take on the role of a clinician who is building a health history for one of the following cases.
Case 2:
55-year-old Asian female living in a high-density poverty housing complex.
Pre-school aged white female living in a rural community.
answer the following questions:
What are the barriers to interpersonal communication?
What are the procedures and examination techniques that will be used during the physical exam of your patient?
Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.
Full Answer Section
- Poverty-Related Factors: Stress, fatigue, and lack of access to healthcare resources can affect the patient's ability to communicate effectively.
Procedures and Examination Techniques
The physical exam for this patient would likely include the following procedures and techniques:
- Vital Signs: Measurement of blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation.
- General Examination: Inspection of the patient's appearance, gait, and general health.
- Head and Neck: Examination of the head, face, eyes, ears, nose, mouth, and neck.
- Chest: Examination of the lungs and heart.
- Abdomen: Examination of the abdomen for tenderness, masses, or other abnormalities.
- Extremities: Examination of the arms and legs for swelling, redness, or other abnormalities.
- Neurological Examination: Assessment of cognitive function, motor function, and sensory function.
S.O.A.P. Approach
The S.O.A.P. approach is a structured method for documenting patient data. It involves the following components:
- Subjective: This section includes the patient's complaints, symptoms, and history.
- Objective: This section includes the findings of the physical examination, laboratory tests, and other diagnostic procedures.
- Assessment: This section is the clinician's interpretation of the subjective and objective data, including the diagnosis and assessment of the patient's condition.
- Plan: This section outlines the treatment plan, including medications, procedures, and follow-up care.
By using the S.O.A.P. approach, clinicians can ensure that patient data is documented in a clear, concise, and organized manner, facilitating communication and continuity of care.
Sample Answer
Case Analysis: 55-year-old Asian Female
Barriers to Interpersonal Communication
Given the patient's age, cultural background, and living situation, several barriers to interpersonal communication may exist:
- Language: If the patient does not speak English fluently, language barriers may hinder communication.
- Cultural Differences: Cultural differences in communication styles and expectations can create misunderstandings.
- Health Literacy: Low health literacy may make it difficult for the patient to understand medical information and ask questions.