Response to cynthia

Specific Socioeconomic, Spiritual, Lifestyle, and Other Cultural Factors Related to Patient Health

Case two involves a 32-year-old Hispanic/Latina pregnant lesbian patient. She has presented for an annual physical plus a complaint of  “vaginal discharge”. The fourth report of the U.S. Department of Health and Human Services, Healthy People 2020 presents information on the relationship between socioeconomic status, ethnicity, and health (Rhoads & Wiggins Petersen, 2021). This patient is in an ethnic and sexual lifestyle group where real or perceived healthcare discrimination can occur. The information given is based on a comprehensive health history. Certain information she gives, for example, she and her partner used a sperm bank for artificial insemination, suggests the availability of finances not indicative of lower-income status. We are not given information on the patient’s spiritual beliefs and should not make assumptions. The patient is receiving prenatal care from an Ob/Gyn. We do not know how many weeks pregnant she is and therefore do not know how long it has been between OB office visits. As a lesbian and a Hispanic, the patient could have been reluctant to bring up the vaginal discharge during her visit due to embarrassment. She does not state how long she has had the vaginal discharge.

Subjective, Objective, Assessment, and Planning (S.O.A.P.) Approach to Documentation

The SOAP note is an organized way to document the patient’s history and physical. It can be used for a focused exam or a comprehensive exam such as for a physical. In case 2, the patient presents for a physical and an additional complaint of vaginal discharge. Her subjective data Starts with her statement, “I am here for my annual physical exam and have been having vaginal discharge.” The patient then answers questions regarding the history of her chief complaint, past medical history, past surgical history, drug and supplement history, allergies, social history, family history, last menstrual period, and review of systems based on the patient’s responses. The pneumonics PQRST or CLIENT OUTCOMES can be used to direct the subjective data collection. Precipitating factors, quality, radiation, severity, and timing are the symptoms covered by the first pneumonic. Character, location, impact, expectation, neglect/abuse, timing, other symptoms, understanding of illness, treatment, complementary, options, modulating factors, exposure to infections/toxins, and spirituality are the latter pneumonic factors (Rhoads & Wiggins Petersen, 2021). This case patient presented for an annual exam and a single complaint. The review of systems is sparse.

Objective data is assessed next. The review of systems was sparse. Objective data is obtained by the practitioner’s exam and tests performed at the visit. If there is no documentation on a body system, it is assumed it was not assessed. In a focused exam, the general,