St. Anne College Lucena Inc.

Diversion Road G- Gulang

Lucena City

In Partial Fulfillment for Academic Requirements

In Related Learning Experience

A Case of Dengue Hemorrhagic Fever

Prepared by:
Joy Rachel D. Tabernilla
Margaret R. Maano
Rose Ann Marbida
Lalaine R. Andal
Gerwin Perlas
BSN IV-B

Presented to:
Nursing Faculty

October, 2010
 TABLE OF CONTENTS

I. OBJECTIVES…………………………………………………………............
..............................2
a. General Objectives
b. Specific Objectives

II. PATIENT
PROFILE………………………………………………………………………
…………………….…..2
a. Biographical data of the patient
b. Clinical data of the patient

III. HISTORY………………………………………………………….................
............................4
a. Nursing History
i. Chief Complain
ii. Admitting Diagnosis
iii. Physical Examination
iv. Final Diagnosis
b. Present Health History
i. 24 hours recall of events
ii. Signs and symptoms experienced by the patient
c. Past Health History
i. Hospitalizations
ii. Surgical Managements
iii. Allergies
1. Foods
2. Drugs
iv. Others

IV. NUTRITION…………………………………………………………..............
.......................4
a. 24 hours food recall
b. Regular/Routine diet
c. Intake and output
d. Vices and habits

V. DISEASE
ENTITY…………………………………………………………………………
…………….5
a. Definition
b. Etiology
c. Transmission
d. Occurrence/Epidemiology
e. Anatomy of the organ involved

VI. PATHOPHYSIOLOGY…………………………………………………………
……………………..11

VII. MANAGEMENT………………………………………………………………
……………………….12
a. Medical Management
b. Nursing Management
c. Pharmacologic Management

VIII. LABORATORY…………………………………………………………..........
......................14
a. Blood analysis

2
 b. X-ray
c. Ultrasound

IX. NURSING CARE

PLAN…………………………………………………………………………….

X. DISCHARGE
PLAN……………………………………………………………………………
…….17

3
I. OBJECTIVES

a. GENERAL OBJECTIVES:

In the light of knowledge, the main goal of the study is to

develop skills, knowledge and right attitude about the case
dengue hemorrhagic fever and its managements. Through this,
we could be able to share it with our fellow students.

b. SPECIFIC OBJECTIVES:

Upon accomplishment of this study, students will be able

to:
 To define the case and its effects to human body.
 To enhanced our knowledge and learning regarding the
disease identity.
 To have a complete details or background about the
patients profile and nutritional status.
 To identify the possible complication that may occur
during the early and late phases of disease.
 To review the anatomy and physiology of the client,
specifically the involve systems
 To develop skills regarding the care of patient with
dengue hemorrhagic fever and its managements.

II. PATIENT PROFILE

a. Biographical data of the patient

Name: N.P.d R.
Age: 9years old
Gender: Female
Date of Birth: September 19, 2000
Civil Status: Child
Nationality: Filipino
Address: Gitnang Bayan Mogpog,
Marinduque
Religion: Roman Catholic

b. Clinical data of the patient

Diagnosis: R/I DHF

Chief Complain: fever and rashes, abdominal
pain
Diet: NPO
Room: 332-b
Attending Physician: Dra. M. A. C.
Date and Time of Admission: July 10, 2010 at 7:48 pm
Date and Time of Discharge: July 17, 2010 at 1:30 pm
Case #: 462679
Membership: Self pay
Type of admission: New
Hospital: St. Anne General Hospital

III.HISTORY
a. Nursing History

4
 i. Chief Complain: fever and rashes, abdominal pain
ii. Admitting Diagnosis: R/I DHF

iii. Physical Examination:

a. GENERAL ASSESMENT:
• conscious and coherent
• cooperative
• with oxygen inhalation at 3LPM via nasal
canula
• weigh f 24 kilograms
VITAL SIGNS: Temperature: 38.5 degrees celcius
PR: 109bpm
RR: 26bpm
BP: 90/60 mmHg
b. PHYSICAL ASSESSMENT
HEAD: >Skull is symmetrical.
>Hair is dry, not brittle and generally color black
EARS: >no discharges noted
EYES: >with pinkish conjunctiva
>with anicteric sclera
NOSE: >no nasal discharge
THROAT/MOUTH :> with dry pale lips
>with slightly moist oral buccal mucosa
SKIN: >with macula-papula rashes
c. REVIEW OF SYSTEM
CHEST & LUNGS: >with symmetrical chest expansion
>Not in respiratory distress
>with rashes
GASTRO-INTESTINAL: >with soft non tender abdomen
upon palpation
>with complain of pain of lower abdomen
GENITO-URINARY: >Bladder is not distended
>with diarrhea; 3 times watery stool, moderate
in amount
EXTREMITIES :> range of motion is normal
>with rashes on upper and lower extremities
>with capillary refill of 4-5 seconds

iv. Final Diagnosis:

 DHF grade II

b. Present Health History

i. 24 hours Recall of Events

The mother of the child stated that prior to

admission, the patient experienced 3 days fever and
develop pruritic-erythematous rashes on upper and
lower extremities.

ii. Signs and symptoms experienced by the

patient
 Fever

5
  pruritic-erythematous rashes
 abdominal pain
 vomiting

c. Past Health History

i. Hospitalizations: none
ii. Surgical Managements: none
iii. Allergies
1. Foods: egg white
2. Drugs: no known allergies
iv. Immunization: complete

v.

IV. NUTRITION

a. 24 hour food recall

24 hours prior to admission patient had taken the
following foods:
 Dinner- 1 cup of rice, 1 piece fried chicken
 Breakfast- lugaw with 1 piece bread
 Lunch- Jollibee burger steak with rice
The patient daily consumption was more on carbohydrates,
some protein and with fewer fats.

b. Regular/Routine diet
Patient regular diet was more on processed foods
and chicken with sometimes fish. She doesn’t like to eat
vegetables. Since she is the youngest, her parents gave
her what she wants.

c. Intake and output

Date and Time Input Output

07/ 11/ 10 – 8am -3x- UO BM- 3x watery

Vomiting- 2x mod.
Amt
- 6 pm
-BM- 2x watery
Vomiting- 2x mod.
amt
07/ 12/ 10 – 4pm 4x- UO BM- 4x watery
Vomiting- 3x mod.
amt
- 6 pm
4x- UO BM- 4x watery
Vomiting- 2x mod.
Amt
07/ 13/ 10 – 4pm 4x- abd. Girth 13 inch

- 6 am 4x- abd. Girth- 24.5

1867cc 660cc
07/ 14/ 10 1587cc 1680cc
07/ 15/ 10 550cc 2000cc

6
 2x BM brownish soft
07/ 16/ 10 250cc 1600cc

d. Vices and habits

The patient love to eat junk foods while in school

every snack time and buy street foods like isaw, betamax
and fishball. After school, she always went to computer
shop with her cousins to play online games.

V. DISEASE ENTITY

a. Definition

Dengue fever is an acute febrile disease caused by infection

with one of the serotypes of dengue virus which is transmitted by
mosquito genus Aedes.

It refers to a benign form of disease with systemic

symptoms, fever, and often rash associated with pain behind the
eyes, the joints, and bones.Dengue hemorrhagic fever is a
severe, sometimes fatal manifestation of dengue virus infection
characterized by a bleeding diathesis and hypovolemic shock.

b. Etiology

 Flaviviruses 1, 2, 3, 4, a family of Togaviridae are small

viruses that contain single strand RNA.

 Arboviruses group B

c. Transmission

1. By bite of an infected mosquito, principally the Aedes

Egypti

2. Aedes albopictus may contribute to trnsmission of engue

virus in rural areas.

3. Other contributory mosquitoes:

a. Aedes polynensis

b. Aedes scutellaris simplex

7
 d. Occurrence/Epidemiology

Dengue is the most rapidly spreading mosquito-borne

viral disease in the world. In the last 50 years, incidence has
increased 30-fold with increasing geographic expansion to
new countries and, in the present decade, from urban to rural
settings. An estimated 50 million dengue infections occur
annually and approximately 2.5 billion people live in dengue
endemic countries. The 2005 World Health Assembly
resolution WHA55.17 urged greater commitment to dengue
by WHO and its Member States. Of particular significance is
the 2008 World Health Assembly resolution WHA58.3 on the
revision of the International Health Regulations (IHR), which
includes dengue as an example of a disease that may
constitute a public health emergency of international concern
with implications for health security due to disruption and
rapid epidemic spread beyond national borders.

e. Anatomy of the organs involved

i. Integumentary Sytem

The skin is the body's

largest organ, covering the
entire body. In addition to
serving as a protective shield
against heat, light, injury,
and infection, the skin also:

• regulates body
temperature.
• stores water and fat.
• is a sensory organ.
• prevents water loss.
• prevents entry of bacteria.

Throughout the body, the skin's characteristics (thickness,

color, texture) vary. For instance, the head contains more hair
follicles than anywhere else, while the soles of the feet contain
none. In addition, the soles of the feet and the palms of the hands
are much thicker. The skin is made up of the following layers, with
each layer performing specific functions:
• epidermis
• dermis
• subcutaneous fat layer
epider The epidermis is the thin outer layer of the skin and consists of
mis three parts:

• stratum corneum (horny layer)

This layer consists of fully mature keratinocytes which
contain fibrous proteins (keratins). The outermost layer is
continuously shed. The stratum corneum prevents the
entry of most foreign substances as well as the loss of fluid
from the body.
• keratinocytes (squamous cells)

8
 This layer, just beneath the stratum corneum, contains
living keratinocytes (squamous cells), which mature and
form the stratum corneum.
• basal layer
The basal layer is the deepest layer of the epidermis,
containing basal cells. Basal cells continually divide,
forming new keratinocytes that replace the cells that are
shed from the skin's surface.

The epidermis also contains melanocytes, which are cells that

produce melanin (skin pigment).

dermis The dermis is the middle layer of the skin. The dermis contains
the following:

• blood vessels
• lymph vessels
• hair follicles
• sweat glands
• collagen bundles
• fibroblasts
• nerves

The dermis is held together by a protein called collagen, made

by fibroblasts. This layer also contains pain and touch receptors.

subcuti The subcutis is the deepest layer of skin. The subcutis, consisting
s of a network of collagen and fat cells, helps conserve the body's
heat and protects the body from injury by acting as a shock
absorber.

ii. Circulatory System

The circulatory system is an organ system that passes

nutrients (such as amino acids and electrolytes), gases, hormones,
blood cells, etc. to and from cells in the body to help fight diseases and
help stabilize body temperature and pH to maintain homeostasis.

This system may be seen strictly as a blood distribution network,

but some consider the circulatory system as composed of the
cardiovascular system, which distributes blood, and the lymphatic
system, which distributes lymph. While humans, as well as other
vertebrates, have a closed cardiovascular system (meaning that the
blood never leaves the network of arteries, veins and capillaries), some
invertebrate groups have an open
cardiovascular system. The most
primitive animal phyla lack circulatory
systems. The lymphatic system, on the
other hand, is an open system.
Two types of fluids move through the
circulatory system: blood and lymph.
The blood, heart, and blood vessels form
the cardiovascular system. The lymph,
lymph nodes, and lymph vessels form the
lymphatic system. The cardiovascular

9
system and the lymphatic system collectively make up the circulatory
system.

c. Cardiovascular System

The main components of the human cardiovascular system are

the heart and the blood vessels. It includes: the pulmonary circulation,
a "loop" through the lungs where blood is oxygenated; and the
systemic circulation, a "loop" through the rest of the body to provide
oxygenated blood. An average adult contains five to six quarts
(roughly 4.7 to 5.7 liters) of blood, which consists of plasma, red blood
cells, white blood cells, and platelets. Also, the digestive system works
with the circulatory system to provide the nutrients the system needs
to keep the heart pumping.

Pulmonary circulation
The Pulmonary circulation is the portion of the cardiovascular
system which transports oxygen-depleted blood away from the heart,
to the lungs, and returns oxygenated blood back to the heart.
Oxygen deprived blood from the vena cava enters the right
atrium of the heart and flows through the tricuspid valve into the right
ventricle, from which it is pumped through the pulmonary semilunar
valve into the pulmonary arteries which go to the lungs. Pulmonary
veins return the now oxygen-rich blood to the heart, where it enters
the left atrium before flowing through the mitral valve into the left
ventricle. Then, oxygen-rich blood from the left ventricle is pumped out
via the aorta, and on to the rest of the body.

Systemic circulation
Systemic circulation is the portion of the cardiovascular system
which transports oxygenated blood away from the heart, to the rest of
the body, and returns oxygen-depleted blood back to the heart.
Systemic circulation is, distance-wise, much longer than pulmonary
circulation, transporting blood to every part of the body.

d. Lymphatic
System

Lymphatic system plays a

large role in immune function and
circulation. The lymphatic system
has multiple interrelated
functions:
• it is responsible for the
removal of interstitial fluid
from tissues
• it absorbs and transports fatty acids and fats as chyle to the
circulatory system
• it transports immune cells to and from the lymph nodes in to the
bone
• The lymph transports antigen-presenting cells (APCs), such as
dendritic cells, to the lymph nodes where an immune response is
stimulated.
• The lymph also carries lymphocytes from the efferent lymphatics
exiting the lymph nodes.

10
 It consists of lymph vessels located just under the skin, meeting
up with lymph nodes located in your neck, armpits, and groin area. As
the lymph vessels move fluid out of the tissues, waste products,
bacteria, dead cells, and large protein molecules are collected. The
waste products are carried to the lymph nodes to be broken down and
eliminated, while the protein rich fluid is transported back to the heart
to rejoin circulation.

When the lymph vessels are unable to transport lymph fluid back
into circulation it accumulates, resulting in swelling and thickening of
the skin. This build-up of protein-rich lymph fluid is known as
lymphedema. Once this condition occurs, the swelling may increase if
an effective treatment program is not initiated

iii. Blood

Blood performs many

important functions within the
body including:
• Supply of oxygen to
tissues (bound to
hemoglobin, which is
carried in red cells)
• Supply of nutrients such
as glucose, amino acids,
and fatty acids (dissolved
in the blood or bound to
plasma proteins
a – erythrocytes b - neutrophil
c – eosinophil d - lymphocyte
• Removal of waste such as carbon dioxide, urea, and lactic acid
• Immunological functions, including circulation of white blood
cells, and detection of foreign material by antibodies
• Coagulation, which is one part of the body's self-repair
mechanism (the act of blood clotting when one gets cut to stop
the bleeding)
• Messenger functions, including the transport of hormones and
the signaling of tissue damage
• Regulation of body pH
• Regulation of core body temperature
• Hydraulic functions

Normally, 7-8% of human body weight is from blood. In adults,

this amounts to 4-5 quarts of blood. This essential fluid carries out the
critical functions of transporting oxygen and nutrients to our cells and
getting rid of carbon dioxide, ammonia, and other waste products. In
addition, it plays a vital role in our immune system and in maintaining
a relatively constant body temperature. Blood is a highly specialized
tissue composed of many different kinds of components. Four of the
most important ones are red cells, white cells, platelets, and
plasma.

a) Red Cells

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 Red cells, or erythrocytes, are
relatively large microscopic cells without
nuclei. In this latter trait, they are similar to
the primitive prokaryotic cells of bacteria.
Red cells normally make up 40-50% of the
total blood volume. They transport oxygen
from the lungs to all of the living tissues of
the body and carry away carbon dioxide. The
Human erythrocytes or
red cells are produced continuously in our
"red cells"
bone marrow from stem cells at a rate of (cell diameter about .0003
about 2-3 million cells per second. inches)
Hemoglobin is the gas transporting protein
molecule that makes up 95% of a red cell.
Each red cell has about 270,000,000 iron-rich hemoglobin molecules.
The red color of blood is primarily due to oxygenated red cells.

b) White Cells

White cells, or leukocytes, exist in variable numbers and types

but make up a very small part of blood's volume--normally only about
1% in healthy people. Leukocytes are not limited to blood. They occur
elsewhere in the body as well, most notably in the spleen, liver, and
lymph glands. Most are produced in our bone marrow from the same
kind of stem cells that produce red blood cells. Others are produced in
the thymus gland, which is at the base of the neck. Some white cells
(called lymphocytes) are the first responders for our immune system.
They seek out, identify, and bind to alien protein on bacteria, viruses,
and fungi so that they can be removed. Other white cells (called
granulocytes and macrophages) then arrive to surround and
destroy the alien cells. They also have the function of getting rid of
dead or dying blood cells as well as foreign matter such as dust and
asbestos. Red cells remain viable for only about 4 months before they
are removed from the blood and their components recycled in the
spleen. Individual white cells usually only last 18-36 hours before they
also are removed, though some types live as much as a year. The
description of white cells presented here is a simplification. There are
actually many specialized sub-types of them that participate in
different ways in our immune responses.

c) Platelets

Platelets, or thrombocytes, are

cell fragments without nuclei that work
with blood clotting chemicals at the site
of wounds. They do this by adhering to
the walls of blood vessels, thereby
plugging the rupture in the vascular
wall. They also can release coagulating
chemicals which cause clots to form in
the blood that can plug up narrowed
blood vessels. There are more than a erythrocyte (left),
dozen types of blood clotting factors thrombocyte
and platelets that need to interact in (center), and leukocyte
the blood clotting process. Recent (right)
research has shown that platelets help
fight infections by releasing proteins

12
that kill invading bacteria and some other microorganisms. In addition,
platelets stimulate the immune system. Individual platelets are about
1/3 the size of red cells. They have a lifespan of 9-10 days. Like the
red and white blood cells, platelets are produced in bone marrow from
stem cells.

d) Plasma

Plasma is the relatively clear, yellow tinted water (92+%), sugar,

fat, protein and salt solution which carries the red cells, white cells,
platelets, and some other chemicals. Normally, 55% of our blood's
volume is made up of plasma. About 95% of it consists of water. As
the heart pumps blood to cells throughout the body, plasma brings
nourishment to them and removes the waste products of metabolism.
Plasma also contains blood clotting factors, sugars, lipids, vitamins,
minerals, hormones, enzymes, antibodies, and other proteins. It is
likely that plasma contains some of every protein produced by the
body--approximately 500 have been identified in human plasma so far.

Iii. Skeletal System

The Skeletal System serves many important functions; it

provides the shape and form for our bodies in addition to supporting,
protecting, allowing bodily movement, producing blood for the body,
and storing minerals.
Its 206 bones form a rigid framework to which the softer tissues and
organs of the body are attached.
Vital organs are protected by the skeletal system. The brain is
protected by the surrounding skull as the heart and lungs are encased by
the sternum and rib cage.
Bodily movement is carried out by the interaction of the muscular
and skeletal systems. For this reason, they are often grouped together as
the musculo-skeletal system. Muscles are connected to bones by tendons.
Bones are connected to each other by ligaments. Where bones meet one
another is typically called a joint. Muscles which cause movement of a
joint are connected to two different bones and contract to pull them
together. An example would be the contraction of the biceps and a
relaxation of the triceps. This produces a bend at the elbow. The
contraction of the triceps and relaxation of the biceps produces the effect
of straightening the arm.

13
 Blood cells are produced by the marrow located in some bones. An
average of 2.6 million red blood cells are produced each second by the
bone marrow to replace those worn out and destroyed by the liver.
Bones serve as a storage area for minerals such as calcium and
phosphorus. When an excess is present in the blood, buildup will occur
within the bones. When the supply of these minerals within the blood is
low, it will be withdrawn from the bones to replenish the supply.

14
VI. Pathophysiology

Modifiable factor: Non-modifiable Factor:

Environmental conditions Age
Immunocompromised Gender
Sweaty skin

Redness &
Bite from mosquito (Portal of Entry in the Skin) itchiness in the
Aedes aegypti area

Virus goes to the blood/circulation and replicate

Infect cells and generate patechiae

cellular response

Immune response
Release of cytokines which consist of Signs and symptoms:
vasoactive agents such as interleukins, tumor Febrile: 38.5C warm skin,
necrosis factor, urokinase and platelet activating flushed decreased WBC
factors which stimulates WBCs and pyrogen
release

Destruction and infection of red bone marrow causing platelet Signs and symptoms:
lyses Decreasing Platelet
Bleeding, melena
stool
Signs and symptoms:
Decreased WBC
Dengue Hemorrhagic Fever Headache body
grade II weakness
Nausea and vomiting
Abdominal pain

15
 VII. MANAGEMENT

a. Medical Management

Progress notes Doctors order

7-10-10 >Please admit under the service of Dra. Cruz

Wt. 25kg consultation.
Pulse 109bpm >Diet avoid highly colored foods
Temperature >For CBC w/ platelet count, CXR PA L view
38.6 c >D5 0.3 NaCl 500cc x 3hrs
9:30am >Paracetamol 250mg/tab q4 PRN
Hemoglobin 14.3 >Watch out for any signs of bleeding
Hematocrit 0.42 >Monitor VS q4
WBC 2.10 >Refer
Platelet 15

Telephone order
>Repeat CBC w/ platelet tomorrow AM
>IVF to follow D5LR 1L x 16hrs
>Revise Paracetamol 250mg to 325mg/tab 1tab
q4 RTC

(+) abdominal pain Telephone order

>Metronidazole Flagyl 25mg 1ml Suspension
10ml TID
>OMX 1 cap gel BID
>Watch out for bleeding
>Isoprenpsin 250mg/5ml susp. 7.5ml TID
>For repeat CBC, platelet count for PT, PTT,
blood typing, for crea, RBS, SGOT, SGPT, albumin
, Na, K
>IVF to follow D5 0.3NaCl 1L x 14hrs
>Increase present IVF to 24 gtts/min
>Monitor VS w/ BP q4
>Close monitoring

7-11-10 5:38pm >To start Ranitidine (Zantac) 25mg IV q12

>Assess hydration status

7-11-10 6:35 pm >Increase IVF rate to 30gtts/min

>Please relay latest BP

7-12-10 T.O
>To follow D5LR 1L@ 30gtts/min

7-12-10 >Revise Isoprenosin 500/tab ¾ tab TID

16
(-) fever AM >Continue meds
(+) vomiting and
LBM
Good pulse

7-12-10 T.O
>Hold Isoprenosin 500mg/tab ¾ tab TID

7-13-10 >Revise Paracetamol to q4 PRN for fever

(+) abdominal pain >Run PNSS 100cc now for ultrasound of whole
(+)LBM abdomen
(+)abdominal >Ranitidine IV to consume the shift to
distention Famotidine 20mg IV q12
BP 90/70bpm >Monitor Input and Output q4 record pls.
measure abdominal girt every shift and record
Close monitoring

7-13-10 T.O: IVF to follow D5LR 1L x 30gtts/min

7-14-10 >Famotidine 20mg IV now

(+) abdominal pain

7-14-10 Telephone Order

>May not given 6am dose of Famotidine
>Hook Oxygen inhalation via nasal cannula at 1
Lpm
>Give Furosemide 125mg IV now
>Detect if BP is 90/60
>Repeat CBC, platelet count now
>IVF to follow D5 0.3NaCl 1L x 25gtts/min

7-14-10 >Give Furosemide 12.5mg IV at 5pm today then

Hematocrit 0.38 q12
Platelet 74 >Detect for BP L 90/60
Reddish urine >Decrease IVF to 2gtts/min
-yelowish >For repeat CBC, platelet count tom AM
Furosemide >Continuous close monitoring
Stil w/ fever
(+) abdominal pain

7-15-10 Telephone order

Urine output 2.8cc >IVF D5IMB 500cc x 16gtts/min
kg/hr >Please weight patient daily and record please
Hematocrit 0.39 >IVF to follow D5IMB 500cc x 16gtts/min
Platelet 118 >For repeat CBC, platelet count tom
(-) fever 8pm >Continue meds
yesterday >maintain 02 support @ ILMP via nasal canula
75% of
maintenance
56.25cc/kg day
good urine out put
BP 90/60 – 100/80

(-) fever >Same IV to follow

Platelet 236 >Present IVF to consume then we remaining

17
(-) abdominal pain PNSS x16 gtts/min to consume
>D/C 02 support
>D/C furocemid
>D/C OMX
>Fumontedin IV to consume
>For possible discharge tom & input and output
monitoring
7/17/10 Present IVF to consume the D/C
+ cough May go home
BP 100/70 home meds
Good urine out put Metronidazole (FLAGYL) 25 mg/ml susp
10 ml 3x a day for 4 more days
Multivitamins (Cherifer) Susp. 5ml once a day
Ascorbic acid + Ziac (Ceelin plus) supp 5ml once
a day
7 days follow up check up on july 24, 2010 1-
5pm c/o Blue Gate Clinic

b. Nursing Management

1. Assess patient condition

2. Monitor vital signs especially temperature, PR and BP.

3. Instruct to increase fluid intake and advise to eat fruits rich in

vitamin C like oranges, pineapple, bayabas and fruit juices.

4. Instruct to avoid highly colored foods.

5. Render health teachings to eliminate vector such as:

 Water from flower pots should be changed at least once a week

 All containers storing water should be covered with a tight lid
 Discarded container-like objects like tyres, coconut shells, bottles,
etc should be disposed off or destroyed.
 Surface wells should be well-maintained so that mosquitoes do not
breed in the vicinity.
 Treat mosquito nets with insecticides.
 Advised house spraying.
 Avoid too many hanging clothes inside the house.

6. Monitor platelet, hemoglobin and hematocrit count.

7. Emphasize importance of proper hygiene and proper garbage

disposal.

c. Pharmacologic Management

 Paracetamol 250mg/tab 1 tab every 4 hours PRN revised to

Paracetamol 325 mg/tab 1 tab every 4 RTC

18
  Metronidazole(Flaygl) 25mg/mL suspension 10mL TID
 Isoprenosine 250 mg/5mL suspension 7.5 mL TID revised

Isoprenosine 500mg/tab ¾ tab TID

 OMX 1 cap BID

 Ranitidine (Zantac) 25mg IV every 12 hours
 Famotidine 20mg IV every 12 hours
 Furosemide 125mg IV now then every 12 hours

VII. Laboratory

a. Blood analysis (hematology)

• 07/ 09/ 10
Determinants Results Normal Interpretation
Values
Hemoglobin 13.3 F- 12-15 mg/ dL normal
Hematocrit 0.40 F- 0.37- 0.45 normal
RBC 4.1 F- 4.2- 5.4 x 10 ↓- anemia
g/L
WBC 4.05 F- 5-10 x 10g/ L ↓-viral infection
Platelet 190 150- 400 x 10 normal
g/L

• 07/ 10/ 10 – 9:00 am

Determinants Results Normal Interpretation
Values
Hemoglobin 14.3 F- 12-15 mg/ dL normal
Hematocrit 0.42 F- 0.37- 0.45 normal
RBC 4.3 F- 4.2- 5.4 x 10 normal
g/L
WBC 2.15 F- 5-10 x 10 g/ ↓-viral infection
L
Platelet 150 150- 400 x 10 normal
g/L

• 07/ 10/ 10
Determinants Results Normal Interpretation
Values
Hemoglobin 13.1 F- 12-15 mg/ dL normal
Hematocrit 0.39 F- 0.37- 0.45 normal
RBC 4.29 F- 4.2- 5.4 x 10 normal
g/L
WBC 3.8 F- 5-10 x 10 g/ ↓-viral infection
L
Platelet 144 150- 400 x 10 ↓-bleeding
g/L

• 07/ 11/ 10 – 06:30 am

Determinants Results Normal Interpretation

19
 Values
Hemoglobin 12.9 F- 12-15 mg/ dL normal
Hematocrit 0.39 F- 0.37- 0.45 normal
RBC 4.18 F- 4.2- 5.4 x 10 ↓-anemia
g/L
WBC 3.7 F- 5-10 x 10 g/ ↓-viral infection
L
Platelet 100 150- 400 x 10 ↓-bleeding
g/L

• 07/ 12/ 10 – 06:24 am

Determinants Results Normal Interpretation
Values
Hemoglobin 13.6 F- 12-15 mg/ normal
dL
Hematocrit 0.41 F- 0.37- 0.45 normal
RBC 4.65 F- 4.2- 5.4 x 10 normal
g/L
WBC 3.2 F- 5-10 x 10 g/ ↓-viral infection
L
Platelet 72 150- 400 x 10 ↓-bleeding
g/L
ABO blood type A
RH positive

• 07/ 13/ 10 – 03:56 am

Determinants Results Normal Interpretation
Values
Hemoglobin 13.6 F- 12-15 mg/ dL normal
Hematocrit 0.40 F- 0.37- 0.45 normal
RBC 4.86 F- 4.2- 5.4 x 10 normal
g/L
WBC 6.8 F- 5-10 x 10 g/ normal
L
Platelet 64 150- 400 x 10 ↓-bleeding
g/L

• 07/ 14/ 10
Determinants Results Normal Interpretation
Values
Hemoglobin 9.9 F- 12-15 mg/ dL normal
Hematocrit 0.38 F- 0.37- 0.45 normal
RBC 4.5 F- 4.2- 5.4 x 10 normal
g/L
WBC 7.0 F- 5-10 x 10 g/ normal
L
Platelet 74 150- 400 x 10 ↓-bleeding
g/L

• 07/ 15/ 10 – 03:27 am

Determinants Results Normal Interpretation
Values
Hemoglobin 10.3 F- 12-15 mg/ dL normal
Hematocrit 0.39 F- 0.37- 0.45 normal
RBC 4.42 F- 4.2- 5.4 x 10 normal

20
 g/L
WBC 10 F- 5-10 x 10 g/ normal
L
Platelet 118 150- 400 x 10 ↓-bleeding
g/L

• 07/ 16/ 10 – 06:16 am

Determinants Results Normal Interpretation
Values
Hemoglobin 13.6 F- 12-15 mg/ dL normal
Hematocrit 0.40 F- 0.37- 0.45 normal
RBC 4.42 F- 4.2- 5.4 x 10 normal
g/L
WBC 9.1 F- 5-10 x 10 g/ normal
L
Platelet 236 150- 400 x 10 normal
g/L

b. X- RAY (07/10/ 10)

Description:
The lung fields are clear with normal lung roots
The heart, mediastinum, diaphragm and costrophrenic sinuses
appear physiologic
Normal soft tissue and osseous structures in the chest wall

CONCLUSION:
Essentially normal chest findings

c. Ultrasound Report (07/ 13/ 10)

There is moderate amount of free fluid seen at the abdomen

area more on upright posterior recess.
The liver is Normal is size with homogenous echotexture
intrahepatic duct and common bile are not dilated.
Gallbladder measures 41x11 mm with no stone seen. Wall is not
thickened.
Pancreas and Spleen are intact with no focal lesion seen.
The Right Kidney measures 89x36x45 mm with a cortical
thickness of 14mm While Left Kidney measures 87x36x35 mm
with a cortical thickness of 13 mm
Both Kidney shows intact cortimedullary order and central echo
complexes
No stone are noted within
Appendix is slightly dilated to 4 mm
Urinary bladder is well distended and echo free

IMPRESSION:
The possibility of an acute appendicitis is not totally rolled out
Suggest surgical consult
Ascites more on the Right posterior recess
Normal liver, gallbladder, pancreas, spleen, kidney and urinary
bladder sonogram
Please correlate clinically

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 X. DISCHARGE PLAN

M- METHOD
 Instruct home meds such as:
 Metronidazole 25mg/mL 10mL 3x a day for 4 more days
 Multivitamins (Cherifer) suspension 5mL once a day
 Ascorbic Acid + Zinc (Ceelin Plus) suspension 5mL once a day

E- EXERCISE/ENVIRONMENT

 Encourage to have enough sleep and rest to promote faster

recovery.
 Encourage to do simple exercise such as walking.
 Encourage to use mosquito net at night while sleeping.

T- TREATMENT

 Instruct the importance of treatment regimen.

H- HEALTH TEACHING

 Water from flower pots should be changed at least once a week

 All containers storing water should be covered with a tight lid
 Discarded container-like objects like tyres, coconut shells,
bottles, etc should be disposed off or destroyed.
 Surface wells should be well-maintained so that mosquitoes do
not breed in the vicinity.
 Treat mosquito nets with insecticides.
 Advised house spraying.
 Avoid too many hanging clothes inside the house.

O-OPD

 Instruct patient that they return to have a check-up at least 7

days after discharged on July 24, 2010 1 to 5 pm at Blue Gate
Clinic.

D-DIET

 Encourage patient to eat high protein and high calorie foods to

enhance faster recovery.

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