Use the following case to complete a focused SOAP note. Ask questions regarding social determinants of health and include within your SOAP note and plan. Incorporate answers to the questions into your SOAP write up.

 

A mother brings in her 14-year-old son, Branch, into the Urgent Care because he has had a nosebleed. She is concerned about it because they have been applying pressure by pinching it and the nosebleed won’t stop. He has no history of nosebleeds. He has no significant medical history and no known allergies. He is on no medications. Mom and Branch deny trauma to the nose. He says he just woke up with a nosebleed and it won’t stop. He tells you that the left side is the side that is bleeding. With further questions you learn that they took the bus to the UC and that Branch must walk to and from school. His mother expresses concern that he must walk alone in their neighborhood. She works as a cashier in a super market near their apartment. She tells you that Branch gets really good grades in school. He studies after school until she arrives when they have dinner. Both are upset about the nosebleed worrying also because they have no insurance. They seem very close as a family.

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