Case study :Dengue fever
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Case study :Dengue fever

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Case study :Dengue fever Case study :Dengue fever Document Transcript

  • Dengue fever 4 5214680067( 482) /case study Dengue fever
  • 2 25551. HN 59646 24 16/3 10 21 25552. Chief complaint 23. History Interview 3.1 Present Illness /case study Dengue fever
  • 2 31 33.2 Past History3.3 Family History3.4 Personal History-- 1-3.5 History of drug allergy /case study Dengue fever
  • - 3.6 History of system ; ROS :1-2 : : 2 : : : : /case study Dengue fever
  • : : 1-2 : : 3 3 : : : : /case study Dengue fever
  • :4. Physical Examination 21 2555 4.1 Vital signsBT = 39 °c P = 104 R = 20BP = 130/72 mmHgWeight 58KgsHeight 166cms BMI = 21.04Kg/m2 4.2 Psychosocial assessment Normal body build ,good conscious ,well orientation ,nopale,look weak and tried,well participate and coordination ,wellco-orperation 4.3 Physical assessmentSkin /case study Dengue fever
  • Red skin and warm to touch ,no cyanosis ,no jaundice ,noabnormal pigment,good skin turgor ,rare papule at both armsand numerous papule at chestNails Pink in color ,normal shape , clean and short nails, noclubbing fingers, no spoon nails,capillary refill <2 s.Head and Neck Normal shape andsize,Symmetry,no lesion ,no evidenceof trauma , no enlargement of lympnodes ,no distentedvien,Full range of motionEyes Normal eye contour , eyebrows and eyelids no edema ,No icteric sclera ,no injection ,normal conjunctivas , normalextra ocular movement ,pupil 3 mm. react to light both eyes.Ears Normal external structure ,normal ear canal ,no ear wax,no abnormal discharge , normal hearing ,no enlargement ofpost auticularlympnodes.Nose /case study Dengue fever
  • Normal external configuration,symmetry, midline septum,Turbinate-pink,normal nasal mucosa,nopolyps,noswelling,nobleeding,no tenderness at maxillary and frontal sinus.Mouth Normal shape and size ,Moisture lips,pink oral mucosaand gingival,normal salivation ,no lesionTongue Normal papillae, no glossitis ,frenulumintract .normal sizeand texture,Intact hard and soft palate.Throat Pharynx and tonsil not inject ,tonsil 1 ,uvala in midline ,nolymphadenopathyNeck Normal shape and size ,Symmetrical from all angles ,nodistenededvein,full range of motion.no massandcysts,Tracheain midline, no enlargement of thyroid glandChest /case study Dengue fever
  • Normal chest contour andsymmetry.A-Pdiameter:transverse diameter = 1:2 no kyphosis,scoliosis andlordosis,Rt=Lt.Respiratory rate 20 bpm rhythm regular.No massand tenderness,Rt and Lt axially lymph node no mass andtendernseeLung Normal lungexpansion,normal air entry ,Lung soundclear ,no adventitious sound.Heart Normal S1S2,no splitting,heart rate 115 bpm. ,no murmurand thrill.Abdomen Normal size and shape,no distension,no ascites,noscar,no lesion,normal active bowel sound ,Soft , no mass,notenderness,liver and spleen not palpable,Abdomentympanic percussion, ,CVA not tenderness.Genitalia Not done /case study Dengue fever
  • Rectal Examination Not doneMusculoskeletal system No deformities of arms and legs ,normal movement joint ,not swelling ,Full rang of motion,muscle power grade Lt= 5,Rt=5Neurologic system Good conscious,E4V5M6,sensation normal, pupil reactto light 3 mm.both eyes5. Differential Diagnosis 5.1 Problem lists 5.1.1 1) ( Fever ) 2) ( Severe headache ) 3) ( Appetite ) 4)(Muscle aches ) /case study Dengue fever
  • 5) ( Diarrhea ) 5.1.2 - Vital sign BT = 39 °c P = 104 R = 20 BP = 130/72 mmHg - ( dehydration ) - Tourniquet test :Positive Problem list sequence of event1) ( Dengue fever )2) ( Acute pyelonephritis )3) Influenza )4) Malaria /case study Dengue fever
  • 24 2 Dengue virus macrophage 3-15 Endrogenouspyrogen hypothalamus 2 antibody cytokines , Metabolism ratemaidiators prostaglandinscomplement permeability /case study Dengue fever
  • Plasma hypovolemic shock ORSTourniquet test Positive - 6. Dengue fever Dengue fever 21 /11/2555 / /case study Dengue fever
  • Touniquet test Positiv eCBC : WBC 5000- 12700Hct 10,90 cell/mm3Hb 0 38% MCV 37-54 12.7 MCH % 49.5 MCHC 14-18 16.7 PLT 80-92 33.8 Lymphocyte 27-31 g/dL Band Monocyte 32-42 203,00Neutrophill 1400 0Eosinophile 00- 44%‘ Basophils 4400 2% 00 42%(ba 10-59 nd 12%) 2-10 0% 40-75 0% 1.0- 6.0 0-1UA :Color Yello Yellow Sp.gr. w ,clear pH ,clear 1.003- /case study Dengue fever
  • WBC 1.021 1.030 RBC 5.6 4.6-8Protien 1-2 0-2 Sugar 1-2 0-2 Ketone Negat Negativ ive e Bacteria Negat Negativ ive e 1+ Negativ e Negat ive Negativ e /case study Dengue fever
  • (Positive data) (Negative data)Deng - -ue /fever , - Aedesaegypt ) - - liver and spleen not - 2 palpable - CBC:Hct 38% PLT203,000cell/m -Body temperature m3 39˚c P = /case study Dengue fever
  • (Positive data) (Negative data)104-look weak and tried-Red skin and warmto touch- Rare papule atboth arms andnumerous papule atchest-Tourniquet testPositive- CBC:WBC12700 /case study Dengue fever
  • (Positive data) (Negative data) Tourniquet test , cell/mm3 Neutrophill42%(ban -- d 12%) -Acute - -Pyelo 24neph -ytis /case study Dengue fever
  • (Positive data) (Negative data) - - -Escherichia coli), Klebsiella), -Body temperature Pseudomonas) 39˚cP = 104 - 4 , , , , - CVA not /case study Dengue fever
  • (Positive data) (Negative data) tenderness UA : ColorYellow, clear WBC 1-2 cell/HP RBC 1-2 cell/HP Bacteria Negative- /case study Dengue fever
  • (Positive data) (Negative data)Influe DNA influenza - --nza virus type A,B,C influenza type A Type B - - -1 - 1. 1- 3 4 2 - - /case study Dengue fever
  • (Positive data) (Negative data) -Body temperature ˚c P = -Pharynx and tonsil not inject , 39-40 c --look weak and tonsil 1+, no tried lymphadenopathy Red skin and -Tourniquet test 2-4 warm to touch Positive 12. /case study Dengue fever
  • (Positive data) (Negative data) , , , , 6538.5-40 ˚c /case study Dengue fever
  • (Positive data) (Negative data)Malar - --ia 4 - - 2 --- - Body temperature /case study Dengue fever
  • (Positive data) (Negative data) ˚c P = 2-3 - --Red skin and - 2-3 warm to touch 3 look weak and 2 tried - BP = mmHg - liver and 15-60 spleen not palpable -2 /case study Dengue fever
  • (Positive data) (Negative data)3 /case study Dengue fever
  • (Positive data) (Negative data)483 72 4 /case study Dengue fever
  • (Positive data) (Negative data) /case study Dengue fever
  • - Tourniquet test ,CBC , UA Tourniquet test- Paracetamal (500 mg) 2 tab -Paracetamal (500 mg) 2 tabprn for fever q 4-6 hr prn for fever q 4-6 hr #20- Oral rehydration salt - Oral rehydration salt #10- TolperisoneHCl (50 mg)1x3 pc - TolperisoneHCl (50 mg)1x3  pc #20 - F/U 23 2555 + CBCParacetamal Paracetamol Prostaglandins /case study Dengue fever
  • Neutrophill 30-60 7 1. 2. 3.Oral rehydration salt Oral rehydration salt(ORS) /case study Dengue fever
  • 1. 2. Hct 3.TolperisoneHCl Tolperisone Cholinergic /case study Dengue fever
  • 1. 2. (permanent problemlist )Problem 21/11/2555 23/11/2555 Activity No.1). Fever Fever Active2). Severe headache Severe headache Inactive3). Mild Dehydration Mild Dehydration Active4). Appetite Appetite Active5). Muscle aches Muscle aches Active6). Diarrhea Diarrhea InactivePlan of ManagementProblem #1 FeverSubjecti 2veObjectiv - Body temperature 39˚c PR = 104 /case study Dengue fever
  • e - look weak and tried - Red skin and warm to touchAssessmentPlan Diagnotic plan : CBC , Tourniquet test Treatment plan: -Advice force oral fluid 2000-2500 ml/day -Paracetamal (500 mg) 2 tab q 4-6 hrprn. for fever Nursing plan : /case study Dengue fever
  • 1.Observe body temperature 2. Paracetamal (500 mg) 2 tab stat 3. Tourniquet test 5 4. (CBC) 5.Problem #2 Severe headacheSubjective 2Objective -Assessment mediatorPlan Diagnotic plan : CBC , Tourniquet test Treatment plan:-Paracetamal (500 mg) 2 tab  q 4-6 hrprn. for pain Nursing plan : 1. Pain scale 2.Problem #3Mild Dehydration /case study Dengue fever
  • Subjective - 2 1 3 -Objective - Body temperature ˚c PR=104 --look weak and tried Red skin and warm to touchAssessment invisible loss , , plasmaPlan Diagnotic plan : CBC , Tourniquet test Treatment plan: Oral rehydration salt Nursing plan : 1. 2. 2000-2500 ml.Problem #4 Appetite /case study Dengue fever
  • Subje - 2 1ctive 3Object - look weak and triediveAssessment Dengue virusPlan Diagnotic plan : CBC , Tourniquet test Treatment plan: - Nursing plan : 1. 2.Problem #5 Muscle achesSubjec 2tive /case study Dengue fever
  • Objecti - look weak and triedveAssessmentPlan Diagnotic plan : CBC , Tourniquet test Treatment plan: - TolperisoneHCl (50 mg)1x3  pc Nursing plan : 1. Pain scale 2.Problem #6 Diarrhea /case study Dengue fever
  • Subject - 1 3iveObjecti -veAssessment mediatorPlan Diagnotic plan : - Treatment plan: Oral rehydration salt Nursing plan : 1. 2. 2000-2500 ml. 3. /case study Dengue fever
  • Patient education plan1. -2.3.4.5 /case study Dengue fever
  • 67 -8. Paracetamal (500 mg)2 4- 6 Oral rehydrationsalt 24 TolperisoneHCl 1 - -9. 232555 /case study Dengue fever
  • Visiting Progression note 1 23 /11/2555 /CBC : WBC 5000- 2700 10,90 cell/mm 0 3HctHb 37-54 37% MCV % 12.8 MCH 14-18 49.1 MCHC 80-92 16.7 PLT 27-31 34.2 Lymphocyte 32-42 g/dL Band /case study Dengue fever
  • / Monocyte 14000 270,000 0-Neutrophill 54% 44000Eosinophile 1% 0‘ Basophils 40%(ba 10-59 nd 57%) 2-10 0% 40-75 0% 1.0- 6.0 0-1Progress NoteProblem #1 Fever /case study Dengue fever
  • SubjectiveObjective - Body temperature 37.8˚c PR = 96 - look weak and tried - Red skin and warm to touchAssessmentPlan Diagnotic plan : CBC Treatment plan: -Paracetamal (500 mg) 2 tab q 4-6 hrprn. for fever ( ) Nursing plan : 1.Observe body temperature 2. (CBC) 3.Problem #2 Severe headacheSubjectiv /case study Dengue fever
  • eObjective -Assessm Paracetamolent ProstaglandinPlan Diagnotic plan : CBC ) Treatment plan: -Paracetamal ( mg) tab  q - hrprn. for pain ( ) Nursing plan : Pain scaleProblem #3Mild DehydrationSubjectiv -e - -Objective - Body temperature 37.8 ˚c PR=96 /case study Dengue fever
  • --look weak and tried Red skin and warm to touch - Hct 37%Assessm invisibleent loss , , plasmaPlan Diagnotic plan : CBC ) Treatment plan: Oral rehydration salt Nursing plan : 1. 2. 2000-2500 ml.Problem #4 AppetiteSubjectiv - /case study Dengue fever
  • eObjective - mild look weak and triedAssessment Dengue virusPlan Diagnotic plan : CBC ) Treatment plan: - Nursing plan : 1. 2.Problem #5 Muscle achesSubjectiv -eObjective - look weak and triedAssessment /case study Dengue fever
  • Plan Diagnotic plan : CBC ) Treatment plan: - TolperisoneHCl (50 mg)1x3  pcProblem #6 DiarrheaSubject -iveObjecti -veAssessment mediatorPlan Diagnotic plan : - Treatment plan: Oral rehydration salt /case study Dengue fever
  • 24 2 3 1 3 21 11 2555 10.00 1) Fever ) 2) Severe headache ) 3) (dehydration) 3) Appetite ) 4)Muscle aches ) 5) Diarrhea ) /case study Dengue fever
  • Vital sign : BT = 39 ˚c P = 104 R = 20BP = 130/72 mmHg Dengue virus infectionTourniquet test : PositiveCBC WBC 2700 cell/mm3,Neutrophill40%(band 57%) , PLT270000 cell/mm3,Hct 37% Case 39 PR 104 Tourniquet test Positive 23 11/2555CBC CBC WBC cell/mm , Neutrophill band , PLT cell/mm ,Hct /case study Dengue fever
  • Final Diagnosis : Dengue fever , Thalassemia trait 39 PR 104 ,Tourniquet test Positive Paracetamal (500mg) 2 tab prn for fever q 4-6 hr , Oral rehydration salt ,TolperisoneHCl (50 mg)1x3  pc 23 11/2555 BT 37.8 CBC CBC WBC cell/mm ,Neutrophill band , PLT cell/mm ,Hct /case study Dengue fever
  • Patient education , , , , /case study Dengue fever
  • ,Follow up23 2555 /case study Dengue fever
  • NP PressLimited Partnership. 2548 . . 1. : /case study Dengue fever
  • /case study Dengue fever