SOAP Note Assessment Questions for 4-Year-7-Month-Old with Fever, Headache, and Emesis
The most important questions to ask focus on ruling out life-threatening causes of headache, fever and vomiting in a child, particularly meningitis, encephalitis, or other serious CNS infections.
Subjective Questions
History of Present Illness
- When exactly did the fever start and what was the highest temperature recorded?
- How severe are the headaches? Where is the pain located? Is it constant or intermittent?
- How many episodes of vomiting occurred? Is it projectile? Associated with movement or position changes?
- Has the child been photophobic or phonophobic?
- Any changes in mental status, confusion, irritability, or excessive sleepiness?
- Any neck stiffness, difficulty bending the neck, or pain with neck movement?
- Any seizure activity or loss of consciousness?
- Any rash, particularly petechial or purpuric rash? 1
Past Medical History
- Details about the pinworm diagnosis and treatment 4 days ago:
- What medication was prescribed for pinworms?
- Has the child completed the full course of treatment?
- Any improvement in symptoms after pinworm treatment?
- Any history of previous pinworm infections? 2
Review of Systems
- Neurological symptoms:
- Any focal weakness, numbness, or tingling?
- Any changes in gait or coordination?
- Any speech changes or difficulty speaking?
- Constitutional symptoms:
- Any weight loss, fatigue, or decreased appetite?
- Any night sweats?
- Respiratory symptoms:
- Any cough, difficulty breathing, or chest pain?
- Gastrointestinal symptoms:
- Any abdominal pain, diarrhea, or constipation?
- Any blood in stool?
- Genitourinary symptoms:
- Any changes in urination pattern or color?
Social and Environmental History
- Recent travel history? 3
- Exposure to others with similar symptoms?
- Recent tick exposure or outdoor activities in wooded areas? 3
- Daycare or school attendance?
- Vaccination status up to date?
Objective Assessment Questions
Vital Signs to Document
- Current temperature, heart rate, respiratory rate, blood pressure
- Oxygen saturation
- Pain score (using age-appropriate scale)
Physical Examination Focus
- General appearance: Level of alertness, responsiveness, irritability
- HEENT:
- Fontanelles (if still open)
- Signs of increased intracranial pressure
- Pupillary response and extraocular movements
- Fundoscopic examination for papilledema 3
- Neck: Nuchal rigidity, Kernig's sign, Brudzinski's sign 3
- Neurological examination:
- Mental status
- Cranial nerve function
- Motor strength and tone
- Deep tendon reflexes
- Coordination
- Gait (if able to walk)
- Skin: Presence of rash, particularly petechial or purpuric 1
- Perianal area: Signs of pinworm infestation (erythema, excoriation) 2
Laboratory and Diagnostic Tests to Consider
Initial Laboratory Tests
- Complete blood count with differential
- C-reactive protein and erythrocyte sedimentation rate
- Basic metabolic panel
- Blood culture
- Urinalysis and urine culture
- Consider lumbar puncture if meningitis is suspected 1
Imaging Studies
- Consider neuroimaging:
- MRI brain with and without contrast is preferred if available and patient can cooperate
- CT head without contrast if MRI not immediately available or if there are signs of increased intracranial pressure 3
Assessment Considerations
- Meningitis or encephalitis
- Post-infectious encephalitis
- Intracranial mass or abscess
- Migraine headache
- Viral illness with secondary headache
- Complications from pinworm infection (rare)
- Sinusitis or mastoiditis
- Tick-borne illness (Rocky Mountain Spotted Fever, etc.) 3
Plan Documentation
- Immediate interventions needed
- Medications to be administered
- Admission vs. discharge considerations
- Follow-up recommendations
- Patient/family education
Pitfalls to Avoid
- Do not rely on absence of classic triad (fever, neck stiffness, altered mental status) to rule out meningitis 1
- Do not delay antibiotics if bacterial meningitis is suspected 1
- Do not attribute all symptoms to pinworm infection without ruling out more serious conditions 2
- Do not underestimate severity in young patients who may present with subtle symptoms 1
Remember that the constellation of fever, headache, and vomiting in a child warrants careful evaluation for central nervous system infection, even if the symptoms appear mild or the child was recently treated for an unrelated condition like pinworms.