SOAP STUDY Case Study 1

SOAPSTUDY: Case Study 1


Infant:Nicholas Arnold:

Dateof the encounter: 3rd May 2015

Nameof the patient: Nicholas Arnold

Birthdate: 2ndMay 2005

Caregiver’sname: Emily Jane

Languagespoken: English

Religiousaffiliation: Catholics


  1. Chief Complaint

Aten old boy reported to our health facility accompanied by hermother. According to Nicholas’s mother, Nicholas has been havinggeneral body weakness and she did not know the problem or ailmentthat his child was suffering from. Nicholas on the other hand saidthat he did not at all know the reason behind his weakness that heclaimed to have started a few weeks ago. Nicholas seemed to be okaythough there were a few signs and symptoms of bruises and scars onsome parts on his body. His mother also said that at variousinstances he would vomit and have fever.

CC:Physical Abuse

  1. History of present illness (HPI)

Nicholaswas ten years old as stated by his mother. He was brought to theoffice complaining of weakness for a few weeks and he had seized toattend school. His mother stated that for a while now he has beenrefusing to go to school claiming that his body was paining and thathe would no longer continue attending the normal school schedules asis required of him. Nicholas’s mother continued to say that beforehe started complaining of the weakness, he was always jovial, happyand talkative than usual. He had also started having friends who wereolder than him who would always come to check on him every singleevening. Immediately after, he started complaining of weakness, hisbehaviors suddenly changed and he became very the opposite of hisearlier behaviors. He became so introverted and most of the times hewould remain locked in his room.Nicholas’s mother confirmed thatNicholas’s elder sister had once met him crying in his room. Hismother stated that in one instance he gave Nicholas some pain killersto lessen the pain that he complained of.

  1. Review of systems (ROS)


Themother said that Nicholas had started refusing to eat and to attendschool. He remained indoors and avoided confrontations with any ofthe family members. His friends had also seized visiting him. In manyinstances when his mother confronted him, he said that he wasexperiencing severe headache and back pain. Nicholas remained silentall through the conversation and after being asked what had happenedhe nodded his head and said nothing had happened only for the painand the general body weakness that he was experiencing.

Hismother continued to say that he had suspected that his son wassuffering from malaria.


  • Head: Mother denies history of any kind of trauma.

  • Ear: Mother denies history of ear discharges, redness, or rashes.

  • Eyes: Mother stated that earlier before his son had started complaining of weakness and headache, she noticed redness in his eyes especially after meeting his friends.

  • Nose: Mother noticed nasal discharges and he frequent sneezing.

  • Mouth: Mother stated that Nicholas lips were okay only that at times he produced a foul smell from his mouth.

  • Throat: Mother denies history of lesions or redness.

Neck:Mother denies neck trauma (falls) or abnormal movement.

Heart:Mother stated the heart beat was okay.

Lungs:Mother notices cough and breathlessness at times.

Abd&ampGI: Mother denies history of abdominal distention, hard stool,vomiting, or diarrhea area.

GU:Mother has been noticing no abnormal discharges from the urine.

Neurological:Motherdenies seeing any abnormal movements, twitching, or seizures.

Extremity:Mother denies any history of trauma, abnormal movement or range ofmotion.

DietAnd Nutrition: Mother stated that Nicholas refused to eat most of thetimes as compared to the earlier days.

RestAnd Sleep Pattern: Mother described that Nicholas slept for only afew hours and most of the times he was always watching movies in hisroom.


Nicholaswas 10 years old and was attending school as normal. His motherstated that he was an excellent performer when it came to hisstudies. After joining the company of the older guys, his performancedeteriorated and he was no longer interested with studies likebefore. She stated that his weight was normal when he was nine yearsold but after turning ten, she started loosing weight day in day outbecause he rarely ate. His past health records was okay. She statedthat he had received all the required vaccinations. His mother statedthat she was very keen when it came to the health of her family. Healways gave it the first priority.She achieved this by frequently andregularly taking her two children for health check ups. She statedthat Nicholas has never ever been admitted in any health facility.There has never ever been any surgical procedure undertaken on him.

Nicholashas also never had any accident or trauma. His mother only statedthat he had only fallen a victim of minor injuries that were managedappropriately. Nicholas’s mother also stated that Nicholas had noallergy of any drug or food. She stated that Nicholas had no currentmedications that he was using.


  • Father: 35year old, overweight, pre-hypertensive with medication, a drug addict and a smoker.

  • Mother: 34 year old. No history of any disease or allergy.


Nicholasthe patient lives with his both parents and his elder sister. Hismother is a manager of a certain company dealing with real estatesand his father is a lecturer of a University that is far away fromhome. The father therefore visits the family once in a week. Thefamily is financially stable. His father is addictedto smoking cigarand smokes while in the house. He also uses some of the illegal drugsbut he does this privately and secretly. The sister is 15 years oldand is also schooling in the same school in which the patientschools. She is so hardworking and more introverted as compared tohis brother.



BP60/40 mmHg, Pulse179beats/min, RR60 breaths/min, Tem103.0F˚,

Sat92%on room air

Ht:60 inchesWt: 2000grams

Length= between percentile 100 and 150.

Weight= between percentile 100 and 150.

HeadCircumference = between percentile 75 and 100.


Thepatient is highly irritable, introverted, and generally weak and hassome physical bruises. The patient also complained of severeheadache, feeling nauseatic and fearful.

  1. Physical examination

Thepatient had spinal injuriesand bruises on the spine. The generalhealth condition of the patient was okay after physical examination.The patient walked and spoke in a slow pace an indication that he hadsuffered from either an accident or a fall while playing in school.Some parts of the patient’s skin were reddish in color anindication of internal injuries. This made the medical workers to bevery keen on those marks as they were more evident near the spine ofthe child. The patient’s mother affirmed that the patient had notbeen involved in any kind of accident. This was an indication thatthe patient had been involved either in an accident while playing athome or in school. After a few questions seeking to reveal whetherthe boy was involved in any accident, the patient at first said thathe was not whatsoever involved in any kind of accident or fall whileplaying. The patient’s mother was so worried about the wholediscovery and therefore threatened to punish the patient if refusedto tell the truth. The patient completely refused to say anythingregarding the marks. The patient’s mother became so upset andstarted beating the child but we stopped it. His mother stated thatthe same case had happened earlier before when he asked the patientwhere the bruises and the marks were from. After thorough beating thepatient revealed to her mother that the bruises were as a result of afight between him and his friends over a little misunderstanding.

Mostpatients at this age tend to have great fear towards their parents orguardians because they fear to face the wrath of punishment. Thepatient spoke out and said that he would only tell the truth if onlythe mother would promise not to punish her. This further saddened themother. The patient’s mother who was at the moment wordless andalmost shedding tears promised not to punish the patient as long ashe said the truth. The patient sobbed and wept uncontrollably beforehe could even speak. The patient’s mother began comforting himpromising him that no matter what the boy would say, she wouldcontinue loving him and would not punish him. Luckily, after a fewminutes the patient started narrating the whole story that was reallyhorrible (Bell, 1985).

Abig number of children at this age tend to be very hyperactive andplayful in their daily activities especially while they are withtheir peers and age mates. The patient’s mother was reallyinquisitive on how, when and where this took place. The patientstated that his friends introduced him to a habit of always visitinga nearby forest after school and during the weekends andholidays.Children at this age ted to stick to the norms of theirpeers and abide by the rules and are always together I their dailyactivities. It is usually very hard for the patients to resist goingto play anywhere their friends proposes as long as they are havingfun. The boy stated that they engaged in a number of activities whilein the forest and those activities were very risky.

Thepatient continued and revealed that his friends who were older thanhim would ask him to do some activities that were too risk for hisage. They would climb trees and tried to move from one tree to thenext while at the top of the trees. They would award the person whowould cross many trees especially being at the top most part of thetrees using branches. He pointed out that at many instances some offriends including himself would fall from the trees and hit theground with such a great thud but they would take it as fun. Thepatient claimed that during their last trip to the forest, the branchof tree that he was using in order to move to the next tree was soweak and unfortunately, it broke. He stated that he fell with hisback from a height not exceeding five meters. He said that he afterhe fell down, he was unconscious for almost an hour. His friends toldhim that they tried all that they could to save the life of theirfriend. Luckily after many try and error first efforts, the patientbecame conscious. At first, he stated that he could not be able tostand up and his friends supported him until they came out of theforest. Some of his friends rushed to a nearby chemist and bought himsome painkillers to lessen the pain. He stated that since that day hehas been using painkiller and relievers to stop the pain though hestated that it did not help him so much as his spine was in greatpain (Nelson, 2011).


  • Head: Normocephalic, open fontanels with flat anterior fontanel, hair normally distributed, skull is symmetrical, and head circumference is normal. No lesions, or discoloration.

  • Eyes: Clear conjunctiva and sclera no signs of jaundice, and no tears with crying. Pupils 4mm constricting to 2mm, round, regular, equally reactive to light. Normal corneal reflex, positive to red reflex, no strabismus, or amblyopia.

  • Ears: Symmetrical, normal position and shape, patent and clear ear canal. Tympanic membrane intact, positive to light reflex.

  • Nose: Bilateral nasal flaring,intact mucus membrane, clear and patent nasal passage, septum midline.

  • Mouth: Intact mucus membrane moist with mild cyanosis including lips. Intact hard and soft palate, no clefts.

  • Throat: Clear and intact, no exudate or drainage. Uvula midline, and positive swallowing reflex.

Neck:Short and thick, intact skin no rashes or irritation, tracheamidline, and normal range of motion. Clavicles are intact, and lymphnodes are small, soft, and no tender.

Heart:No cardiomegaly or thrills regular rate and rhythm with notachycardia, no murmur or gallop, normalheart sounds, S1, S2, and noS3 or S4. Peripheral and central pulses +2 seconds, capillary refill+3 seconds, no edema.

Lungs:In good shape and functioning excellently (Fradin, 1988).

Abdand GI: Abdomen is soft, mild distention, round, no tenderness, noabnormal masses, no organomegaly hypoactive bowel sounds present inall quadrants, no aortic pulsation. No diarrhea, no vomiting, and noblood in stool. No umbilical hernia, umbilical stump fall off, nobleeding, no redness, no discharges, or swelling around the area.

GU:Bladder not tender or distended, skin is bruised and has signs ofinjection marks especially in the arms, few rashes, no abnormaldischarges, normal male genitalia with descended testes, no swelling,and no signs of hernia, circumcised (Luftig, 1997).

Neurological:Bruises around the spinal cord.

Musculoskeletal:Normal ROM, no lump, tenderness, or crepitus. No spinal deformities,hairy patches, or pigmented spots. Negative for any signs of hipdislocation or dysplasia.

D.Diagnostic test

Thediagnostic test results include:

1.Computerized tomography(CT) scan to define the spinal problems.

2.X-rays that reveal the spinal problems.

3.Magnetic resonance imaging (MRI) that uses strong magnetic field andradio waves to produce computer-generated images. It is vital inidentifying spinal cord injuries, blood clots, herniated disks orother masses that may be tamping the spinal cord.

Diagnostictest results

Onlya few diagnostic results were undertaken and they revealed that thepatient had suffered from spinal injury and a few internalinjuries.(Tarter,2001).


The10 year old patient who was brought by his mother to our center dueto weaknesses revealed that he fallen from a tree while playing withhis friends in the forest thus making him to suffer from spinalinjury. He had suffered from minor internal injuries and luckily hehad no dislocation of any limb as indicated by the scan results.Before the incident, the boy was so active and jovial but thingschanged after the accident. He could hardly perform many activities.He always strained and did not want any of his family members torealize so. Headache and nausea was as a result of the pain from theaccident (Committee on Opportunities in Drug Abuse Research, 1996).

A.Differential Diagnosis:

Malaria(Ruled Out)

Malariais a deadly disease brought about by a bite of an infected femalemosquito. The signs and symptoms of malaria include weakness,malaise, vomiting, nausea, headache, fever and loss of appetite. Thesigns and symptoms of malaria are very serious and may prevent theindividual from engaging in some of the activities that he used to doon routinely basis. However, in our case there is no trace of thepresence of the disease. The weakness was due to spinal injury afterthe accident. Headache was due to the pain of his spine.

Dislocationof a limb and bone breakage.(Ruled out)

Thepain and weakness of the patient can also be due to dislocation orbreakage of a bone in the patient’s body. This may either be as aresult of an accident. Dislocation or breakage of a bone causessevere pain and thus resulting to general weakness of the body.However, in our case, the pain is as a result of minor internalinjuries arising from the beatings given to the patient by hisfriends (spinalInjuries, 2004).

Vertebralfracture (ruled out)

Thesigns and symptoms of vertebral fracture are similar to those ofspinal injury though vertebral fractures has unique anatomical andfunctional features that result in specific injuries in variousregions. The signs and symptoms of the disease include weakness,numbness, tingling, neurological shock. Most of the diagnosticprocedures are similar to those of an individual who has spinalinjury. In the case of vertebral fracture, most of the vertebralstructures have fractures either minor or major that are caused afterthe occurrence of an accident. Both surgical and non-surgicalfracture management can be used to deal with the fractures incorporation with other medication, revisits and continuous monitoringof the patient to ensure full recovery.


DefiniteDiagnosis – Spinal injury

Thetreatment option of spinal injuries heavily depends on the cause,source and location of the injury. In such a case, the spinalinjuries are minor and therefore the only way to handle this is tofirst locate the sites where there is injury.

Antibioticsand painkillers can be given to the patient in order to ensurewholesome recovery of the patient from the injury. The patient shouldalso be booked in for counseling services in order to rectify hisbehaviors regarding engaging in risky activities and games (Schinke,1991).


  1. Diagnostic Plan:

  1. Screening

  2. Basic assessment

  3. Treatment planning

Assessmentprocess include

-engagethe client

-gatheradditional information from family members and close friends.

-screen for and detect the damage caused by the drugs and theinjuries.

-determinelevel of care


-determinefunctional impairment and extent of injuries.

-identifystrengths and supports

-identifyproblem domains

-determinethe stage of change

-Plan treatment

-Plan referral and review dates


  1. Therapeutic Plan:

Treatmentfor spinal cord injuries care divided into two stages. Acute andrehabilitation.

Theacute phase involves immobilization of the patient thus minimizingfurther injury the spinal cord.

Surgeryis also important at this phase in order to strengthen the affectedand damaged area of the spine to prevent further injury.

Thepatient requires rigorous physical and occupational therapy becausethe recovery pace varies on every individual.

Exercisetherapy is also important in order to maintain muscle mass andflexibility.


Intravenousmethylprednisolone( A-methapred)



Depo– Medrol


Weakopioids (codeine and dihydrocodeine)

Strongopioids (tramadol, buprenorphine, methadone, diamorphine, fentanyl,hydromorphine, morphine, oxycodone and pethidine)


Asmentioned earlier, the patient should be booked in for counselingservices from a trained and a professional counselor. The patientshould be educated on the effects of engaging in such activities. Afollow up plan should be made in order to closely monitor the patienton the progress. He should also be taught on how to deal with such anincidence and the importance of reporting such a case to the parentor guardian or either a health facility. In addition, the patient’sparents should also be counseled on how to deal with the patient insuch a case (In Haerens, 2013). Parents should also close monitor thechild and be keen in noticing any kind of awkward behavior or painfrom the child. The parents should love the patient and monitor himalways to prevent the re-occurrence of such a case (Films for theHumanities &amp Sciences (Firm), Films Media Group., &ampBenjamin/Cummings Publishing Company, 2013).

Thepatient’s mother was advised to always bring the boy to the healthfacility for continuous follow up and monitoring. This allowed forcontinuous monitoring of the patients spine. Counselling sessionswere also planned whereby the boy would visit the health facilityonce in a week for a duration of one months to make sure that he doesnot engage in risky activities again.


Bell,C. S., Battjes, R., &amp National Institute on Drug Abuse. (1985).Preventionresearch: Deterring drug abuse among children and adolescents.Rockville, Md: Dept. of Health and Human Services, Public HealthService, Alcohol, Drug Abuse, and Mental Health Administration,National Institute on Drug Abuse.

Committeeon Opportunities in Drug Abuse Research. (1996). Pathwaysof addiction: Opportunities in drug abuse research.Washington, D.C: National Academy Press.

Filmsfor the Humanities &amp Sciences (Firm), Films Media Group., &ampBenjamin/Cummings Publishing Company. (2006). Preventingdrug abuse.New York, N.Y: Films Media Group

Fradin,D. B. (1988). Drugabuse.Chicago: Childrens Press.

InHaerens, M., &amp In Zott, L. M. (2013). Prescriptiondrug abuse.

Luftig,D., Field, F., Lexington Broadcast Services Company., &amp VCI HomeVideo (Firm). (1997). Thedrug abuse test.United States: VCI Home Video.

Nelson,D. E. (2011). Teendrug abuse.Detroit: Gale Cengage Learning.

Schinke,S. P., Botvin, G. J., &amp Orlandi, M. A. (1991). Substanceabuse in children and adolescents: Evaluation and intervention.Newbury Park, Calif: Sage Publications.

SpinalInjuries.(2004). Zone Press Pty Ltd.

Tarter,R. E., Vanyukov, M. M., &amp Center for Education and Drug AbuseResearch. (2001). Etiologyof substance use disorder in children and adolescents: Emergingfindings from the Center for Education and Drug Abuse Research.New York: Haworth Press.