Key Information to Gather for SOAP Note in Pediatric Allergic Reaction Case
For a 3-year-old presenting with periorbital swelling and rash who received epinephrine, a thorough SOAP note requires specific information about the allergic reaction, treatment, and follow-up plan. 1
Subjective Information to Collect
History of Present Illness
- Exact timing of symptom onset
- Progression of symptoms (how quickly did swelling/rash develop)
- Description of rash (location, appearance, spread)
- Description of eye swelling (unilateral vs bilateral, degree of swelling)
- Associated symptoms:
- Respiratory symptoms (wheezing, coughing, difficulty breathing)
- Gastrointestinal symptoms (nausea, vomiting, abdominal pain)
- Cardiovascular symptoms (dizziness, syncope)
- Skin symptoms beyond the eye area (hives elsewhere, flushing)
- Timing of epinephrine administration relative to symptom onset
- Response to epinephrine (time to improvement, completeness of resolution)
Exposure History
- Potential triggers immediately before reaction:
- Foods consumed in the past 1-2 hours
- New medications
- Insect stings/bites
- Environmental exposures (new detergents, soaps, etc.)
- Recent changes in diet or environment
Past Medical History
- Previous allergic reactions or anaphylaxis
- Known allergies (food, medication, environmental)
- History of atopic conditions (eczema, asthma, allergic rhinitis)
- Current medications and recent medication changes
Family History
- Family history of allergies, anaphylaxis, or atopic conditions
Objective Information to Document
Vital Signs
- Complete set of vital signs (temperature, heart rate, respiratory rate, blood pressure, oxygen saturation)
- Weight (important for medication dosing)
Physical Examination
- General appearance and level of distress
- Detailed skin examination:
- Distribution and characteristics of rash
- Presence of urticaria, angioedema
- HEENT examination:
- Degree and location of periorbital edema
- Conjunctival involvement
- Oral mucosa and tongue examination for swelling
- Respiratory examination:
- Work of breathing
- Presence of stridor, wheezing, or decreased breath sounds
- Cardiovascular examination:
- Heart sounds, rhythm, capillary refill
- Abdominal examination
- Neurological status
Medication Administration
- Exact dose of epinephrine administered
- Route of administration (typically IM in lateral thigh)
- Time of administration
- Number of doses if multiple were required
Assessment Components
- Severity classification of the reaction (using World Allergy Organization Subcutaneous Systemic Reaction Grading System) 2
- Determination if this was anaphylaxis based on clinical criteria
- Suspected trigger(s) if identifiable
- Response to treatment
Plan Elements to Document
Immediate Management
- Additional medications administered (antihistamines, steroids, etc.)
- IV fluids if administered
- Observation period details (duration planned based on severity)
Discharge Planning
- Prescription for epinephrine auto-injector (typically 2 doses) 2
- Patient/family education on:
- Proper use of epinephrine auto-injector
- Recognition of future allergic reactions
- When to use epinephrine and when to call emergency services
- Avoidance strategies for identified or suspected triggers
Follow-up
- Referral to allergist/immunologist for further evaluation 2
- Timeline for follow-up (typically within 1-2 weeks)
- Instructions for symptom recurrence (biphasic reactions can occur up to 72 hours later) 1
Important Documentation Pitfalls to Avoid
- Failing to document the exact timing of symptom onset, epinephrine administration, and symptom resolution
- Not recording a complete set of vital signs before and after treatment
- Omitting details about the specific location of epinephrine injection (vastus lateralis is recommended) 3
- Neglecting to document parent/caregiver education regarding anaphylaxis management
- Incomplete documentation of the observation period and clinical status at discharge
Remember that thorough documentation is essential for this potentially life-threatening condition, as it will guide future management and help identify the allergen trigger through subsequent testing.