Health History and Screening
Performing a health history and screening on adolescents can prove to be challenging and entertaining at times. This generation is much more reserved towards opening up about their personal information in comparison to the middle and older adult populations.
S.G., a single sixteen year old Caucasian female, was the source for this history and screening. She is a full time high school student and athlete from Roswell, New Mexico, and her last medical examination occurred in August of 2013. She takes no prescribed medications and has no known medical conditions or allergies. All of her childhood immunizations are current. As an infant, S.G. was hospitalized ...view middle of the document...
She desires to achieve her previous energy and activity level. She has a readiness for enhanced sleep as defined by her willingness to enhance sleep, desire to feel rested after sleep, and discipline to follow sleep routines that will support healthy sleep habits. S.G. has a soft, full, thick head of hair. She uses shampoo and conditioner daily with occasional hair masks. Her nails were noted to be strong, smooth, and well-manicured. There were no complaints of headaches, dizziness, syncope, or vertigo. S.G. wears contacts and occasionally suffers from blurred vision to her left eye. Her mother has informed her optometrist, and her last eye exam occurred in August of 2013. Her ears remain fee of pain, drainage, and tinnitus. S.G. typically uses soap and water to clean her ears and denies any excessive amounts of noise exposure. During the spring season, she suffers from seasonal allergies that are treated with over the counter medications and saline nose spray. There are no mouth sores, pain, toothaches, hoarseness, or change in taste noted. She flosses, uses mouthwash, and brushes her teeth daily. Her last oral exam was performed in December of 2013. There was no pain, swelling, or lumps noted to her neck.
S.G. has soft skin without changes to dryness, color, texture, or lesions. She has moderate sun exposure during the summer months but confirms daily use of sunscreen. There are no chronic respiratory, cardiac, peripheral vascular disease, or hematologic illnesses present. Education was provided about the benefits and prevention of hemostasis. She verbalized understanding of avoidance to crossing her legs and prolonged sitting or standing. She also reciprocated knowledge to use of personal protective equipment when dealing with blood or body fluids from other individuals. S.G. and her mother deny any complications associated with her previous knee injury. They both verbalized that extra care is taken to protect her knees from further injury, and that she desires to overcome her fatigue in order to restore her normal activity level.
S.G. was conceived out of wed lock, and her father vacated the state and left her mother while she was 3 months pregnant. He remained absent from their lives until S.G. was well into her 14th year of life. There are 24 billion children in America that are missing their biological fathers in their homes, and those children are at a 74% greater chance of suffering from emotional neglect ("Absent Fathers," n.d.). During that time, he married and had three boy children. His first wife passed away in 2012, and this is when he sought after a relationship with his daughter. Needless to say, S.G.’s mother and father re-united, developed a relationship, and married. Three months ago, this relationship failed, and her father has left her once again. She suffered from some depression during this time, but feels that this...
