Building a Health History Essay

Building a Health History Essay

Building a Health History Essay

The discussion highlights the importance of comprehensive data collection and effective communication in treating a 19-year-old black male athlete experiencing muscle pain. The discussion acknowledges the significance of establishing a rapport with the patient, particularly in the case of adolescents and young adults. According to Molina and Gallo (2020), creating a comfortable environment encourages patients to openly express their experiences and provide valuable subjective and objective information.

The discussion also emphasizes using adaptive questioning and active listening as effective techniques to allow patients to communicate their concerns without interruption. I would apply effective communication and interview techniques to establish a rapport and gather comprehensive information. I would introduce myself, explain the purpose of the interview, and ensure the patient’s privacy and confidentiality. I would use open-ended questions to encourage patients to provide detailed responses and share their concerns regarding muscle pain.

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Active listening skills would be essential to demonstrate empathy and understanding and encourage patients to express themselves fully. Byrne et al. (2020) assert that a patient-centered approach creates a comfortable and non-judgmental environment, allowing the patient to freely express their symptoms, concerns, and any relevant contextual information. I would use non-verbal cues such as maintaining eye contact, nodding, and appropriate body language to convey attentiveness and interest.

Assessment Tool

The OPQRST mnemonic would be the most suitable assessment tool to assess the patient’s health risks related to muscle pain. This tool explores various aspects of the pain experience, including the onset, palliative and provocative factors, quality, region and radiation, severity, and timing of the pain (Ford, 2019).

O – Onset: Determine when the pain started and what was happening then. Understanding the circumstances surrounding the onset of pain can provide insight into potential causes or triggers.


P – Palliative and Provocative factors: Identity what makes the pain better or worse. Inquire about specific activities, positions, or treatments that alleviate or aggravate the pain. This information can help identify contributing factors.

Q – Quality: Describe the pain. Is it burning, sharp, shooting, aching, throbbing, or another sensation? Understanding the characteristics and nature of the pain can assist in narrowing down potential causes and guide further assessment.

R – Region and Radiation: Determine the precise location of the pain and whether it spreads to other areas. Identifying the specific region and associated radiation can help identify potential underlying structures or systems affected.

S – Severity: Assess the pain intensity using a scale such as the functional pain scale or numeric rating scale (NRS). This will help determine how severe the pain is and how it impacts the patient’s ability to engage in daily activities.

Additionally, the functional pain scale and numeric rating scale (NRS) can be implemented to evaluate pain intensity on a scale of zero to ten and determine its impact on daily activities (Ford, 2019). These assessment tools facilitate a comprehensive understanding of the patient’s pain experience and functional limitations.

Factors Impacting the Health and Risk Assessment

Factors impacting this patient’s health and risk assessment are multifaceted and include the patient’s athletic status, ethnicity, environmental factors, age, gender, and the availability of healthcare resources. As an athlete on a scholarship, the patient may face an increased risk of sports-related injuries or overuse injuries, which could be contributing to the muscle pain he is experiencing. Furthermore, being a black male, the patient may be more susceptible to specific health conditions prevalent within their ethnic group, such as hypertension, which can contribute to muscle pain.

Environmental factors play a significant role in health risks as well. Exposure to extreme temperatures or inadequate training facilities can increase the risk of muscle pain or injury (Leyk, 2019). Additionally, the patient’s age is an essential factor to consider. As a 19-year-old, he may be more prone to musculoskeletal injuries or strains related to physical activities that are common in young adults. Gender can also impact health risks, with males potentially being at a higher risk for certain sports-related injuries or musculoskeletal conditions.

Finally, the patient’s access to healthcare, socioeconomic status, and community resources are crucial determinants of their health risks. According to the National Academies of Sciences (2019), limited access to healthcare or inadequate resources in their environment may hinder their ability to seek appropriate care for their muscle pain or address any underlying health conditions. Thus, a comprehensive data collection process is essential to assess all these factors and determine the best course of action for treating the patient effectively.

The Five Targeted Questions to Ask the Patient

  1. Can you describe the nature and location of your muscle pain?
  2. When did you first notice the muscle pain? Was there any specific event or activity associated with its onset?
  3. Have you experienced similar muscle pain in the past? If so, how did you manage or treat it?
  4. Are there any activities or movements that worsen or alleviate the muscle pain?
  5. Do you have any known medical conditions or a family history of musculoskeletal problems?


Byrne, A.-L., Baldwin, A., & Harvey, C. (2020). Whose center is it anyway? Defining person-centered care in nursing: An integrative review. PLOS ONE, 15(3).

Ford, C. (2019, April 11). British Journal of Nursing – adult pain assessment and Management. British Journal of Nursing.

Leyk, D. (2019). Health risks and interventions in exertional heat stress. Deutsches Aerzteblatt Online.

Molina, J., & Gallo, J. (2020). Impact of nurse-patient relationship on quality of care and patient autonomy in decision-making. International Journal of Environmental Research and Public Health, 17(3), 835.

National Academies of Sciences. (2019). Factors that affect healthcare utilization. In National Academies Press (US).


Discussion Week 1: Deborah Vojik

Group 3

19-year-old black male athlete on scholarship with muscle pain

The patient is a 19 YO black male who presents with a physical symptom of muscle pain (undefined). He is an athlete (sport not determined) who is on a scholarship. Comprehensive data collection is critical to determine the best course of action in treating any patient. It’s important to establish a rapport with any patient, however, with adolescents or young adults it is helpful to keep the conversation personal (Ham & Allen, 2012). Instead of stating general facts, the practitioner can considerately ask the patient what is happening in their lives. A tremendous amount of subjective and objective data can be obtained by allowing the patient to talk and giving them space and listening. This can give the practitioner insight into how best to approach and treat the chief concern.

Adaptive questioning or guided questioning with active listening are effective tools that can allow the patient to fully communicate without interrupting the flow of information and enable them to fully express their experience of the current issue. This technique also allows the practitioner to request additional information and clarification as required and gives them the capacity to repeat and reinforce the patient’s statements (echoing). (Effective Nursing Health Assessment Interview Techniques, n.d.) Utilizing the aforementioned interview techniques enables the practitioner to dive more intently into the interview as a level of comfort is established. This sets the stage for a thorough exploration of positive responses using the where, when, what, how, and why of the chief concern (Ball, Dains, Flynn, Solomon, & Stewart,2019).

Grout, Thompson-Fleming, Carroll, & Downs, (2018) assert that studies in pediatric pain are limited. Current knowledge of outpatient pediatric pain is limited to non-routine/ emergency or subspecialty /disease-specific settings, or when pain is the primary complaint.

There are several different risk assessment tools or pain rating scales that I would use to assess pain severity in this borderline adolescent/ adult patient. Considering the patient’s age and presentation I would start by asking the patient to pinpoint exactly on a body diagram where he is experiencing pain. I would then explore further by asking certain questions to get a full understanding of the patient’s pain history. Rating Pain | COEPES, (n.d.) suggest the following pneumonic OPQRST.

O – Onset: When did the pain start? What was happening at that time?

P – Palliative and Provocative factors: What makes the pain better? Worse? (Include specific activities, positions, or treatments.)

Q – Quality: Describe the pain. Is it burning, sharp, shooting, aching, throbbing, etc.?

R – Region and Radiation: Where is the pain? Does it spread to other areas?

S – Severity: How bad is the pain? This can be assessed using a numeric rating scale (NRS) of zero to ten, with zero being no pain and ten being the worst pain imaginable I would ask the patient to rate his experience of pain. The benefits of the NRS are its simplicity and validity. Possible drawbacks include response variability and moderate correlation with functional status.

T – Timing: When does the pain occur? Has it changed since the onset? If so, how?

(Powell, Downing, Ddungu, Mwangi-Powell 2010)

In addition, I would implement the functional pain scale and ask him to rate the pain subjectively as either “tolerable” or “intolerable.” If the pain is “intolerable,” I would assess further to determine whether the pain is so intense as to prevent passive activities using the following scale.

0 No pain

1 Tolerable (and does not prevent any activities)

2 Tolerable (but does prevent some activities)

3 Intolerable (but can use telephone, watch TV, or read)

4 Intolerable (but cannot use telephone, watch TV, or read)

5 Intolerable (and unable to verbally communicate because of pain)

(Rating Pain | COEPES, n.d.), (‌Gloth, Scheve, Stober, Chow, & Prosser,2001).


I have indicated that I would use several risk assessment tools that would be applicable to the patient presenting with this scenario. In individuals that present with acute pain, it is important to assess the variables that contribute to the manifestation of pain and the patient’s functional status to determine the most appropriate course of treatment.

Five targeted questions that I would ask to assess his health risks and begin building a health history.

Do you have a history of related injuries from playing sports or other activities and if so, can you provide a timeline of the events?

How would you describe your overall health and your habits or routines to maintain your health status?

What types of foods do you like to eat and what is your understanding of recommended daily allowances for food groups and caloric intake?

What are your hobbies and what do you like to do for fun and excitement?

How do you express yourself, what brings you joy?


Ball, J., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). Elsevier.

Effective Nursing Health Assessment Interview Techniques. (n.d.). Walden University. Retrieved May 30, 2023, from to an external site.

Grout, R. W., Thompson-Fleming, R., Carroll, A. E., & Downs, S. M. (2018). Prevalence of pain reports in pediatric primary care and association with demographics, body mass index, and exam findings: a cross-sectional study. BMC Pediatrics, 18(1).

‌Gloth, F.M. III, Scheve, A.A., Stober, C.V., Chow, S., Prosser, J. (2001). The Functional Pain Scale: reliability, validity, and Responsiveness in an elderly population. J Am Med Dir Assoc. 2001;2(3):110-114.

Ham, P., & Allen, C. (2012). Adolescent Health Screening and Counseling. American Family Physician, 86(12), 1109–1116.

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