe the components of a complete gynecologic health history.  Include  considerations for special populations such as  LGBTQ+ individuals.
• What health maintenance guidelines should be  included for initial and follow up  might be needed for follow-up assessments?  (i.e., bone density test, Gardasil vaccine, shingles, etc.)?
• What questions would you consider in your patient’s assessment? For example
  • What is your patient’s living situation?
  • Do they have stairs?
  • Do they live by themselves?
  • Do they have a working refrigerator?
• Create your own script for building a health history and use the Health History Template for guidance (consider the type of language you would use to help your patient be more comfortable). As you create your script, consider the difficult questions you want to include in your script.

Assignment: (1- to 2-page reflection)

• In addition to your script for building a health history for this assignment, include a separate section called “Reflection” that includes the following:
  • A brief summary of your experiences in developing and implementing your script during your health history.
  • Explanations of what you might find difficult when asking these questions. What you found insightful and what would you say or do differently.

Sample Essay Taking a Health History: Building a Health History: Asking Difficult Questions

Part I: Script to Build a Health History

Bio Data:

• Patient’s Age-
• Parity-
• Date of Last Menstrual Period (LMP)-

Chief Complain and History of Present Illness:

• How can I help you today? (common concerns that gynecological patients present with  include vaginal bleeding, vaginal discharge,  erythematous/pruritic  vagina, pelvic/abdominal  pain)

Menstrual History

• At what age did you begin menses?
• What was the date of your last menstrual period (LMP)?
• What is the regularity, duration, flow, and symptoms (eg dysmenorrhea) associated with menses?
• Do you have intermenstrual vaginal bleeding?

For Women in Menopause

• At what age did you begin your menses?
• Do you have a history of post-menopausal vaginal bleeding?
• Do you experience any vasomotor symptoms?
• Do you have a history of HRT (Hormone Replacement Therapy?)

Past Gynecologic History

• Do you have a history of any gynecologic problems?
• Do you have a history of pelvic/gynecologic surgeries?
• Do you have a history of pelvic inflammatory disorders (PIDs) or sexually transmitted infections (STIs)?
• When was your last screening for breast cancer/cervical cancer and what were the results?

Sexual History

• Are you /have you ever been sexually active?
• Within the past 12 months, how many sexual partners have you had?
• Are your sex partners’ women, men, or both?
• Which sexual contact do you often engage in (anal, genital, oral)?
• Do you use any contraceptive methods? Which one?
• Have you ever been diagnosed with an STI? When? How were you managed?
• Have you ever been tested for STIs? Would you be interested to get tested?
• Have any of your partners ever been tested for STDs? What were the results? How was it managed?
• Have you ever experienced post-coital vaginal bleeding?
• Have you ever experienced  sexual dysfunction (low sex libido, dyspareunia)
• Have you ever been sexually abused?

Allergies and Medications

• Are you currently taking any prescribed or OTCs medications?
• Do you have any food, environmental, or drug allergies?
• Family History
• Do you have a history of familial/genetic disorders? (Ovarian cancer, breast cancer, genetic mutations, cervical cancer or Endocrine disorders such as hypertension and DM)

Social History

• What is your relationship status?
• What is your socioeconomic status?
• Do you have any drug/alcohol use that I should be aware of?
• What is your occupation?

Obstetric History

• Gravida
• Number of term pregnancies if any (include the mode of delivery, gender, and birth weight of the baby, fetal and perinatal complications, and if there was use of any  modes of  assisted reproductive therapies)
• Have you had any preterm pregnancies?
• Have you had any spontaneous or elective abortions?
• How many live births/living children do you have?

PART II: REFLECTION

After comprehending how to build a health history,  clinicians must know how to use the information collected to make the appropriate diagnosis and differential diagnoses since the primary diagnosis will influence clinical decision-making with regards to pharmacological and non-pharmacological therapy, health promotion,  patient education, consults, and follow-up (Keifenheim et al., 2015). For this assignment, the experience of building a health history with a specific focus on gynecological health history presented unique challenges. The greatest challenge was associated with the intimate aspect of OBS/GYN history taking and physical exam and revealed the essence of establishing trust with a relaxing and private setting for a patient.

A major difference in building this health history was the focus on menopausal/menstrual history and sexual history. Since the American population is also diverse, when building the health history, it was also evident that with the nature of questions and physical exams to perform from a gynecological perspective, patients may hesitate to disclose specific details of their gynecological history since it is very sensitive.  Therefore, during implementation, Mazumder (2016) suggests that the clinician must be empathetic, and create a very comfortable environment. This will positively influence them to openly discuss issues. Similarly, if a patient may appear uncomfortable disclosing their gynecological history, I found that beginning with a family or social history to establish trust and patient rapport was more insightful. Despite the delicate nature of a gynecological history, clinicians cannot miss asking the clinically relevant questions with the history tailored to a specific presenting complaint. Therefore, based on this experience of building a health history, there is nothing that I would do differently.

References

• Keifenheim, K. E., Teufel, M., Ip, J., Speiser, N., Leehr, E. J., Zipfel, S., & Herrmann-Werner, A. (2015). Teaching history taking to medical students: a systematic review. BMC medical education, 15, 159. https://doi.org/10.1186/s12909-015-0443-x
• Mazumder, M. S. I. (2016). Towards Formalized Models of Patients’ History Taking (Doctoral dissertation, Karolinska Institutet).