What questions should I ask when writing a SOAP note for a 1-year-old patient with fever, crying, and emesis post-immunization?

Key Questions for SOAP Note on 1-Year-Old with Post-Immunization Symptoms

When evaluating a 1-year-old with fever, crying, and vomiting after immunization, focus your questioning on timing, severity, and associated symptoms to distinguish between normal vaccine reactions and more serious conditions requiring intervention.

Subjective (History) Questions

Immunization Details

• Which specific vaccines were administered today?
• How long after the immunization did symptoms begin?
• Has the child had similar reactions to previous immunizations?

Fever Assessment

• What is the exact temperature reading and method used (rectal, axillary, temporal)?
• When did the fever begin relative to the vaccination?
• What is the pattern of fever (continuous, intermittent)?
• Has any antipyretic medication been given? What type, dose, and response?

Crying Assessment

• Is the crying persistent or intermittent?
• Is the child consolable or inconsolable?
• How long has the crying lasted? (Especially if approaching 3 hours of inconsolable crying) 1
• Does the crying worsen with movement or touching specific areas?

Vomiting Assessment

• When did vomiting begin relative to vaccination?
• Exact number and timing of emesis episodes
• Character of vomit (food contents, bile, blood)
• Volume of each episode (small amount vs. projectile)
• Any triggers for vomiting (feeding, position changes)?

Associated Symptoms

• Any changes in level of alertness or responsiveness?
• Any unusual movements, seizures, or tremors?
• Any difficulty breathing or changes in breathing pattern?
• Any changes in skin color (pallor, cyanosis, rash)?
• Any signs of pain (pulling at ears, abdominal pain)?
• Any changes in activity level or playfulness?

Objective (Examination) Questions

Vital Signs

• Current temperature, heart rate, respiratory rate
• Weight (to calculate appropriate medication dosing if needed)

Hydration Status

• Confirm absence of dehydration: moist mucous membranes, tears present?
• Normal skin turgor?
• Normal fontanelle (if still open)?
• Urine output: number of wet diapers in past 24 hours?

Neurological Status

• Is child alert and interactive appropriate for age?
• Does child recognize parents/caregivers?
• Any abnormal movements or posturing?
• Any focal neurological signs?

Vaccination Site

• Any redness, swelling, warmth at injection site(s)?
• Size of any local reaction (measure in centimeters)
• Is there tenderness on palpation of injection site?

Respiratory/Cardiovascular

• Any respiratory distress (retractions, nasal flaring)?
• Lung sounds clear?
• Heart sounds and rate normal?

Assessment Questions

Differential Diagnosis Considerations

• Is this likely a normal post-vaccination reaction?
• Could this be a more serious adverse event like hypotonic-hyporesponsive episode? 1
• Could there be a coincidental illness unrelated to vaccination?
• Any signs of serious bacterial infection requiring immediate attention? 2

Severity Assessment

• Does the child require emergency evaluation based on:
  • Temperature ≥40.5°C (105°F) within 48 hours of vaccination? 1
  • Signs of altered mental status? 2
  • Persistent inconsolable crying ≥3 hours? 1
  • Signs of respiratory distress? 2

Plan Questions

Home Management

• Can the family manage symptoms at home?
• Do they have appropriate antipyretics (acetaminophen, ibuprofen) and know proper dosing?
• Do they understand warning signs requiring immediate medical attention?

Follow-up

• When should the child return for reassessment if symptoms persist?
• What specific symptoms should prompt immediate return?
• Is telephone follow-up within 24 hours appropriate?

Documentation

• Were parents counseled about expected vaccine reactions versus concerning symptoms?
• Were the current symptoms documented for consideration before future immunizations?

Special Considerations

• Document timing and nature of symptoms for evaluation of future vaccine administration 1
• Consider prophylactic antipyretic administration for future immunizations if appropriate 1
• Note any family history of adverse vaccine reactions

Remember that post-immunization fever is common in infants and young children 3, but careful assessment is needed to distinguish between expected vaccine reactions and more serious conditions requiring intervention.