Fever And Headache Case Study Health And Social Care Essay

Prior to parturiency, the client chows balanced repasts daily. He bespeaks Multivitamins. He drinks 8-12 spectacless of H2O daily. He does nt hold any nutrient supersensitised reactions. His lesions heal fast. Complete set of dentitions, does nt utilize dental plates. The client is digital audiotape ( diet as tolerated ) diet with no dark colored nutrients. elimination PatternThe client does nt hold discompose extinguishing. He does nt utilize laxatives. His earn is formed. He defecates one snip or twice daily. No jobs see when urinating. His piss is recipe in colour and sum. Upon parturiency, the client defecates one time day-to-day. Still no trouble urinating.Activity and ExerciseThe client has commensurate energy to make the day-to-day activities he desired. He jogs around their puny town sometimes. He likes to read books during his trim clip. He can to the total take attention of himself. dapple in the infirmary, the client walks around his room. He feels weak most of the clip, because he is merely lying down. He watches picture 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 further seeks advice from his older child.Sleep/RestBefore parturiency, the client does nt hold trouble kiping. He makes certain to acquire adequate remainder for the following cardinal hours s activities. He does nt see incubuss. Now, the client said that he was non able-bodied to kip good because he is really concerned about his wellness. He sleeps a small late and wakes up early the following 24 hours.Self-perceptionThe client describes himself as simple and determined. He feels good about himself. He does nt let petty jobs to acquire the outflank of him.Role-RelationshipThe client lives with his sister and her household. They parting with the family disbursals. Whenever they encounter jobs, they sit down and discourse the m.Sexuality-ReproductiveThe client is sexually industrious but refuses to speak about his sexual life.Coping/Stress borderWhen 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 nt take any medicines or drugs. He handles jobs maturely.Values/BeliefsThe client is spiritual. He prays frequently, though seldom attends citizenry. He has programs for himself in the hereafter and he says he will make his best to accomplish them.Family AssessmentNameRelationAgeSexual action mechanismOccupationeducational AttainmentC.GWife31FGross saless ManagerCollege GraduateHeredoMaternal nonePaternal NoneDevelopmental account statementTheoristAgeTask/StagePatient DescriptionErikson36 y/oGenerativity vs. StagnationThe long-suffering is concerned about others. He makes the most out of his clip.Freud36 y/oGenital classThe patient is sexually active .Piaget36 y/oFormal OperationssThe patient thinks about how to cover and work out jobs encountered.Kohlberg36 y/oPost ConventionalThe patient is concerned about his single rights.Fowler36 y/oConjunctive FaithThe patient is cognizant of the honor and takes the enterprise to detect it.Physical ExaminationHeight 55 Weight 70 kilogramVoltBP cxxx/90 mmHg RR 26 cpm PR 72 beats per minute scratch upLight brown in colourBirthmark on swiftness 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 nervus nervus facialisis characteristicsSymmetric facial motionsNo facial hairNo tangible multitudes, lesions, cicatrixsEyessEyebrows symmetrical and every morsel distributed, equal motionsEyelashs equally distributedEyelids be integral, no stains symmetrical motionStudents are every bit circular and reactive to illum eEarsColor same as facial tegument, symmetricalPinna recoils after it is foldedNo dischargeNose out-of-door olfactory organ is symmetric, unvarying in colour, non tender, no lesions, no discharges adenoidal septum integralMaxillary and frontal fistulas non tenderMouth and Pharynx outermost lips symmetric, unvarying in colour, can purse lipsInner lips are garden pinkNo losing dentition, pinkish gumsTongue is in the centre, pink in colour, moves freelyNeckMuscles are equal, caput centeredCan travel neck with no uncomfortablenessNo tangible multitudesSpinal column spur track is straight, shoulders and hips are at same tallnessThorax/LungsSkin intact, no tenderness, no tangible multitudes( + ) wheezesCardiovascular/HeartJugular venas non seeable isobilateral pulsing on peripheral pulsationsCapillary refill trial & lt 4secs convergeSymmetricalAbdomensSkin uniform in colourSymmetrical motions caused by respirationAudible intestine soundsNo tendernessExtremitiesUniform in colour, symmetr icSymmetrical pulsing of peripheral pulsationsCapillary refill & lt 4 secsGenitaliasREFUSEDRectum and AnusREFUSEDPersonal/Social HistoryHabits He likes to read and travel to the promenadeFrailties Drinks on fountainLife style ActiveClient s usual 24 hours like After acquiring off from work, he finds clip to substitute and read a book.Rank in the household 2nd put one overTravel Went to Bacolod for 10 yearssEducational Attainment College GraduateIII. Environmental HistoryThe client lives in a private subdivision in Malabon, manila paper with his sister and her household. He describes their small town as quiet and peaceable. a couple of(prenominal) autos pass by their street. They segregate their refuse and maintain their milieus clean.IV. PathophysiologyA. Theoretical establishDengue Hemorrhagic febrilityPredisposing Factor Age Sexual activity-ImmunodeficiencyPrecipitating Factor Aedes aegypti mosquitoBite of a virus transporting mosquitoMosquito injects eloquent into victi m s tegumentVirus enters in the host s linage watercourseInfects cells and replicate in sufficient sum platelet will supply a shield for the virus from exposure and screening to neutralize preexistent antibody.Novices immune system responseStimulates release of cytokinesenergizing 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 wallCytolysis equilibrate activation systemFluid switchingICF to ECFCoagulopathy ( PT, PTT )ThrombocytopeniaVasculopathy ( plasm escape )Vascular endothelian cell activationHigh Fever, organic mental synthesis failing, concern, sickness & A purging, abdominal bother, petechial roseola in countries of the organic structure, cover stool ( sometimes )B. Client BasedDengue Hemorrhagic FeverNon-modifiable Factors Age 36 y/o Sexual activity masculineModifiable 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 economic consumption of thrombocytesScheduled BTFor replacingHematologic studies reveal that patient has low stem base countDengue Titer Test Done( + )Which states that patient has course of instruction 1 DHF with marks and symptoms manifestedV. Laboratory ResultsUrinalysis ( 7/14/10 )ExaminationConsequenceInterpretationColor ictericYellow in colour may bespeak concentration in urineTransparencySlightly CloudypH6.0pH and unique(predicate) gravitation is within normal boundsSpecific Gravity1.010Glucose damagingProtein++Transeunt lift due to infectionBloodNegativeKetone++ much fats are being used for energy alternatively of glucoseNitriteNegative bilirubinNegativeBlood ( 7/14/10 )Examination average ValueConsequenceInterpretationHemoglobin140-175 g/L141 radiation diagramHematrocrit 0.42-0.500.44Normal red blood cell Count4.50-5.90 Ten 1012/L4.92Normal white blood cell Count4.00-1.050 Ten 109/L4.40Normal basophile0.00-0.01Eisonophil0.01-0.04Pang0.02-0.050.01NormalNeutrophil0.36-0.660.69NormalLymphocyte0.24-0.440.16The 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 )Examin ationNormal ValueConsequenceInterpretationActivated partial(p) 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 shape 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.ImpressionLeft Hydrocoele.Normal Testiss and epididymesNo grounds of varicocoeleVIII. List of precedence Problem1. Hyperthermia related to desiccation utility(prenominal) winding to DHF phase 12. wanting(p) 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 ( nour ishment as Tolerated ) with NDCF ( No Dark Colored Foods ) Proctor VS q4, rigorous I & A O Dx process CBC, Platelet count, Potassium, Urinalysis Dengue Titers skipper of educations Aeknil 1 A IV q4Nafarin 1 check TIDAzithromycin 500 milligram OD7/15/10 Addition unwritten fluid white plague Dx process Blood Typing ( Result Bachelor of humanistic discipline )7/16/10 Facilitate station BT as legitimate 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 Cold compress 10 min BOD and shift key to warm compress 10 Command Scrotal Support7/20/10 May travel placeTen. Discharge PlanMedicine Celebrex two hundred milligram 1 check 2x a twenty-four hours PRN for hurtingExercise Avoid strenuous exercisingsTreatment Patient must take medicines for hurting as needed.Bed remainder.Increase unwritten fluid intakeHealth Education Promote patient to hold a florid life style.Practice good hygiene.Diet Diet as tolerated. go th rough balanced repasts daily, nutrients high in fibre.