Fever And Headache Case Study Health And Social Care Essay

Prior to parturiency, the client chows balanced repasts daily. He takes Multivitamins. He drinks 8-12 spectacless of H2O daily. He does n't hold any nutrient allergic reactions. His lesions heal fast. Complete set of dentitions, does n't utilize dental plates. The client is DAT ( diet as tolerated ) diet with no dark colored nutrients. Elimination Pattern The client does n't hold trouble extinguishing. He does n't 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 Exercise The client has sufficient energy to make the day-to-day activities he desired. He jogs around their small town sometimes. He likes 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 most of the clip, because he is merely lying down. He watches telecasting while in the infirmary. Cognitive-Perceptual The client does n't hold hearing troubles and does n't utilize hearing AIDSs. He does n't have on reading spectacless. He normally decides for himself but seeks advice from his older sister. Sleep/Rest Before parturiency, the client does n't hold trouble kiping. He makes certain to acquire adequate remainder for the following twenty-four hours ‘s activities. He does n't 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-perception The client describes himself as simple and determined. He feels good about himself. He does n't let petty jobs to acquire the best of him. Role-Relationship The client lives with his sister and her household. They portion with the family disbursals. Whenever they encounter jobs, they sit down and discourse them. Sexuality-Reproductive The client is sexually active but refuses to speak about his sexual life. Coping/Stress Tolerance When stressed, the client tries to loosen up himself foremost 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 n't take any medicines or drugs. He handles jobs maturely. Values/Beliefs The 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 AssessmentName Relation Age Sexual activity Occupation Educational Attainment C.G Wife 31 F Gross saless Manager College GraduateHeredoMaternal: None Paternal: NoneDevelopmental HistoryTheorist Age Task/Stage Patient Description Erikson 36 y/o Generativity vs. Stagnation The patient is concerned about others. He makes the most out of his clip. Freud 36 y/o Genital Phase The patient is sexually active. Piaget 36 y/o Formal Operationss The patient thinks about how to cover and work out jobs encountered. Kohlberg 36 y/o Post Conventional The patient is concerned about his single rights. Fowler 36 y/o Conjunctive Faith The patient is cognizant of the truth and takes the enterprise to detect it.Physical ExaminationHeight: 5'5 Weight: 70 kilogram Volt BP: 130/90 mmHg RR: 26 cpm PR: 72 beats per minute Skin Light brown in colour Birthmark on upper part of arm Uniform temperature in custodies and pess Skin turgor & lt ; 2 secs No lentigos Nails Pink nail beds Integral tegument environing the nails Blanch trial or capillary refill & lt ; 4secs Head and Face Head is round in form Symmetric facial characteristics Symmetric facial motions No facial hair No tangible multitudes, lesions, cicatrixs Eyess Eyebrows symmetrical and equally distributed, equal motions Eyelashs equally distributed Eyelids are integral, no stains ; symmetrical motion Students are every bit circular and reactive to illume Ears Color same as facial tegument, symmetrical Pinna recoils after it is folded No discharge Nose External olfactory organ is symmetric, unvarying in colour, non tender, no lesions, no discharges Nasal septum integral Maxillary and frontal fistulas non tender Mouth and Pharynx Outer lips symmetric, unvarying in colour, can purse lips Inner lips are pink No losing dentition, pinkish gums Tongue is in the centre, pink in colour, moves freely Neck Muscles are equal, caput centered Can travel cervix with no uncomfortableness No tangible multitudes Spinal column Spine is straight, shoulders and hips are at same tallness Thorax/Lungs Skin intact, no tenderness, no tangible multitudes ( + ) wheezes Cardiovascular/Heart Jugular venas non seeable Symmetrical pulsing on peripheral pulsations Capillary refill trial: & lt ; 4secs Breast Symmetrical Abdomens Skin uniform in colour Symmetrical motions caused by respiration Audible intestine sounds No tenderness Extremities Uniform in colour, symmetric Symmetrical pulsing of peripheral pulsations Capillary refill: & lt ; 4 secs Genitalias REFUSED Rectum and Anus REFUSEDPersonal/Social HistoryHabits: He likes to read and travel to the promenade Frailties: Drinks on occasion Life style: Active Client ‘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 kid Travel: Went to Bacolod for 10 yearss Educational Attainment: College Graduate III. Environmental History The 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 Based Dengue Hemorrhagic Fever Predisposing Factor: – Age – Sexual activity -Immunodeficiency Precipitating Factor – Aedes aegypti mosquito Bite of a virus transporting mosquito Mosquito injects fluid into victim ‘s tegument Virus enters in the host ‘s blood watercourse Infects cells and replicate in sufficient sum Platelet will supply a shield for the virus from exposure and binding to neutralize preexistent antibody. Novices immune system response Stimulates release of cytokines Activation of memory T-cell response during re-exposure Macrophages or monocytes engulfed the virus holding a thrombocyte ( phagocytosis ) Virus-antibody composite Cytokines destroy cell membrane and cell wall Cytolysis Complement activation system Fluid switching ICF to ECF Coagulopathy ( PT, PTT ) Thrombocytopenia Vasculopathy ( plasma escape ) Vascular endothelian cell activation High Fever, organic structure failing, concern, sickness & A ; purging, abdominal hurting, petechial roseola in countries of the organic structure, bloody stool ( sometimes ) B. Client Based Dengue Hemorrhagic Fever Non-modifiable Factors: – Age: 36 y/o – Sexual activity: Male Modifiable Factors: -Immunodeficiency Poor Environmental Sanitation Aedis Aegypti Mosquito bites Creates multiple lesions in the blood watercourse Increase phagocytic activity Virus multiply in blood stream After 2-3 yearss incubation, febrility appears Paracetamol given Excessive ingestion of thrombocytes Scheduled BT For replacing Hematologic studies reveal that patient has low home base count Dengue Titer Test Done( + )Which states that patient has grade 1 DHF with marks and symptoms manifestedV. Laboratory ResultsUrinalysis ( 7/14/10 )ExaminationConsequenceInterpretationColor Yellow Yellow in colour may bespeak concentration in urine Transparency Slightly Cloudy–pH 6.0 pH and specific gravitation is within normal bounds Specific Gravity 1.010 Glucose Negative–Protein++Transeunt lift due to infection Blood Negative–Ketone++More fats are being used for energy alternatively of glucose Nitrite Negative–Bilirubin Negative–Blood ( 7/14/10 )ExaminationNormal ValueConsequenceInterpretationHemoglobin 140-175 g/L 141 Normal Hematrocrit 0.42-0.50 0.44 Normal RBC Count 4.50-5.90 Ten 10^12/L 4.92 Normal WBC Count 4.00-1.050 Ten 10^9/L 4.40 Normal Basophil 0.00-0.01––Eisonophil 0.01-0.04––Pang 0.02-0.05 0.01 Normal Neutrophil 0.36-0.66 0.69 Normal Lymphocyte 0.24-0.44 0.16 The patient is compromised because of immunodeficiency. Monocyte 0.02-0.12 0.14 Normal Platelet Count 150.00-450.00X10^9/L 125 The patient ‘s thrombocyte count is below normal scope which means that there no equal coagulating map.Blood ( 7/19/10 )ExaminationNormal ValueConsequenceInterpretationHemoglobin 140-175 g/L 140 Normal Hematrocrit 0.42-0.50 0.43 Normal RBC Count 4.50-5.90 Ten 10^12/L 4.84 Normal WBC Count 4.00-1.050 Ten 10^9/L 7.37 Normal Basophil 0.00-0.01––Eisonophil 0.01-0.04 0.04 Normal Pang 0.02 0.02-0.05 Normal Neutrophil 0.36-0.66 0.53 Normal Lymphocyte 0.24-0.44 0.30 Normal Monocyte 0.02-0.12 0.11 Normal Platelet Count 150.00-450.00X10^9/L 215 NormalPotassium ( 7/17/10 )ExaminationNormal ValueConsequenceInterpretationPotassium 3.50-5.50mg/dL 3.7 NormalCurdling and Hemostasis ( 7/18/10 )ExaminationNormal ValueConsequenceInterpretationActivated Partial Thromboplastin- Patient 22.60-35.00 secs 32.6 Normal Activated Partial Thromboplastin- Control 22.60-35.00 secs 30.2 NormalUltrasound Result ( 7/17/10 )ExaminationConsequenceDoppler Scrotal/Testes The 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. Free fluid aggregation is seen within the left scrotal pouch. Impression: Left Hydrocoele. Normal Testiss and epididymes No grounds of varicocoeleVIII. List of Priority Problem1. Hyperthermia related to desiccation secondary to DHF phase 1 2. Deficient Fluid volume related to active fluid volume secondary bleeding 3. 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 q4 Nafarin 1 check TID Azithromycin 500 milligram OD 7/15/10 – Addition unwritten fluid intake – Dx process: Blood Typing ( Result: Bachelor of arts ) 7/16/10 – Facilitate station BT as ordered – Give antamin 1 amp 30 min prior to BT 7/17/10 – Warm compress over scrotal are TID 7/18/10 – WOF marks of shed blooding 7/19/10 – Cold compress 10 min BOD and displacement to warm compress 10 Command – Scrotal Support 7/20/10 – May travel placeTen. Discharge PlanMedicine: Celebrex 200 milligram 1 check 2x a twenty-four hours PRN for hurting Exercise: Avoid strenuous exercisings Treatment: Patient must take medicines for hurting as needed. Bed remainder. Increase unwritten fluid intake Health Education: Promote patient to hold a healthy life style. Practice good hygiene. Diet: Diet as tolerated. Eat balanced repasts daily, nutrients high in fibre.