6. :
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
/case study Dengue fever
7. 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
/case study Dengue fever
8. 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
/case study Dengue fever
9. 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
/case study Dengue fever
10. 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 )
/case study Dengue fever
11. 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
/case study Dengue fever
15. 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
/case study Dengue fever
16. (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
17. (Positive data) (Negative
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
/case study Dengue fever
18. (Positive data) (Negative
data)
Tourniquet test , cell/mm3
Neutrophill42%(ban
--
d 12%)
-
Acute - -
Pyelo 24
neph -
ytis
/case study Dengue fever
19. (Positive data) (Negative
data)
- -
-
Escherichia coli), Klebsiella), -Body temperature
Pseudomonas) 39˚cP = 104
-
4
,
, ,
,
- CVA not
/case study Dengue fever
21. (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
22. (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
1
2.
/case study Dengue fever
32. 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
/case study Dengue fever
33. 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 :
/case study Dengue fever
34. 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
Plan 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
35. Subjective - 2
1 3
-
Objective - Body temperature ˚c PR=104
--look weak and tried
Red skin and warm to touch
Assessment invisible
loss , ,
plasma
Plan Diagnotic plan :
CBC
, Tourniquet test
Treatment plan: Oral rehydration salt
Nursing plan :
1.
2.
2000-2500 ml.
Problem #4 Appetite
/case study Dengue fever
36. Subje - 2 1
ctive 3
Object - look weak and tried
ive
Asses
sment Dengue virus
Plan Diagnotic plan :
CBC
, Tourniquet test
Treatment plan: -
Nursing plan :
1.
2.
Problem #5 Muscle aches
Subjec 2
tive
/case study Dengue fever
37. Objecti - look weak and tried
ve
Asses
sment
Plan 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
38. Subject - 1 3
ive
Objecti -
ve
Assess
ment mediator
Plan Diagnotic plan : -
Treatment plan: Oral rehydration salt
Nursing plan :
1.
2.
2000-2500 ml.
3.
/case study Dengue fever
43. 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
/case study Dengue fever
44. e
Objective -
Assessm Paracetamol
ent Prostaglandin
Plan Diagnotic plan :
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
/case study Dengue fever
45. --look weak and tried
Red skin and warm to touch
- Hct 37%
Assessm invisible
ent loss , ,
plasma
Plan Diagnotic plan :
CBC )
Treatment plan: Oral rehydration salt
Nursing plan :
1.
2.
2000-2500 ml.
Problem #4 Appetite
Subjectiv -
/case study Dengue fever
46. e
Objective - mild look weak and tried
Assessm
ent Dengue virus
Plan Diagnotic plan :
CBC )
Treatment plan: -
Nursing plan :
1.
2.
Problem #5 Muscle aches
Subjectiv -
e
Objective - look weak and tried
Assessm
ent
/case study Dengue fever
47. Plan Diagnotic plan :
CBC )
Treatment plan: - TolperisoneHCl (50 mg)1x3
pc
Problem #6 Diarrhea
Subject -
ive
Objecti -
ve
Assess
ment mediator
Plan Diagnotic plan : -
Treatment plan: Oral rehydration salt
/case study Dengue fever