Age of Patient: 10 years five months
Gender: Male
Parent/Guardian: Magdalene Ekaterina
Subjective
The patient has been experiencing a fever, weak joints and night sweats associated with malaria infection over the last two days.
The patient’s parent confirmed that he was not able to eat as much as he used to an indication of loss of appetite.
He feels dizziness after a long sitting position and general weakness implying poor oxygen supply, a symptom associated with malaria and anemia, however, he has no headache, stomachache, nausea, earache or diarrhea.
He says he is feeling like vomiting now.
The patient has travelled over the last two weeks over a long distance and has confirmed that the symptoms started showing ten days after he settled in the new region an approximation of the last three days.
The patient had earlier taken painkillers and sleeping pills to relieve the fever and to aid in his sleep since yesterday and has no other ongoing current medication.
He is fully immunized against all common communicable diseases.
He reports ulcers in the stomach a condition he has been with for a long time and no other known allergies.
The mother also reports having had him hospitalized for two weeks on 4th of October 2015 suffering from the same problem. There is no surgical history so far, has a good physical, psychological, sexual and mental background without any incidences with a good and healthy development.
Objective
Temperature reads 36.5 degrees Celsius, blood pressure 96/62. The patient weighs 33kg, has a height of about 0.98m with a body mass index ratio of 3367% (Borcherding, 2000).
A closer look at the patients shows clear white eyes with equal sized pupils that are reactive to light.
He exhibits a dark skin tone which the parent claims is an indication of sickness due to its change. The patient was subjected to various laboratory checks which included observation of the urine and blood test.
Urinalysis confirmed the presence of a high concentration of waste, an indication of an overworked system and was taken for further analysis.
A blood test revealed the presence of Plasmodium, which is associated with causing malaria disease and this confirmed the presence of the symptoms claimed by the patient.
No waterborne diseases were observed from the laboratory tests done.
The patient has good hearing, vision and is of sane mind.
The patient appears to be in the middle stages of incubation of the disease as portrayed by the signs and symptoms that have started manifesting.
Blood count is about 20 which is below 40 the most critical and had to treat even though the disease has a significant impact on the patient (Borcherding, 2000).
The absence of any other medical conditions matching the symptoms as ruled out by the urinalysis and blood test affirms the presence of high numbers of Plasmodium parasite.
The patient also reported to have been admitted for malaria in the past four months and had been travelling which is a common malaria transmission line with evidence indicating that either the patient did not finish medication properly or was infected while travelling to a new environment as is common in most cases travelling over long distance without preventive measures (Gately et. al, 2012).
Plan
The evidence provided, observed and tested confirm malaria hence the patient has to be treated for malaria.
He will have to stop taking the sleeping pills and pain killers that he had started on and restrict himself to a new prescription provided.
The patient will require preventive measures to take care of future reinfections such as sleeping in a net and having an environment free from mosquitoes.
He is advised to take antimalarial, in this case, the best prescription being the Vibramycin drug, a well-performing drug.
The drug requires that the patient should not have a history of any allergies and not be subject to a penicillin or acitretin medication in the previous few days.
Vibramycin works by strengthening the immune system which allows it to fight diseases better; by inhibiting the bacteria and Plasmodium parasite, they cannot multiply into large numbers that will overwhelm the system.
Thus, the patient’s body has a higher chance of clearing the already developed bacteria eliminating the disease causing microorganisms (Gately et. al, 2012).
Administering some painkillers and a follow up to ensure the dosage is complete within four days is mandatory, taking 1 and a half tablets after every 8 hours that is approximately three times a day.
The prescription was quite easy to follow due to the simple nature of the patient’s medical history which allowed for a clear narrowing down to the main cause of illness.
In the case of another similar scenario, I would consider looking more keenly at the medication provided on the shelf as there are many new medications in the market; the best prescription treatment involves giving the patient the best rated drug with the minimum side effects. Medication is restricted to painkillers and Vibramycin.
References
Borcherding, S. (2000). Documentation manual for writing SOAP notes in occupational therapy Thorofare, N.J: SLACK.
Gateley, C. A., Borcherding, S., & Borcherding, S. (2012). Documentation Manual for Occupational Therapy: Writing SOAP notes. Thorofare, NJ: SLACK.
