Instructions <\/p>\n
Case 2: 55-year-old Asian female living in a high-density poverty housing complex<\/b><\/p>\n
What are the barriers to interpersonal communication?<\/b><\/p>\n
When seeing this particular patient, it is essential to be sensitive to cultural nuances, such as eye contact or physical touch, and adapt accordingly (Tan & Cho, 2019). Differences in cultural norms, values, and communication styles may all hinder effective communication. Language barriers, such as limited English proficiency, can also hinder communication with this patient. The use of medical jargon may further complicate her understanding. As she lives in high-density poverty housing, she may have limited access to information, technology, or transportation. This may also impact her health literacy, affecting her understanding of medical information or instructions (Tan & Cho, 2019). <\/b><\/p>\n
What are the procedures and examination techniques that will be used during the physical exam of your patient?<\/b><\/p>\n
As the first step, I will greet my patient, introduce myself, and ensure that she feels comfortable. I will assess her general appearance, including her gait, mannerisms, dress, eye contact, mood, and alertness. I will utilize a translator if necessary. Since she lives in poverty housing, it is essential to assess her hygiene and any apparent signs of distress. During the examination, it is crucial to maintain her decency and have her covered when possible. As with all patients, it is essential to remain respectful and ensure consent before examining sensitive or intimate areas. I will measure her height, weight, and vital signs, including blood pressure, pulse, respirations, and temperature. With the patient facing me, I will begin from her head to her toes. I will check her skin for abnormalities, lesions, rashes, or discolorations. I will assess her heart and blood vessels for abnormalities using auscultation, palpation, and inspection. I will also evaluate lung function through auscultation, checking for abnormal sounds or visual signs of respiratory distress as she inhales and exhales. I will palpate her abdomen, listen for bowel sounds, and assess for tenderness or masses. I will evaluate her cranial nerves, motor function, sensory function reflexes, posture, spine, and coordination. I will also assess her joint range of motion, muscle strength, and any signs of deformity or irregularity. I will also inquire about any issues with her breasts, such as masses, pain, changes to the nipple, or discharge. I will also inquire whether she does breast self-examinations and how frequently. I will inquire about her menstrual cycle and if there are any changes. <\/b><\/p>\n
Case 2: Pre-school-aged white female living in a rural community<\/b><\/p>\n
What are the barriers to interpersonal communication?<\/b><\/p>\n
A pre-school-aged white female may have limited communication skills and language due to their age, making it challenging to express thoughts, feelings, symptoms, or discomfort (Srinath et al., 2019). The child\u2019s reliance on parents or guardians as intermediaries may affect the accuracy of information relayed, as parents may interpret symptoms. The unfamiliar environment of a healthcare setting may induce fear or anxiety in the child, potentially hindering open communication. <\/b><\/p>\n
What are the procedures and examination techniques that will be used during the physical exam of your patient?<\/b><\/p>\n
Firstly, observing the child\u2019s behavior, interactions with the parents, and overall demeanor is essential to gauge their comfort level. As she is a minor, her parents or legal guardian will be present and can even assist during the assessment. Allowing the parents to hold or remain close to the child will help. Even showing and letting the child use things like the stethoscope can help alleviate anxiety. This allows the child to familiarize themselves with the environment. While obtaining vitals, one can assess the child’s ability to cooperate. Visual examination will include skin, eyes, ears, nose, and throat for any abnormalities or signs of infection. Palpation must be down gently around the abdomen to check for tenderness, organ enlargement, or any other abnormality. Growth measurements are also crucial at this age, so recording height, weight, and head circumference is essential to evaluate developmental milestones. Evaluating their gross motor skills, reflexes, and other development milestones is important to ensure they are appropriate for their age. It is also important to review and update immunizations. Encouraging parents to participate in the process and providing insight into the child’s health is also vital. <\/b><\/p>\n
Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.<\/b><\/p>\n
The S.O.A.P. approach to documenting is used to ensure comprehensive and organized patient records and to help facilitate effective communication among healthcare providers (Sapkota et al., 2022). Subjective information is provided by the patient or caregiving, including the patient identifiers, chief complaint, history of illness, past medical history, family history, social history, and the review of systems. Objective data is measurable and observable data obtained through physical examination, diagnostic tests, and vital signs. Assessment is when the healthcare provider organizes their findings from subjective and objective information, leading to a diagnosis, differential diagnosis, and sometimes, a problem list. Planning, which is the final component, involves the development of a treatment plan, including interventions, medication follow-up tests, and patient education. It also includes setting goals and evaluating progress during the following encounters.<\/b><\/p>\n
References <\/b><\/p>\n
Sapkota, B., Shrestha, R., & Giri, S. (2022). Community pharmacy-based SOAP notes documentation. Medicine, 101(30). https:\/\/doi.org\/10.1097\/MD.0000000000029495<\/b><\/p>\n
Srinath, S., Jacob, P., Sharma, E., & Gautam, A. (2019). Clinical Practice Guidelines for Assessment of Children and Adolescents. Indian Journal of Psychiatry, 61(2). https:\/\/doi.org\/10.4103\/psychiatry.IndianJPsychiatry_580_18<\/b><\/p>\n
Tan, N., & Cho, H. (2019). Cultural Appropriateness in Health Communication: A Review and a Revised Framework. Journal of Health Communication, 24(5). https:\/\/doi.org\/10.1080\/10810730.2019.1620382<\/b><\/p>\n
<\/p>\n<\/div>\n
Peer 2<\/span><\/p>\n Case Study 3: 16-year-old white pregnant teenager living in an inner-city neighborhood.<\/p>\n 1. Barriers to interpersonal communication include language barriers such as the use of medical jargon or terminology that is not easily understood by the other person can create barriers (Egede et al., 2020). The patient is 16 years old from an inner-city neighborhood, probably her first time pregnant so she will most likely have a poor comprehension of her medical treatment due to limited educational opportunities.<\/p>\n 2. During the physical examination of my pregnant patient, I would include the assessment of both mother and baby. For the mother, I would assess her general health appearance, weight, height, vital signs, mother\u2019s cervix, and nutritional intake such as prenatal vitamins and sources rich in iron and folate. For the baby, I would assess the presentation of the fetus, size of uterus, fundal height, and heart rate of the fetus.<\/p>\n 3. S: 16-year-old pregnant, white female presented today for her first antepartum visit to receive OB care. LMP unknown about 3 months ago (she believes). Patient reported being stressed out from not telling her parents and having to work full-time. Patients state no past medical history.<\/p>\n Family history: Mother had 2 pregnancies both with complications of preeclampsia which resolved after giving birth. Father and mother both have no chronic conditions.<\/p>\n Social history: Patient is single and lives at home with her mother. Father of the baby is not in the picture. She hasn\u2019t been going to school lately because of her full-time job. She does not smoke cigarettes, drink alcohol, or use illicit drugs.<\/p>\n O: Patient appears anxious as evidenced by fidgeting of hands, and untidy appearance. She is alert and oriented x 4 and answers questions appropriately. Vitals as followed, T:97.5F, P 95 bpm, R 20, BP: 143\/88, O2 95%. H: 5’6″, W: 135lb, BMI 22. <\/p>\n Skin: Appropriate for ethnicity. <\/p>\n HEENT: PERRL. Moist Mucous membranes. No lymphadenopathy, no thyromegaly.<\/p>\n Cardiac: RRR. No adventitious heart sounds. <\/p>\n Respiratory: Lungs clear on auscultation. <\/p>\n Gastrointestinal: Normal active bowel sounds in all four quadrants.<\/p>\n Musculoskeletal: Full range of motion in all extremities<\/p>\n Neuro: Strength 5\/5 bilateral upper and lower extremities. <\/p>\n Genitourinary: No dysuria, no odor, no lesions. <\/p>\n Labs\/test: Pap- Smear done in consult T&S, CBC, G\/C, RPR, Rubella, HBsAg, HIV, urine culture, HgbA1C, and stool culture (pending results)<\/p>\n A: The client appears to continue experiencing anxiety. The patient\u2019s statement of \u201cI don\u2019t know what to do with this pregnancy\u201d requires more education and recommended support groups.<\/p>\n P: Educate the patient on the importance of proper nutrition and importance of taking prenatal vitamins daily. Educate the patient to monitor her blood pressure and look out for signs and symptoms of preeclampsia. Educate the patient on the importance of all follow up visits to ensure maternal and fetal health. Refer patient to teenage pregnancy support group.<\/p>\n Case Study 3: 35-year-old transgender white male living in a homeless shelter.<\/p>\n 1. Barriers to interpersonal communication include discrimination and interpersonal rejection. Discrimination and interpersonal rejection were overwhelmingly cited as lead causes of housing insecurity (Glick et al., 2020). Homelessness and housing insecurity are associated with a range of negative health outcomes, such as barriers to health care, increased utilization of acute-care services, violence victimization, stress, substance use, difficulty securing employment, and food insecurity (Glick et al., 2020).<\/p>\n 2. During the physical examination, I will examine the patient’s genitals as well as their secondary sex traits, obtain a sexual activity history from the patient, STD testing and other blood work, and hormone testing.<\/p>\n 3. S: 35-year-old white transgender male presented today for a physical. <\/p>\n PMH: Patient had gender changing surgeries in the past.<\/p>\n Family History: Patient is estranged from mother and father, cannot give their PMH.<\/p>\n Social History: Patient is single and lives in a homeless shelter. Is sexually active and does not use protection. He smokes 1 pack of cigarettes daily, drinks occasionally, and has a history of using illicit drugs in the past.<\/p>\n O: Patient appears pleasant and untidy in appearance. Vitals signs as followed, T: 98.5F , P: 77 bpm, R: 18, BP: 123\/78. H: 5’11” W: 150lb <\/p>\n Skin: Appropriate for ethnicity. <\/p>\n HEENT: PERRL. Dry Mucous membranes. No lymphadenopathy, no thyromegaly. <\/p>\n Cardiac: RRR. No adventitious heart sounds <\/p>\n Respiratory: Bilateral lower lungs diminished on auscultation.<\/p>\n Gastrointestinal: Normal active bowel sounds in all four quadrants. Liver and spleen are not enlarged. <\/p>\n Musculoskeletal: Full range of motion in all extremities <\/p>\n Neuro: Strength 5\/5 bilateral upper and lower extremities.<\/p>\n Genitourinary: No dysuria, no odor, no lesions.<\/p>\n Labs: Blood work CBC, CMP, STD\/HIV (pending results)<\/p>\n A: Patient appears to exhibit signs of moderate depression contributed by emotional response to questions.<\/p>\n P: Referral to social worker since the patient is homeless. Educate on practice of safe sex, abstaining from drugs and alcohol use, and follow up appointments.<\/p>\n Reference<\/p>\n Egede, L. E., Walker, R. J., Campbell, J. A., Dawson, A. Z., & Davidson, T. (2020). A new paradigm for addressing health disparities in inner-city environments: Adopting a disaster zone approach. Journal of Racial and Ethnic Health Disparities, 8(3), 690\u2013697. https:\/\/doi.org\/10.1007\/s40615-020-00828-1 Links to an external site.<\/p>\n Glick, J. L., Lopez, A., Pollock, M., & Theall, K. P. (2020). Housing insecurity and intersecting social determinants of health among transgender people in the USA: A targeted ethnography. International Journal of Transgender Health, 21(3), 337\u2013349. https:\/\/doi.org\/10.1080\/26895269.2020.1780661<\/p>\n <\/span><\/span><\/div>\n<\/div>\n <\/span><\/div>\n","protected":false},"excerpt":{"rendered":" Instructions respond to at least two of your peers by extending, refuting\/correcting, or adding additional nuance to their posts. Peer 1 Case 2: 55-year-old Asian female living in a high-density poverty housing complex What are the barriers to interpersonal communication? When seeing this particular patient, it is […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","template":"","meta":[],"disciplines":[13],"paper_types":[],"tagged":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions\/4371"}],"collection":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions"}],"about":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/types\/questions"}],"author":[{"embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/comments?post=4371"}],"version-history":[{"count":0,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/questions\/4371\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/media?parent=4371"}],"wp:term":[{"taxonomy":"disciplines","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/disciplines?post=4371"},{"taxonomy":"paper_types","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/paper_types?post=4371"},{"taxonomy":"tagged","embeddable":true,"href":"https:\/\/www.writemyessays.app\/blog\/wp-json\/wp\/v2\/tagged?post=4371"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}