Sara, a 14-year-old, has come to the office for her school physical. She is very remote, moody, and unwilling to answer any questions you ask her as part of her physical exam. She seems to have changed a great deal in the past year, and is thinner, more unkempt, and lethargic. You notice also that her mother is constantly badgering her and rolling her eyes in exasperation at her lack of cooperation. What could you do to facilitate the examination and improve communication with Sara?

What possible problems could Sara be experiencing?

What should you do about the concerns that you have for Sara?

Answer and Explanation:

1. To facilitate the examination and communication with Sara, it would be important to politely ask her mother to leave the room. This could make Sara more relaxed and allow her to feel more comfortable answering questions, as we can see that her mother's presence is bothering her. Then it would be important to tell Sara that everything that was said in the room would be confidential and no one besides her and the interviewer would know about anything she said, for this reason, she could speak without fear of suffering any reprisal or having the content of the conversation disseminated.

2. Sara may be facing issues related to her teenage insecurities. She is 14 years old and it is common for teenagers at this age to become irritable, moody and anxious. She may also be facing problems related to substance ingestion, hormonal imbalance, among others.

3. To resolve concerns about Sara, it is important that the interviewer establish a relationship of complicity, so that Sara can inform what she is feeling, what is causing this behavior and what kind of situations she is involved. It is also important that she undergo medical tests that show the hormonal level and substances present in her body.

answer: the choice of providing direction for individualized care of a patient.   the care plans is a flow of communication and organizing the constantly changing of the care plan.  

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