Key Questions for SOAP Note in a 2-Year-7-Month-Old with Head Injury
When evaluating a 2-year-7-month-old child who presents to the Pediatric ER with a head injury without loss of consciousness, focus on the PECARN criteria to determine risk of clinically important traumatic brain injury and need for imaging.
Subjective (History) Questions
Mechanism of Injury
- Exact mechanism of the injury (how did the child hit their head?)
- Height of fall or force of impact
- Surface the child hit their head against
- Whether the injury was witnessed or unwitnessed
- Time elapsed since the injury occurred
- Was the child involved in a road traffic accident? (high-risk mechanism) 1
Symptoms
- Any loss of consciousness (duration if any)
- Any difficulty arousing the child after injury 1
- Any vomiting (number of episodes, timing) 1
- Any seizures after the injury
- Any behavioral changes or acting abnormally according to parents
- Any headache complaints (severity if verbal enough)
- Any dizziness or balance problems
- Any confusion, disorientation, or memory issues
- Any visual disturbances
Past Medical History
- Previous head injuries or concussions
- Pre-existing neurological conditions
- Current medications
- Developmental status (appropriate for age?)
- Bleeding disorders or anticoagulant use
- History of previous ED visits for trauma 1
Objective (Examination) Questions
Vital Signs
- Heart rate (note any bradycardia)
- Blood pressure
- Respiratory rate
- Temperature
- Oxygen saturation
Neurological Examination
- Glasgow Coma Scale (should be 14-15 for mild head injury)
- Mental status (alert, verbal, responsive)
- Pupillary response (equal, reactive, any anisocoria)
- Motor strength and symmetry
- Balance and coordination
- Cranial nerve examination
Head Examination
- Presence and location of any scalp hematoma (especially non-frontal) 1
- Any palpable skull fracture
- Any signs of basilar skull fracture (periorbital ecchymosis, Battle's sign, hemotympanum, CSF otorrhea or rhinorrhea) 1
- Any lacerations, abrasions, or contusions
Assessment Questions
Risk Stratification
- Does the child meet PECARN criteria for very low risk? 1, 2
- Normal mental status
- No loss of consciousness
- No vomiting
- Non-severe injury mechanism
- No signs of basilar skull fracture
- No severe headache
Imaging Considerations
- Based on risk factors, is CT imaging indicated?
- If observation is chosen instead of immediate CT, what parameters should be monitored?
Plan Questions
Observation vs. Imaging
- If low risk, can the child be safely observed for 4-6 hours? 1
- Has the child's neurological status remained stable during observation?
- Are the parents reliable for home monitoring?
Discharge Planning
- Are there reliable caregivers who can monitor the child at home?
- Do caregivers understand return precautions?
- What follow-up is needed?
Return Precautions
- What specific symptoms should prompt return to the ED? 1
- Persistent vomiting
- Severe or worsening headache
- Difficulty waking up or staying awake
- Confusion or unusual behavior
- Seizures
- Weakness or numbness in arms or legs
- Difficulty walking or talking
Documentation Considerations
- Document exact timeline of events
- Record caregiver's exact words regarding mechanism of injury 1
- Note any discrepancies in the history without accusatory language
- Document neurological assessments at regular intervals during observation
- Record all interventions and their timing
Remember that children under 2 years have different risk criteria than older children, but at 2 years and 7 months, this patient falls into the older age category for PECARN criteria assessment 2, 1, 3.