Religious, Cultural, Spiritual Beliefs, History Taking, Physical Exam, & Documentation Strategies
This paper examines Case 2: an adolescent Hispanic/Latino boy living in a middle-class suburb, focusing on barriers to interpersonal communication, physical examination procedures, and documentation strategies using the SOAP approach.
Barriers to Interpersonal Communication
Several potential barriers may impact effective communication with an adolescent Hispanic/Latino male patient. Language differences could pose a significant challenge if the patient’s primary language is Spanish and the healthcare provider is not fluent (Diamond et al., 2019). Even if the patient speaks English, cultural nuances and idioms may lead to misunderstandings. Additionally, adolescents often experience heightened self-consciousness and may be reluctant to discuss sensitive health topics, particularly with an adult authority figure (Radovic et al., 2018).
Cultural factors may also influence communication. Hispanic/Latino cultures often emphasize respect for authority figures, which could make the patient hesitant to ask questions or express concerns openly. Furthermore, traditional gender roles and expectations within some Hispanic/Latino families might affect how the adolescent male patient interacts with healthcare providers, especially regarding topics related to sexual health or emotional well-being (Diamond et al., 2019).
The suburban middle-class setting may introduce its own set of communication barriers. Assumptions about the patient’s socioeconomic status or access to healthcare resources could lead to misunderstandings or oversights in care. Moreover, the patient may feel pressure to conform to perceived middle-class health norms, potentially leading to underreporting of health issues or behaviors that deviate from these expectations.
Procedures and Examination Techniques
Physical examination of an adolescent Hispanic/Latino male should be conducted with sensitivity to cultural norms and the patient’s comfort level. The examination would typically include:
Vital signs measurement: blood pressure, heart rate, respiratory rate, and temperature.
Height and weight assessment, including calculation of body mass index (BMI).
Head-to-toe examination, including:Eye examination for visual acuity and overall eye health
Ear, nose, and throat inspection
Cardiovascular assessment, including heart sounds and peripheral pulses
Respiratory examination, including lung sounds
Abdominal palpation and auscultation
Musculoskeletal assessment, including posture and range of motion
Neurological examination, including reflexes and sensory function
Skin inspection for any abnormalities or signs of skin conditions common in Hispanic/Latino populations
Pubertal development assessment using Tanner staging, conducted with appropriate privacy and explanation.
Screening for common health issues in Hispanic/Latino adolescents, such as obesity, type 2 diabetes, and hypertension (Velasco-Mondragon et al., 2016).
Throughout the examination, it is crucial to explain each step clearly, obtain ongoing consent, and respect the patient’s privacy and cultural beliefs.
SOAP Approach for Documenting Patient Data
The SOAP (Subjective, Objective, Assessment, Plan) approach is a widely used method for organizing and documenting patient information in clinical settings. Each component serves a specific purpose in creating a comprehensive patient record:
Subjective (S): This section includes information provided by the patient or their family members. It encompasses the patient’s chief complaint, history of present illness, past medical history, family history, social history, and review of systems. For the adolescent Hispanic/Latino male, this might include any symptoms he reports, his daily activities, diet, exercise habits, and any cultural or family-specific health practices.
Objective (O): This part contains observable and measurable data collected during the physical examination and through diagnostic tests. It includes vital signs, physical examination findings, laboratory results, and imaging studies. For this patient, it would encompass the findings from the previously described physical examination procedures.
Assessment (A): In this section, the healthcare provider synthesizes the subjective and objective data to formulate a diagnosis or differential diagnoses. It may also include an evaluation of the patient’s overall health status and any identified risk factors. For the adolescent patient, this might involve assessing his growth and development, considering potential health risks related to his cultural background, and evaluating any acute or chronic health issues.
Plan (P): The final section outlines the treatment plan, including medications, further diagnostic tests, referrals to specialists, patient education, and follow-up arrangements. For this adolescent patient, the plan might include recommendations for diet and exercise, vaccinations, screening tests, and strategies to address any identified health concerns while considering cultural factors that may influence adherence to the plan.
The SOAP approach provides a structured format for documenting patient encounters, ensuring comprehensive and consistent recording of essential information. It facilitates clear communication among healthcare providers and supports continuity of care (Sprouse, 2020).
In conclusion, effective communication, culturally sensitive physical examination, and thorough documentation using the SOAP approach are crucial elements in providing high-quality care to an adolescent Hispanic/Latino male patient. By addressing potential barriers, tailoring examination techniques, and maintaining detailed records, healthcare providers can ensure comprehensive and culturally competent care for this patient population.
References:
Diamond, L., Izquierdo, K., Canfield, D., Matsoukas, K., & Gany, F. (2019). A systematic review of the impact of patient-physician non-English language concordance on quality of care and outcomes. Journal of General Internal Medicine, 34(8), 1591-1606.
Jason, K., Wilson, M., Catoe, J., Brown, C., & Gonzalez, M. (2024). The impact of the COVID-19 pandemic on Black and Hispanic Americans’ work outcomes: A scoping review. Journal of Racial and Ethnic Health Disparities, 11(3), 1157-1172.
Radovic, A., McCarty, C. A., Katzman, K., & Richardson, L. P. (2018). Adolescents’ perspectives on using technology for health: Qualitative study. JMIR Pediatrics and Parenting, 1(1), e2.
Sprouse, M. (2020). SOAP notes: What are they and how do you write them? The Journal for Nurse Practitioners, 16(6), 435-438.
Quigley, D. D., Qureshi, N., Predmore, Z., Diaz, Y., & Hays, R. D. (2024). Is Primary Care Patient Experience Associated with Provider-Patient Language Concordance and Use of Interpreters for Spanish-preferring Patients: A Systematic Literature Review. Journal of Racial and Ethnic Health Disparities, 1-14.
Quayle, E., Larkin, A., Schwannauer, M., Varese, F., Cartwright, K., Chitsabesan, P., … & Bucci, S. (2024). Experiences of a digital health intervention for young people exposed to technology assisted sexual abuse: a qualitative study. BMC psychiatry, 24(1), 237.
Velasco-Mondragon, E., Jimenez, A., Palladino-Davis, A. G., Davis, D., & Escamilla-Cejudo, J. A. (2016). Hispanic health in the USA: A scoping review of the literature. Public Health Reviews, 37, 31.
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Religious, Cultural, Spiritual Beliefs, History Taking, Physical Exam, &
Documentation Strategies
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.
Case 1 Case 2 Case 3 • 76-year-old Black/African-American male with disabilities living in an urban setting. • Adolescent Hispanic/Latino boy living in a middle-class suburb • 55-year-old Asian female living in a high-density poverty housing complex. • Pre-school aged white female living in a rural community. • 16-year-old white pregnant teenager living in an inner-city neighborhood. • 35-year-old transgender white male living in a homeless shelter.
Once you received your case number, answer the following questions:
1. What are the barriers to interpersonal communication? 2. What are the procedures and examination techniques that will be used during the physical exam of your patient? 3. Describe the Subjective, Objective, Assessment, Planning (S.O.A.P.) approach for documenting patient data and explain what they are.
Submission Instructions:
• Your instructor will assign you your case number and you will post on the case number you have been assigned. • You will reply to the other two case studies (One of each). • Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
