SOAP Note: Patient in Immigrant Status

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SOAP Note: Patient in Immigrant Status
29.12.2021
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SOAP Note

1. Life Style Patterns

a. Immigrant status. The immigrant status of the patient affects her well-being strongly. The major reason for it is connected with the dramatically increased nostalgia for the motherland that has started in the recent course of time and provokes occasional headaches based on negative emotions and distressing memories. On the other hand, the neighbors treat the patient respectfully and properly regardless of her immigrant status. Hence, this aspect does not affect the condition of the patient’s health.

b. Spiritual resources/religion. The patient is a devoted and faithful Catholic. Religion plays a crucial role in her life, as she attends church services regularly. The faith is great support for her during hard times in life.

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c. Health perception. The patient demonstrates a slightly negative perception of her own health condition. To be more precise, she claims that she has serious problems with her health and suffers from them every day, but they are not unbearable. That is why she attends the hospital and seeks the doctors’ advice only in cases the ache or other problem is prolonged or intensified.

d. Nutritional patterns: Appetite (any changes); satisfaction with the current weight; gains or losses; recall of usual intake; any cultural restrictions/intolerances; amount of fluid per day and type.

Nutritional patterns are stable and have not altered significantly since the patient’s youth. She is not satisfied with her weight and has never been before. The overweight and increased appetite are constant. There are no restrictions in the patient’s nutritional list.

e. Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinence.

The patient claims she experiences the change of the bowel habits occasionally. Moreover, there are often bowel sounds after the meal according to the patient’s description, and she feels heaviness and essential discomfort. The bladder’s habits are also changed particularly.

f. Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxins

North Miami is a suburban city. The ecological situation within the territory of Miami is known for a strong effect of the most serious and threatening environmental factors. These factors include excessive traffic and dangerous emissions in huge quantities on the daily basis. Besides, the patient lives in the city district where these emissions are considered to be the most threatening and huge.

g. Occupational health: Known exposure to environmental toxins at work

The patient is retired. Hence, there are no potential health risks at the working place. Moreover, the patient worked as a professor earlier. Therefore, the toxins and threats at the working place may be excluded.

h. Functional assessment: ADLs, IADLs, interpersonal relationships/resources

The patient claims that she is very active, but it is a relative statement. To be more precise, the examples of the activities of daily living mentioned by her include walking for 30 minutes in the evening, whereas the majority of the day is spent watching TV shows, reading sometimes, and meeting friends. Caring activities such as bathing, dressing, toileting, brushing teeth, and eating are performed properly and timely.

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The instrumental activities of daily living are partially fulfilled. The patient does not drive and does not use a personal computer at all. The pone is used, but not often. She manages medication, and shopping is done once per week when the patient and three of her friends go together to the market. The finances are managed by her son. The interpersonal relations are quite close and supportive with those three friends, whereas the patient is also a respected and amiable member of the church community.

i. Role and family relationships: Immediate family composition; how are family decisions made; the impact of family member’s health on family

The patient has three children, namely, two sons and a daughter. All the children live separately, each in another city. They rarely visit their mother, but when they do, they tend to stay for a week or even a month. Moreover, the daughter is the one who visits the patient most often of all and calls her every day. The decisions in the family are made by all the members contributing to the general discussion and figuring out the optimal solution. There is no impact of family members’ health on the family in general.

j. Cognitive function: Memory; speech; judgment; senses

Memory is excellent; this aspect is confirmed even by the patient’s close friends. Speech is also precise and proper. Judgment is adequate, but the senses reveal the negative and strong impact of the aging process.

k. Rest/sleep patterns: Number of hours; naps; a number of pillows; any aids for sleep

There are no complaints concerning rest or sleep patterns. The patient sleeps seven hours per day regularly. There is one hour nap in the afternoon. The patient uses one firm pillow. No aids for sleep are needed.

l. Exercise patterns: Type and frequency

The patient adheres to no exercise patterns except for the walking activity.

m. Hobbies/recreation: Leisure activities; any travel outside of the US

No hobbies. The patient attends church regularly. She watches particular shows and soap operas every day. No traveling experience.

n. Social habits: Tobacco; alcohol; street drug use

No social habits. The patient has never smoked or used alcohol. There were also no problems with drug abuse.

o. Intimate partner violence.

There is no partner since the patient is divorced. No violence happened during marital life.

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p. Coping/stress management: Any major life change in the past 2 years; do you feel tense; source; what helps.

The patient has no serious or meaningful changes in life now, neither had she in the past two years. Stress is treated my tasty meal and the whole day at home watching favorite films.

q. Sexual patterns: Are you sexually active; gender preference; has anything changed about your sexual health/function.

The patient is not sexually active.

2. Review of Systems

Symptoms to Inquire About

 

Document pertinent negatives and/or positives

The first system is addressed to provide a guide

General Wgt ?; weakness; fatigue; fevers

 

Pertinent positives: Overweight; weakness is often observed;

Negatives: no significant fatigue or fevers.

Skin Rash; lumps; sores; itching; dryness; color change; ? in hair/nails Positives: dryness of the skin is constantly observed. It becomes especially strong after hand washing and during the winter season.

Negatives: no rash; lumps; sores; itching. Hair is thinning slightly, but the nails are firm. No color change of the patient’s complexion.

Head Headache; head injury; dizziness or vertigo Positives: headaches; dizziness to a certain extent.
Eyes

 

Vision ?; eye pain, redness or swelling; corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; Positives: vision has significantly worsened during the last several years. Headaches are often accompanied by pain in the eyes and their redness. The patient has no lenses but puts on spectacles while watching TV or reading.

The last eyes examination was conducted four years ago.

Ears Hearing ?; tinnitus; earaches; infections; discharge; hearing loss; hearing aid use Positives: hearing is worsening, but the progress is not as serious as in the case of eyesight.

Negatives: no infections connected with the hearing capability.

Nose/

Sinuses

Colds; congestion; nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds; change in sense of smell; sinus pain Positives: the patient claims that she usually catches a cold several times during the autumn and even more during the cold season. Moreover, it is hard to cure them since they almost always have some complications. Furthermore, nose-bleeding is often. It is intense and hard to be stopped.
Throat/

Mouth

Bleeding gums; mouth pain, toothache; lesions in mouth or tongue; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste Toothache is a rare experience for the patient.

Negatives: no problems with the mouth cave. The patient visits a dentist for examination regularly.

Neck Lumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motion Negatives: no problematic areas or threatening aspects detected.
Breasts Lumps; pain; discomfort; nipple discharge; rash; surgeries; history of breast disease; performs self-breast exams and how often; last mammogram; any tenderness, lumps, swelling, or rash of axilla area Positives: discomfort is the only thing the patient complains about.
Pulmonary Cough — productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last chest x-ray, TB skin test No pulmonary complaints or observations.
Cardiac Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema; cyanosis, nocturia; H/O murmurs; hypertension; anemia; CAD Positives: chest discomfort.
G/I Appetite ?; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; ? in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance Positives: appetite is excessive. The patient suffers from heartburn almost every day; sometimes she has bowel habits changes, diarrhea, and bowel sounds.
GU Frequency; nocturia; urgency; dysuria; hematuria; incontinence

Females: Use of kegel exercises after childbirth; use of birth control methods; HIV exposure; menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps menopause; hot flashes; postmenopausal bleeding;

Males: Caliber of the urinary stream; hesitancy; dribbling; hernia, sexual habits, interest, function, satisfaction; discharge from or sores on the penis; HIV exposure; testicular pain/masses; testicular exam and how often

No symptoms and no items’ use.
Peripheral Vascular Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots; discoloration of hands; ulcers Positives: numbness is a rare case, but happens. Also, the problem is connected with varicose veins.
Musculoskeletal Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease Positives: occasional pain in joints during the day and especially in the evening. The patient is capable to move properly, but limits this activity purposefully.
Neuro Syncope; seizures; weakness; paralysis; stroke; numbness/tingling; tremors or tics; involuntary movements; coordination problems; memory disorder or mood change; H/O mental disorders or hallucinations No complaints.
Heme Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation Negatives: easy bruising; it is hard to stop bleeding.
Endo Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size; H/O diabetes; thyroid disease; hormone replacement; abnormal hair distribution Positives: excessive sweating is observed when walking.
Psych Nervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses No complaints or inclinations were detected.
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