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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, respiratory and cardiac systems are done (Rhoads & Wiggins Petersen, 2021). The objective data for case 2 is relatively complete except for her general data and appearance and her musculoskeletal condition. The exam seems thorough and addresses her concern about the vaginal discharge.
Assessment findings combine the subjective data and objective data to formulate a new diagnosis/support a previous diagnosis, develop differential diagnoses, and make a problem list (Rhoads & Wiggins Petersen, 2021). On this patient’s problem list is bacterial vaginosis (BV) in pregnancy (Uddin, et al., 2020).
The plan has five components. Nonpharmacologic, pharmacologic, and education interventions need to be presented. The plan should be discussed with the patient, and significant other if needed, and state a follow-up time. If a referral is required, this should be discussed and set up. All of these steps must be documented. The patient in case 2 needs treatment with metronidazole 2grams. It is important to educate the patient on the origins, treatment, and risks of BV in pregnancy. She can be told BV is not uncommon in childbearing-age women. It is an imbalance of vaginal flora and the presence of certain bacteria that cause an increase in mucous production and the “fishy” smell. BV can cause a two-fold increase in preterm birth and low birthweight babies. It is vital to take the medication and then follow up in the clinic or with her OB. BV can be present without detection for some time (Chaponda, et al., 2021). In my personal 28 years as a high-risk labor and delivery nurse, BV often causes uterine irritability, i.e. cramping. The patient should look for signs of cramping and low back pain as a sign for immediate care. Wear loose clothing and cotton panties. She can also take a probiotic to add lactobacillus back to the vaginal flora. Metronidazole can cause nausea, so eat something bland like toast with it. No referral is needed at this time.
Functional Anatomy and Physiology of a Psychiatric Mental Health Patient
The cerebrum of the brain is where our higher mental functions occur. The cerebrum has lobes each providing physiologic or behavioral responses to stimuli. The frontal lobe conducts voluntary movement and speech. It also processes affect, drives, and awareness of self. The parietal lobe interprets sensory data, provides comprehension of written language, and gives proprioception. The temporal lobe interprets sound and locates its source. Within the temporal lobe is the Wernicke area, where written and spoken language is comprehended. The temporal lobe is an integration center for the senses and assists with balance. It additionally integrates behavior, emotions, and personality. The occipital lobe processes and interprets vision-related stimuli. One of the most important areas of the brain for mental health is the limbic system. This is the center for fear, aggression, mating, and short-term memory. The nurse practitioner must know what behaviors indicate neurologic disorder, physical/organic disorder resulting in change in mentation, developmental delays, or mental illness. She must know which health problems may be an indicator of mental illness. Additionally, family history, seasons of life, age, pregnancy, religion, and culture all affect how mental illness may present (Rhoads & Wiggins Petersen, 2021).
Chaponda, E. B., Bruce, J., Michelo, C., Chandramohan, D., & Chico, R. M. (2021). Assessment of syndromic management of curable sexually transmitted and reproductive tract infections among pregnant women: An observational cross-sectional study. BMC Pregnancy & Childbirth, 21(1), 1-10. https://doi.org/ (Links to an external site.)
Rhoads, J., & Wiggins Petersen, S. (2021). Advanced health assessment and diagnostic reasoning (4th ed.). Jones & Bartlett Learning.
Uddin, F., Zeeshan, F., Younus, R., Yasmin, H., Bugti, S., & Hassan, A. (2020). Prevalence of bacterial vaginosis in females of child-bearing age and utility of pH and whiff test in diagnosis. Journal of Rawalpindi Medical College, 24(1), 51-56. https://doi.org/ (Links to an external site.)