Soap Note

Soap Note

Name:E.V.  Pt. Encounter Number:0002/18
Date:01/01/2018 Age:17 Sex:Female.

Headache, joint pain, vomiting.



The patient have had headache over the last 3 days since they came from a trip to various mines in the South African countries. The patient headache has been on and off and gets relieved by pain killers. She rated the pain as 7 in a scale of 0 to 10. The headache has been accompanied by joint pain as well as nausea and vomiting. The worsening of the symptomsprompted the visit for medical care.


Medications: she has been taking ibuprofen 400mg three times daily for the pain.



Allergies: no known drug or food allergies.


Medication Intolerances:None.


Chronic Illnesses/Major traumas: None.


Hospitalizations: None.


Surgeries: None.

Immunization status: Updated.



Family History

Father: 45, no medical history, Mother: 42, no medical history. Paternal GM: 70, HTN. Paternal GF: 75, DM. Maternal GM: 65, HTN, Maternal GF: 70, No medical history.


Social History

She lives together with her parents together with the eldest brother. The father is a doctor and mother is a lecturer. There is no history ofsubstance use in the family.They all observe safety measureswhile using cars on the road as well as during games and back at home.



She is sick looking, sweating and shivering.



Patient reports increased heartbeat.  No chest pains or edema.



Moist skin that is warm.



No coughs, wheezing or shortness of breath. No history of TB.



No use of corrective lenses, no reports of blood vision.



The patient denies episodes of diarrhea or constipation. She however had instances of abdominal pains in the last two days but subsided later. She has also vomited yellow vomitus three times which prompted the seeking of medical attention. No history of ulcers. She reports loss of appetite for the last two days.



No ringing in the ears, no pain or discharge.


No sexual activities. LMP 12/23/2017

No urinary symptoms.




No dysphagia, no discharge from the nose, dry lips and existence of halitosis.



She reports joint pain in the last two days.



Has knowledge and carries out self-breast examination. No lumbs.



History of headache that responds to over the counter medication, this however changed as the painintensified. No episodes of seizure.



The patient reports increased thirst since the symptoms commenced.



No history of psychiatric condition in the patient.


Weight  45    Temp100 BP130/92
Height 5.2’’ Pulse99 Resp21
General Appearance

The patient is sick looking, hydrated, alert and well groomed. She answers questions appropriately.



Skin is warm on tough with poor skin turgor. Yellow palms and soles.



The head is in a normocephalic shape. Eyes: pale conjunctiva, yellow sclera with no discharge. The pupils are equal and reactive to light. Ears: the auditory canals are patent with no impacted wax. No discharge. The tympanic membranes are grey on otoscopic examination. Nose: there are no nasal polyps, the nostrils are patent with no discharge. All the teeth are patent with no bleeding in the gums.



S1, S2 heard with the rhythm and rate regular. Capillary refill of 4 seconds. Pulse 90bpm. No edema on the face or the extremities.



Symmetrical chest wall. Respiratory rate of 20 breaths per minute. Both lungs are clear on auscultation.



Active bowel sounds over the four quadrants. No obvious tenderness. Guarding on percussion to the right upper quadrant suggestive of hepatomegaly. The abdomen is soft on palpation.



No discharge from the nipples, no lumps, change of color or dimpling from both breasts.



Patient reported a normal discharge that is clear with no smell. No further exploration was done.


Full range of motion observed on the four extremities throughout the period of examination though with difficulty as patient complains of pain.


The speech is clear, she has a normal gait and stable balance.



The patient is oriented to time, person and place. Normal behavior throughout the assessment period. She is well groomed. Nosign of mental disorder.


Lab Tests
CBC- pending.

Blood work-ups- Pending

Special Tests


·         Malaria.

Causes increased body metabolic rate to present with fever and increase the heart activity. The malaria parasite also causes hemolysis to lead to paleness, tachycardia, jaundice, hepatomegaly and splenomegaly (Amalu, & Okafor, 2016). Joint pain as well as stomachache together with nausea and vomiting can also follow.

·         Migraine.

Presents with headache that persists for 1 to 3 days. The headache may be localized then diffuse. The pain increases in intensity with increased activity and movement(Jürgens, Schulte, & May, 2014).One gets relief from pain killers and resting in dark rooms as well as sleeping.

·         Intracranial hemorrhage

Presents with sudden headache that is severe and is followed with loss of consciousness, loss of balance and coordination (Kase, 2015). The patient may also present with nausea and vomiting. In most instances, it originates as a complication of another condition rather than the bleeding itself.


Final diagnosis

Malaria– This can be traced from the history due to the uncommon nature of malaria in the US but individuals develop it from visits to malaria endemic areas as in the case at hand(World Health Organization, 2015). Besides, the patient has classical symptoms of malaria ranging from jaundice, fever, headache as well as joint pain. This can be confirmed by analysis of the blood samples to determine the presence of malaria parasite in the blood. The hepatomegaly also confirms hemolysis by the parasite.


§  Further testing: None.

§  Medication

Ibuprofen 400 mg three time a day for relief of headache as well as fever.

Artemether 20mg and Lumefantrine 120mg twice daily for three day for the malaria (Amalu, & Okafor, 2016).

§  Education

The patient to maintain high intake of fluids to enhance dehydration. The education will extend to taking of medication since the first dose and the second dose of thew antimalarial should be 8 hours with the subsequent doses being after every 12 hours.

§  Nonmedication treatments

Reducing of clothing reduces the fever.

§  Follow-up

The patient to come for checkup after completing medication or any time in the case the condition worsens.


Amalu, C. T., & Okafor, F. C. (2016). Symptoms associated in the diagnosis and management of malaria in a semi urban tropical community. Animal Research International9(2).

Jürgens, T. P., Schulte, L. H., & May, A. (2014). Migraine trait symptoms in migraine with and without aura. Neurology82(16), 1416-1424.

Kase, C. S. (2015). Intracerebral hemorrhage. Elsevier Health Sciences.

World Health Organization. (2015). Guidelines for the treatment of malaria. World Health Organization.