Key Questions for SOAP Note in a 1-Year-Old with Increased Work of Breathing
When creating a SOAP note for a 1-year-old with increased work of breathing in the pediatric ER, focus on respiratory assessment, potential causes, and severity indicators to guide immediate management decisions.
Subjective (History) Questions
Respiratory Symptoms
- When did the increased work of breathing start? (Acute vs. gradual onset)
- Is there any cough? If yes:
- Is it wet or dry?
- When did it start?
- Any pattern (worse at night, with activity, etc.)?
- Any noisy breathing? (Wheezing, stridor, grunting)
- Any color changes (cyanosis, pallor)?
- Any nasal flaring or retractions (subcostal, intercostal, suprasternal)?
- Has the child been able to feed normally?
- Any choking episodes or possible foreign body aspiration?
Associated Symptoms
- Current fever or fever history?
- Recent upper respiratory symptoms (runny nose, congestion)?
- Any vomiting or diarrhea?
- Any changes in activity level or lethargy?
- Any rashes?
Medical History
- Any previous episodes of respiratory distress?
- History of prematurity or neonatal respiratory issues?
- Known asthma, bronchopulmonary dysplasia, or reactive airway disease?
- Previous hospitalizations for respiratory issues?
- Recent exposure to sick contacts?
- Vaccination status?
Environmental Factors
- Exposure to tobacco smoke or other irritants?
- Recent changes in home environment?
- Potential allergen exposures?
Objective (Physical Examination) Focus
Vital Signs
- Respiratory rate (normal for 1-year-old: 20-40 breaths/minute)
- Heart rate (normal for 1-year-old: 80-140 beats/minute)
- Temperature
- Blood pressure
- Oxygen saturation (target SpO2 ≥92%) 1
Respiratory Assessment
- Work of breathing:
- Presence and severity of retractions (subcostal, intercostal, suprasternal)
- Nasal flaring
- Grunting (indicates severe disease and impending respiratory failure) 1
- Use of accessory muscles
- Breath sounds:
- Presence of wheezing (expiratory, inspiratory, or both)
- Crackles/rales
- Decreased breath sounds
- Stridor
- Chest examination:
- Symmetry of chest movement
- Percussion note
- Air entry
General Assessment
- Level of consciousness and mental status
- Hydration status
- Capillary refill time
- Presence of cyanosis (central or peripheral)
- Signs of distress or fatigue
Assessment Considerations
Differential Diagnosis Focus
- Bronchiolitis
- Pneumonia
- Asthma/reactive airway disease
- Foreign body aspiration
- Croup
- Congenital heart disease with heart failure
Severity Assessment
- Ability to feed and maintain hydration
- Work of breathing at rest vs. with activity
- Response to initial interventions
- Need for oxygen support (indicated if SpO2 ≤93% on three separate measurements) 1
Plan Components
Immediate Interventions
- Oxygen requirements (target SpO2 92-97%) 1
- Need for continuous monitoring 1, 2
- Respiratory support considerations (high-flow oxygen, CPAP)
- Medications (bronchodilators, steroids, antibiotics if indicated)
Diagnostic Testing
- Chest radiograph indications
- Laboratory tests (CBC, CRP if febrile)
- Blood gas considerations
Common Pitfalls to Avoid
- Relying solely on clinical appearance without pulse oximetry - Essential to detect significant hypoxemia 1
- Using only intermittent oxygen measurements - Can miss significant hypoxemia; continuous monitoring including sleep periods is necessary 1
- Failing to assess feeding ability - Important indicator of respiratory distress severity in infants
- Not considering foreign body aspiration - Always consider in cases of sudden onset respiratory distress 3
- Overlooking signs of impending respiratory failure - Watch for grunting, altered mental status, and fatigue 3, 1
By systematically addressing these questions and assessment areas, you'll create a comprehensive SOAP note that guides appropriate management for this 1-year-old with increased work of breathing.