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 Assessment
Name
Relation
Age
Sexual activity
Occupation
Educational Attainment
C.G
Wife
31
F
Gross saless Manager
College Graduate
Heredo
Maternal: None
Paternal: None
Developmental History
Theorist
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 Examination
Height: 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
REFUSED
Personal/Social History
Habits: 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. Pathophysiology
A. 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 manifested
V. Laboratory Results
Urinalysis ( 7/14/10 )
Examination
Consequence
Interpretation
Color
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 )
Examination
Normal Value
Consequence
Interpretation
Hemoglobin
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 )
Examination
Normal Value
Consequence
Interpretation
Hemoglobin
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
Normal
Potassium ( 7/17/10 )
Examination
Normal Value
Consequence
Interpretation
Potassium
3.50-5.50mg/dL
3.7
Normal
Curdling and Hemostasis ( 7/18/10 )
Examination
Normal Value
Consequence
Interpretation
Activated Partial Thromboplastin- Patient
22.60-35.00 secs
32.6
Normal
Activated Partial Thromboplastin- Control
22.60-35.00 secs
30.2
Normal
Ultrasound Result ( 7/17/10 )
Examination
Consequence
Doppler 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 varicocoele
VIII. List of Priority Problem
1. 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 1
IX. Ongoing Appraisal
7/14/10
– 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 place
Ten. Discharge Plan
Medicine: 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.