Student one

McCullough, Lindsay
Monday17 Oct at 22:57
Manage discussion entry

Module 1 Discussion: Case 2

1. What are the barriers to interpersonal communication?

Barriers in interpersonal communication hinders you from communicating with the patient

and discourages patients from communicating with you. Negative attitudes towards healthcare

providers can elicit barriers to interpersonal communication. Initial encounters with patients who

may be angry, or hostile can challenge the provider-patient relationship. A language or cultural

barrier may be present with the 55-year-old Asian female patient. For example, differences in

providers and patients’ cultural backgrounds and beliefs have been identified as barriers to

interpersonal communication and care (Kwame & Petrucka, 2021).

2. What are the procedures and examination techniques that will be used during the physical

exam of your patient?

The physical exam is completed through the collection of objective data regarding the

patient’s health using your senses of sight, hearing, touch, and smell. It is essential to realize a

patient’s history both complements and validates the physical exam and provides clues to guide

you through the examination process (Rhoads & Petersen, 2021). The history and physical exam

provide the foundation of the patient’s treatment plan. Gaining patient trust and confidence is

vital for obtaining an accurate history and physical exam. There are two types of physical exams

these include a comprehensive exam and a focused exam. A comprehensive exam is a head-to-

toe exam that is performed on all nonemergent new patients who are receiving ongoing primary

care. The focused exam is performed in emergency situations if a patient presents with a specific

problem-orientated complaint. Assessment techniques include inspection, palpation, percussion,

Palpation requires touch to collect data and is characterized as light, moderate, or deep. Palpation

determines characteristics such as temperature, texture, tenderness, and sensation (Rhoads &

Petersen, 2021). Palpation gives you information about internal characteristics. Percussion uses

tapping to assess underlying structures. It establishes location, size, density, and reflex.

Percussion sounds are described as either tympanic, hyper-resonant, resonant, dull, or flat

(Rhoads & Petersen, 2021). Auscultation listens to body sounds using a stethoscope and is

essential for assessing the lungs, heart, and abdomen. When assessing an Asian female patient

living in poverty it is essential to consider their ability to deal with daily demands of life, level of

instruction you can provide, and ability of the patient to comply with the management plan. In

the pediatric population it is important to remember children are unpredictable and you must

establish comfort prior to the exam. Pediatric patients living in rural areas should be especially

assessed for risk of obesity. A study conducted showed pediatric obesity was higher among those

living in rural areas than urban areas (Harrington et al., 2020).

3. Describe the subjective, objective, assessment, planning (SOAP) approach for documenting

patient data and explain what they are.

Providers commonly use the subjective data, objective data, assessment, and plan (SOAP)

format when documenting a history and physical. The subjective section includes information or

facts that the patient presents or that the chart provides. Sections within subjective data section

include chief complaint, history of present illness, past medical history, medications, allergies,

last menstrual period, family history, social history, nutritional assessment, and review of the

systems (Rhoads & Petersen, 2021). The objective section is data and information obtained by

the provider with their eyes, ears, and hands. Lab findings and diagnostic test results obtained at

the time of the exam or immediately afterwards are recorded in the objective section. Assessment

pulls the findings presented in the subjective and objective sections to form a diagnosis (Rhoads
 & Petersen, 2021). The plan outlines the treatment plan related to the chief complaint, current

comorbidities, and or other problems that have become evident during the exam.  

References 

Harrington, R. A., Califf, R. M., Balamurugan, A., Brown, N., Benjamin, R. M., Braund, W. E.,

Hipp, J., Konig, M., Sanchez, E., & Maddox, K. E. (2020). Call to action: Rural health: A

presidential advisory from the American heart association and American stroke

association. Circulation, 141(10), 615-644.https://doi.org/10.1161/CIR.0000000000000753Links

to an external site.

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and

communication in nurse-patient interactions: barriers, facilitators, and the way forward. BMC

Nursing, 20(158). https://doi.org/10.1186/s12912-021-00684-2

Rhoads, J., & Petersen, S. W. (2021). Advanced health assessment and diagnostic reasoning (4th ed.).

Jones and Bartlett Learning. https://bookshelf.vitalsource.com/books/9781284207088

Student two

Alcime, Queennie
Yesterday20 Oct at 0:58
Manage discussion entry

Case #1 Physical Exam, & Documentation Strategies

What are the barriers to interpersonal communication?

The interpersonal communication barriers in the situation can be the patient's age, race, the

patient's disability, and location (Johnson & Richard-Eaglin, 2020). An example of how the
patient’s age may be a barrier is with the 76-year-old black African-American his age can be a

barrier because he may have difficulty hearing or understanding what is being said. As well as

the adolescent who may not be comfortable opening up about health concerns. In both cases, the

patient's race may be a barrier to communication because they may feel uncomfortable

communicating with people of different races/backgrounds. The adolescent Hispanic/Latino

might be more comfortable speaking in Spanish, which is something to consider when

communicating with patients whose first language might have not been English. Also, the

patient’s location may be a barrier to communication because they might not have access to

transportation to get to the doctor's office or hospital. 

What are the procedures and examination techniques that will be used during the physical

exam of your patient?

The examination techniques that I would use for both of these patients in a physical exam

would start off with inspection that’s where I would visually inspect the patient’s body for any

obvious abnormalities, then palpation that’s where I will use my hands to fill for any

abnormalities in the patient’s body, next percussion where I will use my fingers to tap on the

patient’s body to assess the underlying structures, thereafter, auscultation where I will use my

stethoscope to listen to the heart lungs and other organs for any abnormalities. I will also assess

their range of motion to see the patient’s ability to move their joints and muscles and I will also

assess their neurological state, this is where I assess the patient’s reflexes, muscle strength, and

sensation (Bradley et al., 2021). All of these are what usually takes place during a physical

examination along with taking patient vital signs, more additional tests and examination

techniques may be required depending on the patient’s specific needs. 

Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for

documenting patient data and explain what they are.

care while documenting patient data, this method is the most commonly used by medical

providers to document patients' notes in medical records (Andrus et al., 2018). The subjective

portion of the SOAP approach includes the patient's symptoms and complaints. This information

is gathered through the patient's self-report and/or from family members or other caregivers. The

objective portion of the SOAP approach includes the clinician's observations of the patient. This

information is gathered through physical examination, laboratory testing, and/or imaging studies.

The assessment portion of the SOAP approach includes the clinician's interpretation of the data

and the formulation of a plan of care. This information is used to determine the diagnosis and to

develop a treatment plan. Lastly, the planning portion of the SOAP approach includes the

implementation of the plan of care and the monitoring of the patient's progress. This information

is used to ensure that the patient's symptoms are improving and that the treatment plan is

working.

References

Andrus, M. R., McDonough, S. L., Kelley, K. W., Stamm, P. L., McCoy, E. K., Lisenby, K. M.,

Whitley, H. P., Slater, N., Carroll, D. G., Hester, E. K., Helmer, A. M., Jackson, C. W., & Byrd,

D. C. (2018). Development and validation of a rubric to evaluate diabetes soap note writing in

APPE. American Journal of Pharmaceutical Education, 82(9), 6725.

https://doi.org/10.5688/ajpe6725

Bradley, C. L., Wieder, K., & Schwartz, S. E. (2021). Shifting from soap notes to consult notes for

clinical documentation by Pharmacy Students. American Journal of Pharmaceutical

Education, 86(7), 8781. https://doi.org/10.5688/ajpe8781

Johnson, R., & Richard-Eaglin, A. (2020). Combining soap notes with guided reflection to address

implicit bias in health care. Journal of Nursing Education, 59(1), 59–59.

https://doi.org/10.3928/01484834-20191223-16