SOAP Note: Patient in Immigrant Status

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.

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.

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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.

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.

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