Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Fever / Chills / Sweating / Muscle aches / Fatigue / Travel history to malaria-endemic area (if applicable)
History of Present Illness:
Onset, duration, and severity of symptoms.
Character of fever (intermittent – every few days, quotidian – daily, tertian – every other day).
Presence of associated symptoms (chills, sweats, muscle aches, headache, nausea, vomiting, diarrhea).
Recent travel history to malaria-endemic area (location, duration of travel).
Previous history of malaria infection (if any).
Past Medical History:
Underlying medical conditions (e.g., sickle cell disease, HIV infection) that can worsen malaria.
Allergies to medications, particularly antimalarial medications.
Medications:
List all current medications, including any antimalarial prophylaxis taken before travel.
Social History:
Occupation (increased risk for some professions – e.g., military personnel, travelers).
Living situation (increased risk in areas with poor sanitation and mosquito breeding grounds).
Pregnancy status (malaria can be more severe in pregnant women).
Physical Exam:
Vital signs: Assess for fever, tachycardia (rapid heart rate), tachypnea (rapid breathing).
General observation: Look for signs of paleness, jaundice (yellowing of skin), dehydration, and confusion.
Head and neck exam: Palpate for splenomegaly (enlarged spleen).
Abdominal exam: Assess for hepatomegaly (enlarged liver).
Laboratory Tests:
Malaria smear: Microscopic examination of a blood smear is the gold standard for diagnosing malaria and identifying the specific parasite species.
Rapid diagnostic tests (RDTs): These point-of-care tests can provide a quick diagnosis of malaria infection but may not be as sensitive as smears for detecting all parasite types.
Complete blood count (CBC): May reveal anemia (low red blood cell count) due to parasite destruction of red blood cells.
Electrolytes: May show imbalances due to dehydration or complications of severe malaria.
Imaging Studies (not routinely performed):
Chest X-ray: May be indicated if pneumonia is suspected as a complication.
Assessment:
Malaria diagnosis: State whether malaria infection is confirmed, suspected, or ruled out based on clinical presentation, testing results, and travel history.
Severity of infection: Briefly describe the perceived severity of the infection based on symptoms, parasite burden on blood smear, and presence of complications.
Specific parasite species (if identified): Mention the identified malaria parasite species (e.g., Plasmodium falciparum, Plasmodium vivax).
Plan:
Treatment:
Antimalarial medication will be prescribed based on the specific parasite species, severity of infection, and patient’s medical history.
Supportive care will be provided to manage symptoms (e.g., antipyretics for fever, fluids for hydration).
Hospitalization may be necessary for severe malaria or patients with complications.
Follow-up: Schedule follow-up visits to monitor treatment response, parasite clearance, and potential complications.
Education:
Educate the patient about malaria, transmission routes, symptoms, treatment options, and prevention strategies (e.g., mosquito nets, insect repellent, chemoprophylaxis for travel to endemic areas).
Discuss the importance of completing the entire course of antimalarial medication as prescribed, even if symptoms improve.
Public Health Reporting:
Report suspected or confirmed cases of malaria to local public health authorities as required.