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“A 35-year-old white male with a history of morbid obesity with disabilities in rural setting”

In order to determine a patient’s medical state, personal information must be gathered from them during a patient assessment, with an emphasis on their medical history, physical examination, and current illnesses.

An effective treatment depends on accurate patient data collected during an evaluation. In order to create a medical status that can accurately diagnose and treat health problems while utilizing medical jargon, clinicians must collect crucial pieces of patient history. Health information about a patient is fictitious data about their symptoms and interactions with doctors that is kept private and secret. The role of the physician in creating a health history for a 35-year-old Caucasian male with morbid obesity and impairments in a rural setting will be discussed in this study.

Communication and interview techniques for building a health history.

It’s crucial to develop efficient communication in order to obtain an adequate health record. The patient in the conversation is a 35-year-old Caucasian male who lives in a rural region and has a history of morbid weight and handicap. Astute learning, the capacity to adapt to the patient’s level of knowledge, empathy, the capacity to assess the patient’s answers, the avoidance of medical jargon, and a leaning toward a particular religion or gender orientation are all qualities that the clinician must possess. To determine whether an interpretation is necessary, it is critical to understand the patient’s kind and degree of disability as well as the type of communication modality that will be employed (Merker et al., 2021). Because each patient is different, everyone deserves a different evaluation. Social factors including age, gender, ethnicity, and environment all have an impact on how patients are interviewed in order to compile a thorough health history. To get accurate patient medical condition and information, building trust is crucial. It is crucial to establish effective contact with this patient in order to win his trust and accurately measure the effects of his health on both his health and his impairment as a result of the aforementioned causes.

Target your questions for building a health history.

The patient in the scenario is a person with morbid obesity and a disability, which helps to construct a medical status. The evaluation will be influenced by the type of disability, which will also determine the communication strategy to be utilized and whether a family member or interpreter has to be present throughout the interview. Instead of focusing just on lifestyle counseling and medical therapy, clinicians should focus on understanding the causes of a patient’s health record, including social difficulties, and providing patient-centered care to effectively address a patient’s condition (Shen et al., 2018). Depending on the patient’s level of handicap, the targeted questions will be determined. The first step in compiling an accurate and thorough patient history and physical is efficient communication. For the best possible care, it is crucial to take a patient’s socioeconomic determinants of health into account when conducting an interview. A patient who has a history of morbid obesity and impairment and lives in a remote area can ask: “What obstacles do you have in getting the health care and treatment you need?” The patient’s orientation state must be ascertained by asking questions to obtain personal data such as date of birth, gender, and social position such as, “Are you married?” Who are your roommates? health insurance, physical environment, transportation, employment, and societal values are all factors. The establishing of a good connection between the therapist and the patient will be helped by these inquiries.

What kind of support would you receive from friends and family?

-How have you found your neighborhood?

What resources does your society have available?

What do you believe would make your life easier in terms of leading a healthier one?

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?

Establishing the patient’s trust and confidence is crucial when dealing with morbid obesity and handicap since it will help with communication, promote self-esteem, and give the patient the privacy he needs due to the psychological effects of obesity. paying great attention to the environmental and genetic factors that affect obesity. Obtaining information and facilitating assessments of his diet, interests, and behavioral changes, as well as inquiring about and comprehending his issues, are some helpful techniques. It is challenging to evaluate an obese patient due to the restrictions and changes in body composition from what is thought of as a normal weight. To determine his risk of heart disease, it is helpful to calculate his Body Mass Index (BMI) depending on his weight. When patients have enough data access and efficient diagnostic communications, they are best equipped to participate in their healthcare.

The instruments and questions listed below are general risk assessment tools that could be used with a variety of patients (Lloyd-Jones et al., 2019).

The Centers for Disease Control and Prevention (CDC)’s Behavioral Risk Factor Surveillance System (BRFSS) questionnaire asks about several health risks, including eating habits, physical activity level, and smoking behaviors.

The Heart Attack Risk Calculator from the American Heart Association (AHA) estimates a person’s chance of suffering a heart attack during the following ten years.

Potential health-related risks based on the patient’s age, gender, ethnicity, or environmental setting.

Based on the patient’s age, gender, ethnicity, and rural location, several health-related issues should be assessed. For instance, the patient’s advanced age increases their vulnerability to illnesses including arthritis, heart disease, and cerebrovascular disease. The absence of medical care and/or the accessibility of emergency responders may also put the patient at a higher risk of suffering in a rural place (Ball et al., 2019).

In addition, the patient’s gender and ethnicity may put them at a higher risk for developing illnesses. For instance, women are more likely than men to get arthritic, cardiovascular, and stroke conditions, while minorities are more likely to develop diabetes and high blood pressure.

Select one of the risk assessments instruments.

The patient in question is susceptible to a number of health issues, including diabetes, cardiovascular disease, and obesity. The patient would undoubtedly benefit from a health risk assessment by being informed of particular risk areas and how to reduce those risks. One such system of assessment is the Framingham Risk Score (Ball et al., 2019). Based on a person’s age, gender, blood pressure, cholesterol, and smoking history, this tool estimates their 10-year chance of developing heart disease. A specific preventative strategy might be created based on the patient’s risk. The Reynolds Risk Score, which forecasts the likelihood of having a stroke, and the Adult Treatment Panel III (ATP III), which assesses the likelihood of developing heart disease, are other risk assessment tools that could be helpful for this 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.

Do you live by yourself?

The answer to this question helps the clinician understand the patient’s living situation and the dangers he or she may face if unable to care for themselves.

How do you commute or transfer?

Justification: The physician will learn about the dangers of transferring patients as well as the constraints that come with being obese and disabled.

How do you meet your daily needs, first?

The purpose of this question is to determine whether the patient needs assistance and who in the patient’s family or social network is a source of support.

Are you in possession of an advance directive?

Knowing who the patient has designated to make decisions for him when he is unable to do so due to his health issue or disability is the justification.

 Do you find it difficult to seek medical care?

Because of his size and disabilities, getting to a doctor’s appointment may be challenging. The clinician will do an assessment to see if the patient needs help scheduling appointments and arranging transportation to get medical care.

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.

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2020). Bates’ Pocket Guide To Physical Examination And History Taking. Lippincott Williams & Wilkins.

Lloyd-Jones, D. M., Braun, L. T., Ndumele, C. E., Smith Jr, S. C., Sperling, L. S., Virani, S. S., & Blumenthal, R. S. (2019). Use of risk assessment tools to guide decision-making in the primary prevention of atherosclerotic cardiovascular disease: a special report from the American Heart Association and American College of Cardiology. Circulation, 139(25), e1162-e1177.

Merker, V. L., Plotkin, S. R., Charns, M. P., Meterko, M., Jordan, J. T., & Elwy, A. R. (2021). Effective provider-patient communication of a rare disease diagnosis: A qualitative study of people diagnosed with schwannomatosis. Patient Education and Counseling, 104(4), 808-

Shen, M. J., Peterson, E. B., Costas-Muñiz, R., Hernandez, M. H., Jewell, S. T., Matsoukas, K., & Bylund, C. L. (2018). The effects of race and racial concordance on patient-physician communication: a systematic review of the literature. Journal of Racial and Ethnic Health Disparities, 5(1), 117-140.

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