Fever And Headache Case Study Health And Social Care Essay

Prior to parturiency, the thickening chows balanced repasts daily. He fritters Multivitamins. He drinks 8-12 spectacless of H2O daily. He does nt comport any nutrient allergic reactions. His lesions retrieve fast. Complete set of dentitions, does nt use dental plates. The leaf node is DAT ( diet as tolerated ) diet with no dark colored nutrients.Elimination PatternThe client does nt hold bring out extinguishing. He does nt utilize laxatives. His stool is formed. He defecates one time or twice daily. No jobs experienced when urinating. His piss is normal in colour and sum. Upon parturiency, the client defecates one time day-to-day. Still no trouble urinating.Activity and ExerciseThe client has sufficient energy to establish the day-to-day activities he desired. He jogs a assault their fiddling town sometimes. He wants to read books during his trim clip. He can to the full take attention of himself. While in the infirmary, the client walks around his room. He feels weak inti mately of the clip, because he is merely lying imbibe. He watches telecasting while in the infirmary.Cognitive-PerceptualThe client does nt hold hearing troubles and does nt utilize hearing AIDSs. He does nt have on reading spectacless. He normally decides for himself but seeks advice from his older sister.Sleep/RestBefore parturiency, the client does nt hold trouble sleeping. He makes certain to acquire adequate remainder for the following twenty-four hours s activities. He does nt see incubuss. Now, the client said that he was non able to kip good because he is really concerned about his wellness. He sleeps a small late and wakes up early the following twenty-four hours.Self-perceptionThe client describes himself as simple and determined. He feels good about himself. He does nt let petty jobs to acquire the best of him.Role-RelationshipThe client lives with his sister and her household. They portion with the family disbursals. Whenever they encounter jobs, they sit down and disc ourse them.Sexuality-ReproductiveThe client is sexually active but refuses to speak about his sexual life.Coping/Stress ToleranceWhen stressed, the client tries to loosen up himself beginning(a) before confronting the job because he might do determinations he will repent. He talks to his sister or close friends whenever he has jobs. He does nt take any medicines or drugs. He handles jobs maturely.Values/BeliefsThe client is spiritual. He prays frequently, though seldom attends mass. He has programs for himself in the hereafter and he says he will make his best to accomplish them.Family AssessmentNameRelationAgeSexual activityOccupationEducational AttainmentC.GWife31FGross saless ManagerCollege GraduateHeredoMaternal nonePaternal NoneDevelopmental HistoryTheoristAgeTask/StagePatient DescriptionErikson36 y/oGenerativity vs. StagnationThe patient is concerned about others. He makes the most out of his clip.Freud36 y/oGenital PhaseThe patient is sexually active.Piaget36 y/oFormal Opera tionssThe patient thinks about how to hide and work out jobs encountered.Kohlberg36 y/oPost ConventionalThe patient is concerned about his single rights.Fowler36 y/o connexion FaithThe patient is cognizant of the truth and takes the enterprise to detect it.Physical ExaminationHeight 55 Weight 70 kilogramVoltBP 130/90 mmHg RR 26 cpm PR 72 beats per minute barkLight brown in colourBirthmark on upper part of armUniform temperature in custodies and pessSkin turgor & lt 2 secsNo lentigosNailsPink nail bedsIntegral tegument environing the nailsBlanch trial or capillary refill & lt 4secsHead and FaceHead is round in formSymmetric facial characteristicsSymmetric facial motionsNo facial hairNo apparent multitudes, lesions, cicatrixsEyessEyebrows harmonious and as distributed, equal motionsEyelashs equally distributedEyelids are integral, no stains symmetrical motionStudents are every bit circular and reactive to illumeEarsColor same as facial tegument, symmetricalPinna recoils after i t is foldedNo dischargeNoseExternal olfactory organ is symmetric, unvarying in colour, non tender, no lesions, no dischargesNasal septum integral maxilla and frontal fistulas non tenderMouth and PharynxOuter lips symmetric, unvarying in colour, can purse lipsInner lips are pinkNo losing dentition, pinkish gums vernacular is in the centre, pink in colour, moves freelyNeckMuscles are equal, caput centeredCan travel cervix with no uncomfortablenessNo tangible multitudesSpinal columnSpine is straight, shoulders and hips are at same tallnessThorax/LungsSkin intact, no tenderness, no tangible multitudes( + ) wheezesCardiovascular/Heart jugular vein venas non seeable cruciform pulsing on peripheral pulsationsCapillary refill trial & lt 4secsBreastSymmetricalAbdomensSkin uniform in colourSymmetrical motions caused by respirationAudible intestine soundsNo tendernessExtremitiesUniform in colour, symmetricSymmetrical pulsing of peripheral pulsationsCapillary refill & lt 4 secsGenitaliasREFUS EDRectum and AnusREFUSEDPersonal/Social HistoryHabits He likes to read and travel to the promenadeFrailties Drinks on occasionLife style ActiveClient s usual twenty-four hours like After acquiring off from work, he finds clip to rest and read a book.Rank in the household 2nd kidTravel Went to Bacolod for 10 yearssEducational Attainment College GraduateIII. environmental HistoryThe client lives in a private subdivision in Malabon, Manila with his sister and her household. He describes their small town as quiet and peaceable. Few autos pass by their street. They segregate their refuse and maintain their milieus clean.IV. PathophysiologyA. Theoretical BasedDengue Hemorrhagic FeverPredisposing ingredient Age Sexual activity-ImmunodeficiencyPrecipitating Factor Aedes aegypti mosquitoBite of a virus transporting mosquitoMosquito injects fluid into victim s tegumentVirus enters in the host s blood watercourseInfects cells and replicate in sufficient sumPlatelet will supply a shield for th e virus from video and binding to neutralize preexistent antibody.Novices immune system responseStimulates release of cytokinesActivation of memory T-cell response during re-exposureMacrophages or monocytes engulfed the virus holding a thrombocyte ( phagocytosis )Virus-antibody compositeCytokines destroy cell membrane and cell wallCytolysisComplement activation systemFluid switchingICF to ECFCoagulopathy ( PT, PTT )ThrombocytopeniaVasculopathy ( plasma shunning )Vascular endothelian cell activationHigh Fever, organic structure failing, concern, sickness & A purging, abdominal hurting, petechial roseola in countries of the organic structure, bloody stool ( sometimes )B. Client BasedDengue Hemorrhagic FeverNon-modifiable Factors Age 36 y/o Sexual activity MaleModifiable Factors-ImmunodeficiencyPoor Environmental SanitationAedis Aegypti Mosquito bitesCreates multiple lesions in the blood watercourseIncrease phagocytic activityVirus multiply in blood streamAfter 2-3 yearss incubation , febrility appearsParacetamol givenExcessive ingestion of thrombocytesScheduled BTFor replacingHematologic studies reveal that patient has low home base countDengue Titer tribulation Done( + )Which states that patient has grade 1 DHF with marks and symptoms manifestedV. Laboratory ResultsUrinalysis ( 7/14/10 )ExaminationConsequenceInterpretationColorYellowYellow in colour may bespeak tightfistedness in urineTransparencySlightly CloudypH6.0pH and specific gravitation is within normal boundsSpecific Gravity1.010Glucose banishProtein++Transeunt lift due to infectionBlood controvertKetone++More fats are being used for energy alternatively of glucoseNitriteNegativeBilirubinNegativeBlood ( 7/14/10 )Examination chemical formula ValueConsequenceInterpretationHemoglobin140-175 g/L141 traffic patternHematrocrit0.42-0.500.44NormalRBC Count4.50-5.90 Ten 1012/L4.92NormalWBC Count4.00-1.050 Ten 109/L4.40NormalBasophil0.00-0.01Eisonophil0.01-0.04Pang0.02-0.050.01NormalNeutrophil0.36-0.660.69No rmal lymphocyte0.24-0.440.16The patient is compromised because of immunodeficiency.Monocyte0.02-0.120.14NormalPlatelet Count150.00-450.00X109/L125The patient s thrombocyte count is below normal scope which means that there no equal coagulating map.Blood ( 7/19/10 )ExaminationNormal ValueConsequenceInterpretationHemoglobin140-175 g/L140NormalHematrocrit0.42-0.500.43NormalRBC Count4.50-5.90 Ten 1012/L4.84NormalWBC Count4.00-1.050 Ten 109/L7.37NormalBasophil0.00-0.01Eisonophil0.01-0.040.04NormalPang0.020.02-0.05NormalNeutrophil0.36-0.660.53NormalLymphocyte0.24-0.440.30NormalMonocyte0.02-0.120.11NormalPlatelet Count150.00-450.00X109/L215NormalPotassium ( 7/17/10 )ExaminationNormal ValueConsequenceInterpretationPotassium3.50-5.50mg/dL3.7NormalCurdling and Hemostasis ( 7/18/10 )ExaminationNormal ValueConsequenceInterpretationActivated incomplete Thromboplastin- Patient22.60-35.00 secs32.6NormalActivated Partial Thromboplastin- Control22.60-35.00 secs30.2NormalUltrasound Result ( 7/17/10 )ExaminationConsequenceDoppler Scrotal/TestesThe testicles are normal in size, echopatterns and constellation with no focal lesions noted. The right steps about 4.4 tens 2.6 s2.1 centimeter ( LWH ) . While the left steps about 4.0 tens 2.8 ten 2.1 centimeter ( LWH ) . No extratesticular mass lesion is noted. The epididumes are non unusual. uncaring fluid aggregation is seen within the left scrotal pouch.ImpressionLeft Hydrocoele.Normal Testiss and epididymesNo grounds of varicocoeleVIII. List of Priority Problem1. Hyperthermia link up to evaporation secondary to DHF phase 12. Deficient Fluid volume related to active fluid volume secondary bleeding3. Activity Intolerance related to generalise failing secondary to DHF phase 1IX. Ongoing Appraisal7/14/10 On DAT ( Diet as Tolerated ) with NDCF ( No Dark Colored Foods ) proctor VS q4, rigorous I & A O Dx process CBC, Platelet count, Potassium, Urinalysis Dengue Titers Master of educations Aeknil 1 A IV q4Nafarin 1 check TIDAzithromyci n ergocalciferol milligram OD7/15/10 Addition unwritten fluid intake Dx process Blood Typing ( Result Bachelor of liberal arts )7/16/10 Facilitate station BT as ordered Give antamin 1 amp 30 min prior to BT7/17/10 Warm compress over scrotal are TID7/18/10 WOF marks of shed blooding7/19/10 parky compress 10 min BOD and displacement to warm compress 10 Command Scrotal Support7/20/10 may travel placeTen. Discharge PlanMedicine Celebrex 200 milligram 1 check 2x a twenty-four hours PRN for hurtingExercise Avoid strenuous exercisings sermon Patient must take medicines for hurting as needed.Bed remainder.Increase unwritten fluid intakeHealth Education Promote patient to hold a healthy life style.Practice good hygiene.Diet Diet as tolerated.Eat balanced repasts daily, nutrients high in fibre.