Consultation

FMC/2024/08858

Nurse Bassey · 2024-12-18 11:05 · Patient record →

In progress

SOAP note

confidence 0.86

Subjective

Chief complaint: fever for 4 days, intermittent, worse at night, with headache and generalised body pain. Vomited twice yesterday. No diarrhoea. Self-medicated with paracetamol and an incomplete course of artemether-lumefantrine purchased at a chemist.

Objective

Temperature 38.6°C, BP 118/76 mmHg, pulse 96 bpm. Chest clinically clear. Abdomen soft; mild splenic tip palpable. Investigations ordered: malaria parasite test, full blood count.

Assessment

Primary: Uncomplicated Plasmodium falciparum malaria (B50.9), pending parasitological confirmation. Differentials: typhoid fever (A01.0), viral syndrome (B34.9). Diagnostic uncertainty: prior partial ACT course may reduce smear sensitivity.

[REVIEW: Incomplete prior ACT course — confirm adherence counselling documented]

Plan

Artemether-lumefantrine 80/480 mg PO twice daily for 3 days (full 6-dose course, taken with food). Paracetamol 1 g PO 8-hourly as required for fever, maximum 4 g/day. Review in 3 days with results, sooner if unable to tolerate oral fluids. Patient educated on completing the full antimalarial course.

Differential diagnosis

conf 0.82

01high

Uncomplicated P. falciparum malaria

B50.9

Intermittent fever worse at night
Headache and generalised body pain
Palpable splenic tip
Holoendemic transmission setting

02moderate

Typhoid (enteric) fever

A01.0

Stepwise fever with vomiting
Endemic setting

03low

Viral syndrome

B34.9

Self-limiting fever pattern possible

Clinical pearl

Incomplete over-the-counter ACT courses are among the commonest causes of apparent treatment failure in Nigerian outpatient malaria — always ask what was bought at the chemist before labelling resistance.