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Discussion replies should at least 200 words, formatted, and cited in current APA style with support from at least 1 academic sources. No AI please. Incorporate a minimum of 1 current (published within the five years) scholarly journal articles. Journal articles should be referenced according to the current APA style. I have attached the discussion below.
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Debra Discussion Reply 1
Barriers to Interpersonal Communication
A patient’s health history is important in making decisions pertaining to the patient’s
health. A health history helps the clinical team to understand the risks that the patient
faces and how these risks can be managed. Communication is essential when building a
patient’s health history (Arnold & Boggs, 2019). A clinician must communicate with
patient through asking questions to build the patient’s health history. When
communicating with patients, it is imperative to note that a clinician must consider the
patient’s profile. This is to enable the clinician to navigate the barriers to interpersonal
communication that can impede upon the communication process. In the case of the 16year-old pregnant white girl, it is important to note that teenagers may have challenges
opening up, especially when in front of their parents. Giving a teenager privacy or building
rapport can ensure that the teenager opens up (Arnold & Boggs, 2019). Also, it is
important to use easy to understand vocabulary considering the patient’s background. In
the case of the 35-year-old transgender, one of the barriers to effective communication is
the use or improper terminologies vocabulary, or pronouns. When clinicians use pronouns
that the patient feels do not represent them, a transgender patient is most likely to
distrust the clinician. This can lead to poor history taking.
Techniques and Procedures for Physical Examination
Physical examination is an important pillar in the diagnosis of illnesses or identifying
risks for illnesses. In a pregnant teenager, physical examination is undertaken to check the
health of the expectant mother and that of the fetus. General physical examination entails
checking the mother’s blood pressure, weight, and body mass index (Jarvis, 2019). These
are important indications of possible complications to the pregnancy. The fetal heart rate
is also taken during the physical examination to assess the development of the fetus. Also,
an obstetric examination is undertaken. The obstetric examination focuses on the
presence of discharge or lesions, and the color as well as the consistency of the cervix. For
a 35-year-old transgender patient, it is imperative to note that certain body areas and
systems may be sensitive to the patient. As such, undertaking exams such as rectal
examination, genital, and breast exam should be approached with caution after discussing
with the patient. In most cases, these systems are examined based on the patient’s health
promotion needs or the individual risks that the patient presents with (Jarvis, 2019).
SOAP Approach to Documenting Patient Data
The subjective, objective, assessment, and plan (SOAP) format is a common modern
approach to documenting patient medical information and encounter in a structured and
easy to understand way. The subjective section of the SOAP identifies the patient’s
medical information from the patient’s perspective (Schloss & Konam, 2020). These
include the reason the patient has sought medical attention or the chief complaint. It also
includes information such as the history of the presenting illnesses including the
symptoms that the patient is experiencing. The patient’s past medical history, social
history, and family history is also part of the subjective information. Lastly, the patient
also reviews each body systems and presents any symptoms that they experience in each
system. Objective data includes the information collected by the clinician during the
physical examination. They include vital signs such as blood pressure, temperature, heart
rate, and blood rate (Schloss & Konam, 2020). The objective data also include information
the clinician collects after examining each body system. The assessment section of the
SOAP includes the list of differential diagnoses as supported by the subjective and
objective data. It also includes the presumptive diagnosis. The plan section includes the
diagnostic tests such as imaging and laboratory tests to be ordered based on the patient’s
symptoms. It also includes the pharmacological and non-pharmacological agents for the
management of the presumptive condition.
References
Arnold, E. C., & Boggs, K. U. (2019). Interpersonal relationships e-book: professional
communication skills for nurses. Elsevier Health Sciences.
Jarvis, C. (2019). Physical Examination and Health Assessment E-Book. Elsevier Health
Sciences.
Schloss, B., & Konam, S. (2020, September). Towards an automated SOAP note: classifying
utterances from medical conversations. In Machine Learning for Healthcare Conference (pp.
610-631). PMLR.
Roxana Discussion Reply 2
Case study 2 presents two patients: a 55-year-old Asian female living in a highdensity poverty housing complex and a pre-school-aged white female living in a rural
community. When collecting health history of any patient, it is imperative to note that
there are several barriers which can negatively affect communication between a clinician
and the patient. These may be because of factors such as age, culture, and language
barrier. In case of the 2nd patient, for instance, a pre-school child may not be able to
communicate in an effective way and present their health history in a comprehensive
manner. In such cases, the clinician may rely on the child’s guardian or parent to collect a
comprehensive history of the child. For the first patient, factors such as the patient’s
culture and background must be considered. For instance, Asians are reserved and like to
be formal when interacting with individuals that they are not familiar with (Jarvis, 2023).
It is until an Asian patient establishes a trusting relationship with their provider will they
be able to open up about their personal health information. It is important to note that
Asian patients tend to respond with ‘no’ in many questions when they are no familiar to a
provider. This can be misleading and can lead to poor history taking. The clinician must,
therefore, strive to build a trusting relationship with the patient to facilitate the process of
collecting information from the patient. This can be essential in ensuring that the clinician
makes appropriate decisions regarding the care their deliver to the patient.
When undertaking a comprehensive physical examination, it is imperative to
understand the difference in patients. Cultural differences may require a different
approach when physically examining a patient. For instance, when assessing an Asian
patient, it is important to seek for express permission from the patient before
commencing the head-to-toe assessment. Among Asians, the head is considered to be
sacred (Jarvis, 2023). The clinician must, therefore, explain to the patient why they need
to undertake an examination of the head or before touching the head. In a similar fashion,
as the feet touch the ground, they are considered dirty, and, as such, an Asian patient may
not be open to the clinician touching their feet. Examination methods such as inspection
can come in handy in such a situation if the patient is not open to other physical
assessment even after the clinician has explained the importance of such test. When
examining the pre-school child, it is important to make sure that she is comfortable.
Physical examination can be uncomfortable to children. Examining the patient while she is
on her parent’s lab can help with the process of examination. In addition, letting the child
play with the stethoscope can help in improving cooperation.
The SOAP format is used in documenting patient’s medical information from the
clinical issue that the patient presents with to the plan of care. The clinician starts with the
subjective data which captures the patient’s complains in their own words. This section of
the documentation also capture information such as medical and surgical history, and the
patient’s social history (Sudarsan et al., 2021). The objective section of the documentation
captures the results of the physical examination for the body systems and vital signs as
undertaken by the clinician. The assessment data includes the analysis of the objective
and the subjective data. It can include items such as the differential diagnosis. Lastly, the
plan section of the documentation include information such as the pharmacological and
the non-pharmacological interventions.
Reference
Jarvis, C. (2023). Physical examination and health assessment-Canadian E-book. Elsevier
Health Sciences.
Sudarsan, P., Balakrishna, A. G. M., Asir, J. A. R., Balu, D., Krishnamoorthy, S. G., & Borra, S.
S. (2021). Development and validation of A-SOAP notes: Assessment of efficiency in
documenting patient therapeutic records. Journal of Applied Pharmaceutical
Science, 11(10), 001-006.
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