Case study :Dengue fever

Dengue fever

4

5214680067

( 482)

/case study Dengue fever

2 2555

1.

HN 59646

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21 2555

2. Chief complaint

2

3. History Interview

3.1 Present Illness


2

3

1 3

3.2 Past History

3.3 Family History

3.4 Personal History

-

- 1

-

3.5 History of drug allergy


-

3.6 History of system ; ROS

:

1-2

:

:

2

:

:

:

:


:

:

1-2

:

: 3

3

:

:

:

:


:

4. Physical Examination

21 2555

4.1 Vital signsBT = 39 °c P = 104 R = 20

BP = 130/72 mmHg

Weight 58KgsHeight 166cms

BMI = 21.04Kg/m2

4.2 Psychosocial assessment

Normal body build ,good conscious ,well orientation ,no

pale,look weak and tried,well participate and coordination ,well

co-orperation

4.3 Physical assessment

Skin


Red skin and warm to touch ,no cyanosis ,no jaundice ,no
abnormal pigment,good skin turgor ,rare papule at both arms

and numerous papule at chest

Nails

Pink in color ,normal shape , clean and short nails, no

clubbing fingers, no spoon nails,capillary refill <2 s.

Head and Neck

Normal shape andsize,Symmetry,no lesion ,no evidence

of trauma , no enlargement of lympnodes ,no distentedvien

,Full range of motion

Eyes

Normal eye contour , eyebrows and eyelids no edema ,

No icteric sclera ,no injection ,normal conjunctivas , normal

extra 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 of

post auticularlympnodes.

Nose


Normal external configuration,symmetry, midline septum

,Turbinate-pink,normal nasal mucosa,nopolyps,noswelling,no

bleeding,no tenderness at maxillary and frontal sinus.

Mouth

Normal shape and size ,Moisture lips,pink oral mucosa

and gingival,normal salivation ,no lesion

Tongue

Normal papillae, no glossitis ,frenulumintract .normal size

and texture,Intact hard and soft palate.

Throat

Pharynx and tonsil not inject ,tonsil 1 ,uvala in midline ,no

lymphadenopathy

Neck

Normal shape and size ,Symmetrical from all angles ,no

distenededvein,full range of motion.no massandcysts,Trachea

in midline, no enlargement of thyroid gland

Chest


Normal chest contour andsymmetry.A-P

diameter:transverse diameter = 1:2 no kyphosis,scoliosis and

lordosis,Rt=Lt.Respiratory rate 20 bpm rhythm regular.No mass

and tenderness,Rt and Lt axially lymph node no mass and

tendernsee

Lung

Normal lungexpansion,normal air entry ,Lung sound

clear ,no adventitious sound.

Heart

Normal S1S2,no splitting,heart rate 115 bpm. ,no murmur

and thrill.

Abdomen

Normal size and shape,no distension,no ascites,no

scar,no lesion,normal active bowel sound ,Soft , no mass,no

tenderness,liver and spleen not palpable,Abdomen

tympanic percussion, ,CVA not tenderness.

Genitalia Not done


Rectal Examination Not done

Musculoskeletal system

No deformities of arms and legs ,normal movement joint ,

not swelling ,Full rang of motion,muscle power grade Lt= 5

,Rt=5

Neurologic system

Good conscious,E4V5M6,sensation normal, pupil react

to light 3 mm.both eyes

5. Differential Diagnosis

5.1 Problem lists

5.1.1

1) ( Fever )

2) ( Severe headache )

3) ( Appetite )

4)

(Muscle aches )


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 event

1) ( Dengue fever )

2) ( Acute pyelonephritis )

3) Influenza )

4) Malaria


24 2

Dengue virus macrophage

3-15
Endrogenouspyrogen
hypothalamus

2

antibody

cytokines , Metabolism rate
maidiators prostaglandins
complement

permeability


Plasma

hypovolemic
shock

ORS

Tourniquet test Positive

-

6.

Dengue fever Dengue fever

21 /11/2555

/


Touniquet test Positiv
e
CBC : WBC 5000- 12700
Hct 10,90 cell/mm3

Hb 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 32-42 203,00
Neutrophill 1400 0

Eosinophile 00- 44%

‘ Basophils 4400 2%

00 42%(ba

10-59 nd 12%)
2-10 0%
40-75 0%
1.0-
6.0
0-1
UA :Color Yello Yellow
Sp.gr. w ,clear
pH ,clear 1.003-


WBC 1.021 1.030
RBC 5.6 4.6-8
Protien 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


(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 =


data)
104
-look weak and tried
-Red skin and warm
to touch
- Rare papule at
both arms and
numerous papule at
chest
-Tourniquet test
Positive
- CBC
:WBC12700


data)
Tourniquet test , cell/mm3
Neutrophill42%(ban
--
d 12%)

-

Acute - -
Pyelo 24
neph -
ytis


data)
- -

-
Escherichia coli), Klebsiella), -Body temperature
Pseudomonas) 39˚cP = 104
-

4
,
, ,
,
- CVA not


data)
tenderness
UA :
ColorYellow, clear
WBC 1-2 cell/HP
RBC 1-2
cell/HP
Bacteria Negative

-


data)
Influe DNA influenza - --

nza virus type A,B,C influenza type A
Type B

- -

-1 -

1. 1-
3
4 2
-
-


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

1

2.


data)

, , ,
, 65
38.5-40 ˚c


data)
Malar - --

ia 4

- -

2

--- -

Body temperature


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


data)

3


data)

48
3 72
4


data)


- 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 +
CBC

Paracetamal

Paracetamol

Prostaglandins


Neutrophill

30-60

7

1.

2.

3.

Oral rehydration salt

Oral rehydration salt(ORS)


1.

2.
Hct
3.

TolperisoneHCl

Tolperisone

Cholinergic


1.

2.

(permanent problem

list )

Problem 21/11/2555 23/11/2555 Activity
No.
1). Fever Fever Active
2). Severe headache Severe headache Inactive
3). Mild Dehydration Mild Dehydration Active
4). Appetite Appetite Active
5). Muscle aches Muscle aches Active
6). Diarrhea Diarrhea Inactive

Plan of Management

Problem #1 Fever

Subjecti 2
ve
Objectiv - Body temperature 39˚c PR = 104


e - look weak and tried
- Red skin and warm to touch
Assess
ment

Plan 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 :


1.Observe body temperature
2. Paracetamal (500 mg) 2 tab stat
3. Tourniquet test 5
4. (CBC)
5.
Problem #2 Severe headache

Subjective 2
Objective -
Assessme
nt

mediator

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


Subjective - 2

1 3

-

Objective - Body temperature ˚c PR=104
--look weak and tried
Red skin and warm to touch

Assessment invisible

loss , ,

plasma

CBC
, Tourniquet test
Treatment plan: Oral rehydration salt
Nursing plan :
1.

2.

2000-2500 ml.

Problem #4 Appetite


Subje - 2 1

ctive 3

Object - look weak and tried

ive

Asses

sment Dengue virus

CBC
, Tourniquet test
Treatment plan: -
Nursing plan :
1.

2.

Problem #5 Muscle aches

Subjec 2

tive


Objecti - look weak and tried

ve

Asses

sment


CBC

, Tourniquet test

Treatment plan: - TolperisoneHCl (50 mg)1x3  pc

Nursing plan :

1. Pain scale

2.

Problem #6 Diarrhea


Subject - 1 3

ive

Objecti -

ve

Assess

ment mediator

Plan Diagnotic plan : -


Nursing plan :

1.

2.

2000-2500 ml.

3.


Patient education plan

1.

-

2.

3.

4.

5


6

7 -

8.

Paracetamal (500 mg)

2 4- 6

Oral rehydration

salt

24

TolperisoneHCl

1 - -

9. 23

2555


Visiting Progression note

1 23 /11/2555

/

CBC : WBC 5000- 2700

10,90 cell/mm

0 3
Hct

Hb
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


/

Monocyte 14000 270,000

0-
Neutrophill 54%
44000
Eosinophile 1%
0
‘ Basophils 40%(ba
10-59
nd 57%)
2-10
0%
40-75
0%
1.0-

6.0

0-1

Progress Note

Problem #1 Fever


Subjective

Objective - Body temperature 37.8˚c PR = 96

- look weak and tried

- Red skin and warm to touch

Assessment

Plan 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 headache

Subjectiv


e

Objective -

Assessm Paracetamol

ent Prostaglandin


CBC )
Treatment plan: -Paracetamal ( mg) tab  q
- hrprn. for pain ( )
Nursing plan :
Pain
scale

Problem #3Mild Dehydration

Subjectiv -

e
-

-

Objective - Body temperature 37.8 ˚c PR=96


--look weak and tried

Red skin and warm to touch

- Hct 37%

Assessm invisible

ent loss , ,

plasma


CBC )


Nursing plan :

1.

2.

2000-2500 ml.

Problem #4 Appetite

Subjectiv -


e

Objective - mild look weak and tried

Assessm

ent Dengue virus


CBC )

Treatment plan: -

Nursing plan :

1.

2.

Problem #5 Muscle aches

Subjectiv -

e

Objective - look weak and tried

Assessm

ent



CBC )

Treatment plan: - TolperisoneHCl (50 mg)1x3 

pc

Problem #6 Diarrhea

Subject -

ive

Objecti -

ve

Assess

ment mediator

Plan Diagnotic plan : -



24

2

3

1

3

21 11 2555 10.00

1) Fever )

2) Severe headache )

3) (dehydration)

3) Appetite )

4)

Muscle aches )

5) Diarrhea )


Vital sign : BT = 39 ˚c P = 104 R = 20

BP = 130/72 mmHg

Dengue virus infection

Tourniquet test : Positive

CBC WBC 2700 cell/mm3,Neutrophill40%(band 57%) , PLT

270000 cell/mm3,Hct 37%

Case 39

PR 104


23 11/2555

CBC CBC WBC cell/mm , Neutrophill band

, PLT cell/mm ,Hct


Final Diagnosis : Dengue fever , Thalassemia trait

39 PR 104

,


Paracetamal (500

mg) 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


Patient education

,

,

,

,


,

Follow up23 2555


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Limited Partnership.

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Case study :Dengue fever

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