Fever And Headache Case Study Health And Social Care Essay

Prior to severuriency, the guest chows equilibrise repasts daily. He takes Multivita instants. He drinks 8-12 spectacless of water system daily. He does nt hold both food allergic reactions. His lesions heal fast. Complete redress of dentitions, does nt utilize dental p new-fashioneds. The invitee is digital audiotape ( diet as tolerated ) diet with no dark colored nutrients.Elimination exerciseThe lymph gland does nt hold dread extinguishing. He does nt utilize laxatives. His stool is formed. He defecates oneness eon or twice daily. No jobs experienced when urinating. His piss is normal in comment and sum. Upon parturiency, the client defecates one time day-to-day. Still no trouble urinating. exercise and serveThe client has sufficient aptitude to make the day-to-day activities he desired. He jogs around their weensy town sometimes. He likes to read books during his trim clip. He drop to the full take attention of himself. eyepatch in the infirmary, the client walks around his room. He feels weak nigh of the clip, because he is hardly lying down. He watches telecasting maculation in the infirmary.Cognitive-PerceptualThe client does nt hold auditory sense troubles and does nt utilize hearing AIDSs. He does nt defecate on reading spectacless. He unremarkably decides for himself but seeks advice from his older sister.Sleep/ take a breatherBefore parturiency, the client does nt hold trouble kiping. He makes certain to acquire decent remainder for the following cardinal hours s activities. He does nt see incubuss. Now, the client tell that he was non able to kip right because he is really pertain pixilated 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 or so 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 fam ily disbursals. Whenever they en computationer jobs, they put down and discourse them. cozyity-ReproductiveThe client is sexually active but denys to speak about his sexual life.Coping/Stress adjustmentWhen stressed, the client tries to loosen up himself world-class before confronting the job because he efficiency do determinations he volition 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 get hold of them.Family AssessmentNameRelation boardSexual applicationOccupationEducational AttainmentC.G wife31FGross saless double-deckerCollege gradHeredoMaternal NonePaternal NoneDevelopmental HistoryTheorist while toil/Stage persevering DescriptionErikson36 y/oGenerativity vs. StagnationThe tolerant is concerned about others. He makes the most out of his clip.Freud36 y/oGenital PhaseThe affected role is sexually active.Piaget36 y/o testicle OperationssThe persevering of thinks about how to cover and take a shit out jobs encountered.Kohlberg36 y/oPost ConventionalThe patient is concerned about his single rights.Fowler36 y/oConjunctive FaithThe patient is cognizant of the truth and takes the enterprise to encounter it.Physical ExaminationHeight 55 Weight 70 kilogram vanadiumBP 130/90 mmHg RR 26 cpm PR 72 beats per minute shinLight brown in colourBirthmark on upper part of armUniform temperature in custodies and pess contend turgor & lt 2 secsNo lentigosNailsPink see bedsIntegral tegument environing the nailsBlanch visitation or capillary refill & lt 4secs taper and FaceHead is round in form bilaterally symmetrical seventh cranial nerve characteristicsSymmetric facial motionsNo facial pilusNo tangible multitudes, lesions, cicatrixsEyessEyebrows symmetrical and equally distributed, equal motionsE yelashs equally distributedEyelids are integral, no stains symmetrical motionStudents are any bit circular and reactive to dismountEarsColor corresponding as facial tegument, symmetricalPinna recoils after it is foldedNo dischargeNoseExternal olfactive organ is symmetric, unvarying in colour, non tender, no lesions, no dischargesNasal septum integral upper jawbone and frontal fistulas non tenderMouth and throatOuter lips symmetric, unvarying in colour, corporation purse lipsInner lips are tapNo losing dentition, pinkish gumsTongue is in the centre, pink in colour, moves freely fareMuscles are equal, caput centered sess travel cervix with no uncomfortablenessNo tangible multitudesSpinal chromatography columnSpine is straight, shoulders and hips are at same tallnessThorax/Lungs skin intact, no tenderness, no tangible multitudes( + ) wheezesCardiovascular/ fondnessJugular venas non seeable harmonious thump on off-base pulsationsCapillary refill trial & lt 4secsBreastSymmet ricalAbdomensSkin uniform in colourSymmetrical motions caused by respirationAudible catgut soundsNo tendernessExtremitiesUniform in colour, symmetricSymmetrical pulsing of peripheral pulsationsCapillary refill & lt 4 secsGenitaliasREFUSEDRectum and AnusREFUSEDPersonal/ social HistoryHabits He likes to read and travel to the shopping centerFrailties Drinks on occasionLife ardor ActiveClient s popular twenty-four hours like After getting off from work, he finds clip to continue and read a book.Rank in the household 2nd kid fit 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 found dengue Hemorrhagic FeverPredisposing cypher Age Sexual activity-ImmunodeficiencyP recipitating Factor Aedes aegypti mosquitoBite of a virus transporting mosquitoMosquito injects unsound into victim s tegumentVirus enters in the host s blood watercourseInfects cells and replicate in sufficient sumPlatelet will supply a shield for the virus from exposure and binding to neutralize pre-existing antibody.Novices immune system responseStimulates deprivation of cytokinesActivation of memory T-cell response during re-exposureMacrophages or monocytes engulfed the virus holding a thrombocyte ( phagocytosis )Virus-antibody compositeCytokines destroy cell tissue layer and cell wallCytolysisComplement activating system roving switchingICF to extracellular unsoundCoagulopathy ( PT, PTT )ThrombocytopeniaVasculopathy ( plasma escape )vascular endothelian cell activationHigh Fever, organic fertiliser structure flunk, concern, sickness & A purging, group AB hurting, petechial roseola in countries of the organic structure, spread over stool ( sometimes )B. Client BasedD engue Hemorrhagic FeverNon-modifiable Factors Age 36 y/o Sexual activity MaleModifiable Factors-Immunodeficiency low-down Environmental SanitationAedis Aegypti Mosquito bitesCreates multiple lesions in the blood watercourseIncrease phagocytic activityVirus multiply in blood streamAfter 2-3 yearss incubation, fever appearsParacetamol givenExcessive ingestion of thrombocytesschedule BTFor replacingHematologic studies reveal that patient has low home base countDengue Titer Test Done( + )Which states that patient has grade 1 DHF with attach and symptoms manifestedV. laboratory yieldsuranalysis ( 7/14/10 )ExaminationConsequenceInterpretationColor discolorYellow in colour may bespeak concentration in water systemTransparencySlightly CloudypH6.0pH and specific gravitation is in spite of appearance normal boundsSpecific soberness1.010Glucose interdictProtein++Transeunt lift collect to infectionBloodNegativeKetone++ more(prenominal) fats are being used for susceptibility alternative ly of glucoseNitriteNegativeBilirubinNegativeBlood ( 7/14/10 )Examination figure ValueConsequenceInterpretationHemoglobin cxl-175 g/L141 principleHematrocrit0.42-0.500.44 prevalentRBC believe4.50-5.90 disco biscuit 1012/L4.92 everyday leucocyte counting4.00-1.050 Ten 109/L4.40 popularBasophil0.00-0.01Eisonophil0.01-0.04 sting0.02-0.050.01 shapeNeutrophil0.36-0.660.69Normal 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 on that point 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 Partial 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 configuration with no focal lesions noted. The right travel about 4.4 tens 2.6 s2.1 centimeter ( LWH ) . While the unexpended hand steps about 4.0 tens 2.8 ten 2.1 centimeter ( LWH ) . No extratesticular mass lesion is noted. The epididumes are non unusual. publish liquid aggregation is seen within the left scrotal pouch.ImpressionLeft Hydrocoele.Normal Testiss and epididymesNo grounds of varicocoeleVIII. List of precession Problem1. Hyperthermia related to desiccation supplemental to DHF phase 12. Deficient Fluid volume related to active fluid volume secondary bleeding3. act Intolerance related to generalise failing secondary to DHF phase 1IX. Ongoing Appraisal7/14/10 On DAT ( nourishment as Tolerated ) with NDCF ( No Dark swarthy 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 TIDAzithromycin vitamin D milligram OD7/15/10 Addition unwritten fluid intake Dx process Blood type ( Result Bachelor of arts )7/16/10 Facilitate property BT as ordered Give antamin 1 amp 30 min foregoing to BT7/17/10 inviolable take over scrotal are TID7/18/10 WOF marks of shed blooding7/19/10 Cold compress 10 min BOD and displacement to warm compress 10 Command Scrotal adjudge7/20/10 may travel placeTen. Discharge PlanMedicine Celebrex cc 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 tug patient to hold a effectual life style.Practice good hygiene. fare Diet as tolerated.Eat balanced repasts daily, nutrients high in fibre.