SAINT MARY’S UNIVERSITY

SCHOOL OF HEALTH SCIENCES

SY 2010-2011

Individual Case Study

On DENGUE HEMMORHAGIC FEVER SUBMITTED BY:

ALJOHN DELA CRUZ BAHNI

BSN-4

SUBMITTED TO:

KHRISTEL ANNE G. BUTAC

CLINICAL INSTRUCTOR

PERSONAL PROFILE

Case No.: 8126

Hospital No.: 302

Name of patient: Angel Cassey Gawongna Acapen

Address: Nayon,Lamut,Ifugao

Sex: Female

Age: 2 7/12

Birthdate: December 17,2007

Birthplace: Ifugao Provincial Hospital

Nationality: Filipino

Language/Dialect Spoken: English/Ilocano

Religion: Roman Catholic

Father’s name: Douglas Acapen Occupation: Engineer

Mother’s name: Sheryl Acapen Occupation: Auditor

Type of Admission: New

Date of Admission: August 2,2010

Time of Admission: 2 PM

Resident on Duty: Dra. Menia

Allergies: (NKA) No Known Allergy

Attending Physician: Dra. Rowena Constantino

Health Insurance: PHIC

ADMISSION HISTORY

History of Past Illness

The patient usually suffers from illnesses such as diarrhea, cough and colds. The patient has no food, drug and environmental allergies. The child had not acquired other disease than cough and colds. The child had a complete immunization. The mother and father does not have a history of disesaes of familial tendency.

History of Present Illness One week prior to admission, patient started to have cough, fever, and colds. Consult was done and the child was given Amoxicillin and Bromhexin. However, the patient’s condition perssisted hence consult with attending phisycian and the subsequent admission to Medical Mission Group Hospital(MMG) was done. Physical examination results were: awake not in distress, (-) vomiting, (-) loose bowel movement(LBM), (-) bleeding, (-) Intercoastal(IC) retraction, unIcteric sclera, pink conjunctiva, flat abdomen, (+) crackles. The attending physician, Dra. Rowena Constantino, requested CBC,UA, Chest X-Ray PA to be done.

BRIEF DESCRIPTION OF THE DISEASE

DENGUE HEMORRHAGIC FEVERDengue Hemorrhagic Fever is an infectious disease carried by mosquitoes and caused by any of four related dengue viruses. It

is a tropical disease caused by different strains of dengue virus which are transmitted by mosquitoes of the genus Aedes. It is an acute infectious disease characterized by severe pain behind the eye and in the joints and bones and accompanied by an initial erythema and a terminal rash of varying morphology. This disease is used to be called "break-bone" fever because it sometimes causes severe joint and muscle pain that feels like bones are breaking. Occasionally, this condition is called Acute Infectious Thrombocytopenia Purpura.

Dengue [DEN-ghee] is a flu-like viral disease spread by the bite of infected mosquitoes. Dengue hemorrhagic fever is a severe, often fatal, complication of dengue.

Dengue Fever – the type without significant hemorrhages

Dengue Hemorrhagic Fever – those cases with gross hemorrhages and with etiologic agent identified; a severe illness endemic in most of tropical Asia, characterized by abnormal vascular permeability, hypovolemia and abnormal blood clotting mechanism.

ETIOLOGY and EPIDEMIOLOGY

There are four serotypes of Dengue Virus (1,2,3 and 4 Group B Arbovirus). It has been reported that although antigenetically close to each other, they may give only partial cross-protection, after being infected by any of them.

Three other Arbovirus: Chikungunya, O’nyong-nyong and West Nile Fever, have been identified with dengue-like diseases.

Dengue Fever is transmitted by the bite of an infected mosquito. The viruses that cause it are maintained in a cycle that involves humans and a domestic, day-biting mosquito that prefers to feed on humans. Once infected, a mosquito remains infective for life.

The dengue fever mosquito (Aedes aegypti) is dependent on humans and never lives more than 90 meters from dwellings, thus guaranteeing her meals. The sound of her wings cannot be heard and she attacks from below or behind, e.g. underneath chairs and mainly at the feet and ankles. This mosquito is domestic, day-biting with low and limited flying movements.

Transmission occurs by bite of Aedes aegypti female mosquitoes – the same vector of urban yellow fever – a day-active species with low fly-autonomy that is abundant in and around human habitations. The females are very nervous feeders, disrupting the feeding process at the slightest movement, only to return to the same or a different person to continue feeding moments later. Because of this behavior the mosquito will often feed on several persons during a single blood meal and, if infective, may transmit the dengue virus to many people in a short time. It is not uncommon to see several members of the same household become ill with dengue fever within a 24-36 hour frame, suggesting that a single infective mosquito infected all of them.

Sources:1. Infected Persons- the virus is present in the blood of patients during the acute phase of the disease and will become a reservoir

of virus, accessible to mosquitoes which may then transmit the disease.2. Stagnant water within the household and premises are the usual breeding places

Mode of transmission

By the bite of an infective Aedes Aegypti mosquito, viruses have been isolated from this mosquito during epidemic.

Factors which favor spread of infection1. Water stored within the household for a long period of time or stagnant water within the premises .2. High human population density; the more crowded the human population, the higher the infection rate.

Usual places of dissemination: Schools and Hospitals

Incidence1. Age: the infection may occur at any age but it is common among school children with the peak between 4 and 6 years old.2. Sex: both sexes equally affected.3. Season: more frequent during rainy season or months.4. Geographical: more prevalent in urban communities or localities.

CLINICAL MANIFESTATIONS

First 4 Days

The onset is sudden with hyperpyrexia (39˚ to 40˚) and headache. The patient is flushed and acutely ill; the conjunctivae are injected; dry cough because throat appears also injected. There is anorexia with nausea and vomiting; severe abdominal pain and tenderness. Bigger children may complain of retrobulbar pain and body aches. The liver may be enlarged.

4th-7th Days:

Hyperpyrexia persists and all the earlier symptoms increase. The temperature often shows a biphasic curve. The palms and soles are noticeably flushed Tourniquet test is often positive (+) from the onset or after a few days. Petechiae may be observed in pressure areas usually first on the face or distal portions of the extremities but sparing the axilla

and chest.

7th-10th Days:

The fever subsides The limbs are cool and rash appears on the lower extremities, purplish or brownish motted appearance or violaceous red with

blanched areas about 1 cm or less in size. The rashes last 2 to 3 days. The face and hands appear edematous. Pruritis may be present and at times is annoying. There may be bradycardia during covalescence. From this stage on the child begins to improve steadily.

Severe Manifestations:

Usually, the result of a second dengue viral infection.

CLASSIFICATION:Severe, Frank type- with flushing, sudden high fever, severe hemorrhage, followed by sudden drop of temperature, shock and terminating in recovery or death.

Moderate- with high fever, but less hemorrhage, no shock.

Mild- with slight fever, with or without petechial hemorrhage but epidemiologically related to typical cases usually discovered in the course of investigation of typical cases.

INCUBATION PERIOD

Uncertain. Probably 6 days to one week.

PERIOD OF COMMUNICABILITY

Man: 1 day before febrile period until the end of it Mosquito: 8-12 days after blood meal

RISK FACTOR

AGEIMMUNOSUPPRESSED PATIENTS

SIGNS AND SYMPTOMS

flu-like illness high fever and chills shaking sweating severe headaches severe pain behind the eyes extreme muscle and joint pains ( hence the name 'break-bone fever' ) generalized rash over the body 'bruising' and bleeding on the limbs, face and trunk of the affected person.

DIAGNOSTIC TEST

Blood testTourniquet test

Tourniquet test (Rumpel Leads Test)

Inflate the blood pressure cuff on the upper arm to a point midway between the systolic and diastolic pressure for 5 minutes. Release cff and make an imaginary 2.5 cm square or 1 inch square just below the cuff, at the antecubital fossa. Count the number of petechiae inside the box.

*A test is positive when 20 or more petechiae per 2.5 cm square or 1 inch square are observed.

TREATMENT

There is no specific treatment for dengue. Persons with dengue fever should rest and drink plenty of fluids. They should be kept away from mosquitoes for the protection of others. Dengue hemorrhagic fever is treated by replacing lost fluids. Some patients need transfusions to control bleeding.

PREVENTION1. MINIMIZE MOSQUITOES:

To minimize mosquito bites it is obvious that mosquito-prone areas (such as vessels holding water, discarded cans and bottles, and old tire half submerged in swampy water) should be avoided.

2. UNDERSTAND THE BASIC BEHAVIOUR AND FEEDING HABITS OF THE MOSQUITO CARRIER. The adult mosquito prefers to live indoors and feed on humans during 2 peaks of biting activity: early morning for 2-3 hours after daybreak and in the afternoon several hours before dusk.

3. SCREEN OR AIR-CONDITION ROOMS 4. BURN MOSQUITO COILS in the immediate area. CARE is suggested here because breathing problems, or even asthma,

may rarely develop. Electric plug chemicals will also help to repel mosquitoes from a room. 5. AVOID PERFUMES : mosquitoes are attracted to scents. 6. WEAR LONG SLEEVES AND PANTS, AND AVOID DARK CLOTHES. Light colored clothing should cover the arms and

legs. 7. SPRAY A " KNOCK DOWN" INSECTICIDE in sleeping and living areas at dusk. 8. USE A SKIN-SPRAY INSECT REPELLENT. 80% DEET (N.N-diethyl-m- toluamide) may be used by adults, but should not

be applied to babies, and only sparingly (quick sprays, 2-3 in 24 hours) to children 6-24 months, because of the potential of toxic effects. Children and pregnant women are recommended to use a natural insect repellent with citronella or eucalyptus (available from WORLDWISE OnLINE).

9. PERMETHRIN is an insecticide that can be used to soak mosquito nets and protective clothing

ANATOMY AND PHYSIOLOGY

.BLOOD

-Is a specialized bodily fluid that is composed of a liquid called blood plasma and blood cells suspended within the plasma.

Plasma

-is the liquid component of blood, in which the blood cells are suspended.

-It makes up about 55% of total blood volume.

Blood Cells

-is any cell of any type normally found in blood. These fall into three general categories: Red blood cells White blood cells Platelets

is circulated around the body through blood vessels by the pumping action of the heart. hematopoiesis is the process of blood formation, which primarily occurs in the red bone marrow (skull, pelvis, ribs, sternum &

proximal epiphyses of the humerus & femur.

BONE MARROW

-is the site of hematopoeisis,or blood cell formation. All skeletal bones are involved in children, but as children age, marrow activity is usually limited to the pelvis,ribs,vertebrae, and sternum in adults. Marrow is one of the largest organs of the body, making up to 4% to 5% total body weight. The marrow is highly vascular. Within it are primitive cells called stem cells. The stem cells have the ability to self replicate, thereby ensuring a contnuous supply throughout the life cycle. When stimulated to do so, stem cells can begin a process of differentiation into either myeloid or lymphoid stem cells. These stem cells are committed to produce specific types of blood cells. Lymphoid stem cells produce either T or B lymphocytes. Myeloid stem cells differentiate into three broad cell types: erythrocytes, luekocytes, and platelets.

PLASMA 55%PLASMA 55%

CONSTITUENT MAJOR FUNCTIONS

Water Solvent for carrying other substances

Salts(Electrolytes) Sodium Potassium Calcium Magnesium Chloride Bicarbonate

Osmotic Balance, pH buffering, and regulation of permeability

Plasma Proteins Albumin Fibrinogen Globulins

osmotic balance, pH buffering clotting of blood defense(antibodies), and lipid transport

Substances transported by blood: Nutrients(e.g. glucose, fatty acids, vitamins, amino acids) Waste products of metabolism(urea an d uric acid) Respiratory gases oxygen and carbon dioxide Hormones

FORMED ELEMENTS 45%FORMED ELEMENTS 45%CELL TYPE NUMBER

(Per mm3 of blood)FUNCTIONS

ERYTHROCYTE 4-6 million >Transport oxygen and help transport carbon dioxide

LEUKOCYTE

Granulocytes:

Basophil

4-11 thousand

20-50(0-1% of WBC’s)

>Defense and immunity

>Granules contain histamine(vasodilators chemical), which is discharge at sites of inflammation

>Kill parasitic worms; increase during allergy attacks; might

Eiosinophils

Neutrophils

Agranulocytes:

Lymphocytes

Monocytes

100-400(1-4% of WBC’s)

3000-7000(40-70% of WBC’s)

1500-3000(20-45% of WBC”s)

100-700(4-8% of WBC”s)

phagocystize antigen-antibody complexes and inactivate some inflammatory chemicals

>active phagocyte; number increases rapidly during short term or acute infections

>part of immune system; one group(B lymphocytes) produces antibodies; other group (T Lymphocytes) involved in graft rejection, fighting tumors and viruses, and activating the B Lymphocytes

>active phagocytes that become macrophages in the tissues; long term “clean up team”; increase in number during chronic infections such as tuberculosis

PLATELETS 250,000-500,000 > needed for normal blood clotting; initiate clotting cascade by clinging to broken area; help to control blood loss from broken blood vessel

A. RED BLOOD CELL

are the most common type of blood cell also known as RBCs, or erythrocytes function primarily to carry oxygen in blood to all cells of the body are small shaped like biconcave disk diameter of a typical human erythrocyte disk is 6–8 µm women have about 4 to 5 million erythrocytes per microliter (cubic millimeter) of blood men about 5 to 6 million Erythropoiesis is the process by which red blood cells are produced

Erythrocytes develop from committed stem cells through reticulocytes to mature erythrocytes in about 7 days and live a total of about 120 days.

aging erythrocyte undergoes changes in its plasma membrane, making it susceptible to recognition by phagocytes and subsequent phagocytosis in the spleen & liver.

B. LEUKOCYTES

LEUKOCYTES or white blood cells are far less numerous than red blood cells they are crucial to body defense against disease. White blood cells are the only complete in the blood that is they contain nuclei and the usual organelles. Leukocytes form a protective movable army that helps

Decrease oxygen level in blood

Stimulus: ↓ RBC count, ↓ oxygen availability/ ↑

tissue demand for oxygen

Kidney releases eryhtropoietin

Erythropoietin stimulates red bone marrow to

enhance erythropoiesis

defend the body against damage the bacteria, virus’s parasites and tumors cells. The circulatory system are simply their means of transportation to areas of he body where their services are needed in the inflammatory and immune response.

GRANULOCYTES are granule containing WBCs. They have lobed nuclei w/ typically consist of several rounded nuclear areas connected by thin strands of nuclear material. The granules in their cytoplasm stain specifically w/ Wright stain. The granulocytes include the nuetroplis, eosinophils, and basophils.

a. Viscosity - blood is more viscous than water. Changing the % of cells, cellular fragments, plasma proteins or other dissolved substances changes the viscosity. Viscosity is increased if either the plasma (fluid) is decreased (ex. during dehydration) or if the substances within the blood are increased (ex. polycythemia)

b. Concentration the cells (red blood cells and white blood cells) that are dissolved within the plasma are dependent on the concentration of the plasma because water is free to move into or out of the cell by osmosis. Normally, the plasma is isotonic to the cells. If however, the plasma becomes hypertonic, the cells will lose water and shrink. A process called crenation. If the plasma becomes hypotonic, the cells will take on water and swell. If they take on too much water, they could burst. A process called hemolysis. Maintaining plasma concentration is essential for the integrity of these cells.

c. Volume - A typical female has 4-5 liters of blood and a typical male has 5-6 liters of blood. Maintaining blood volume is essential in maintaining blood pressure. If blood pressure drops below a critical level, blood delivery throughout the body is impaired and death is probable.

d. pH - plasma proteins, like all proteins of the body, have a 3-dimensional shape that is dependent on the correct amount of hydrogen (and hydroxyl) ions being present. If the pH is altered from the normal value of 7.35-7.45, the plasma proteins lose their 3-D shape and are denatured and unable to carry out their functions.

e. Temperature - the enzymes of the body are responsible for all of the chemical changes that occur. The function of enzymes to work properly is dependent on temperature. Enzymes work efficiently at body temperature. Below body temperature, the enzymes work more slowly. They can slow down enough to not be able to meet the needs of the body. If the temperature rises, the enzymes will work more efficiently but, if the temperature is raised too high (106 or so) they are denatured, resulting in brain damage and perhaps death. The function of the blood is to pass through the hypothalamus of the brain to be monitored for temperature. If blood temperature is too high or too low, homeostatic mechanisms are initiated to reestablish normal body temperature

C. PLATELETS

Fig. 1.3- Leukocytes

a. Platelets are not cells, they are fragments of bizarre multinucleated cells called megakaryocytes, which rupture, releasing thousands of anucleated “pieces” that quickly seal themselves off from surrounding fluids.

b. Appear as dark staining irregulary shape body scattered among the other blood cells.

II. Circulatory system

The circulatory system (or cardiovascular system) is an organ system that moves nutrients, gases, and wastes to and from cells, helps fight diseases and helps stabilize body temperature and pH to maintain homeostasis.

The main components of the human circulatory system are the heart, the blood, and the blood vessels. The circulatory system 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.

A. Systemic circulation

Systemic circulation is the portion of the cardiovascular system which carries oxygenated blood away from the heart, to the body, and returns deoxygenated blood back to the heart.

B. Pulmonary circulation

Pulmonary circulation is the portion of the cardiovascular system which carries oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart.

C. Coronary circulation

The Coronary circulatory system provides a blood supply to the heart.

LIVER

is the largest internal organ in the human body normally weighs between 1.4 - 1.6 kilograms it is a soft, pinkish-brown organ.

It is located on the right side of the upper abdomen below the diaphragm. The liver lies to the right of the stomach and overlies the gallbladder

Plasma proteins are mainly produced by the liver. These include:

Albumin - the main function of albumin is to increase the osmotic force in the blood. This osmotic force is responsible for drawing fluids into the bloodstream in order to maintain blood volume (and thus blood pressure). If albumin levels increase, more fluid is drawn into the blood and normal blood volumes are increased (and thus blood pressure is increased). If albumin levels are decreased (say due to liver damage and the liver is not producing enough or there is kidney damage and albumin is being lost from the body), less fluid is drawn into the blood and normal blood volume is decreased (and thus blood pressure is decreased).

Clotting proteins - the liver is responsible for making the many proteins associated with blood clotting including fibrinogen, plasminogen, clotting factors etc). These must be maintained at proper levels for properly functioning coagulation.

Alpha and beta globulin - proteins responsible for carrying non-soluble lipids in the blood.

Gamma globulins - These proteins, also called antibodies, are NOT made by the liver.

PATHOPHYSIOLOGY

LABORATORY RESULTS

HEMATOLOGY

-is a series of tests used to evaluate the composition and concentration of the cellular component of blood

- this Lab. Study is also indicated to know any suspected anemia and the response to the treatment, blood loss and the response to blood replacement.

Elevated RBC’s suggest inadequate tissue oxygenation. Hypoxia stimulates renal secretion of erythropoetin. This stimulates the bone marrow to increase the RBC production.

Elevated WBC’s may indicate infectious heart diseases and myocardial infarction.Hematocrit is the ratio between the RBC and the Plasma. -Decreased in severe anemias, anemia of pregnancy, acute massive blood loss.-Increased in erythrocytosis of any cause, and in dehydration or hematoconcentration associated with shock.Hemoglobin -Decreased in various anemias, pregnancy, severe or prolonged hemorrhage, and with excessive fluid intake.-Increased in polycythemia, COPD, failure of oxygeb because of heart failure, and normally in people living in high altitudes.Hemoglobin F-Increased in infants and children, and in thalassemia and many anemiasNeutrophils-Increased with acute infections, trauma or surgery, leukemia, malignant disease, necrosis-decreased with viral infection, bone marrow suppression, primary bone marrow diseaseEosinophils-Increased in allergy, parasitic disease, collagen disease, subacute infections-Decreased with stress, use of some medications(ACTH, Epinephrine, thyroxin)

Basophils -Increase with leukemia and following surgery or trauma-Decreased with allergic reactions, stress, allergy, parasitic disease, use of corticosteroids Lymphocytes-Increased with infectious mononucleosis, viral and some bacterial infections, hepatitis-Decreased with aplastic anemia, SLE, immunodefficiency includung AIDSPlatelet count

-Increased in malignancy, myeloproliferative disease, rheumathoid arthritis, and postoperatively; about 50% of patients with unexpected increase in platelet count will be found to have malignancy-Decreased in throbocytopenic purpura, acute leukemia, aplastic anemia, and during cancer chemotherapyClotting Time-Types:Proyhrombin Time, Partial Thromboplastin Time, Activated Partial Thromboplastin TimeBleeding Time- 1 to 9 minutes

Date: August 2, 2010

TEST RESULT NORMAL VALUES

Hemoglobin 117 M:135-180 F:120-160 g/L

Hematocrit 0.31 M:0.40-0.54 F:0.37-0.42

WBC Count 6.3 4-10x10

RBC Count 3.33 M:4.5-5.0 F:4.2-5.4x10

Nuetrophils 64 35-70

Lymphocyte 36 20-35

Eosinophils 0-4

Blood Type

Clotting Time 5-10 minutes

Bleeding Time 1-4 minutes

Platelet Count 200 140-450x10

NOTE!- Laboratory values may vary according to the techniques used in different laboratories.

URINALYSIS

Date: August 2,2010

Macroscopic Examination

Color: Yellow Protein: Trace

Transparency: Hazy Glucose: Negative

pH: 5.0 Specific Gravity: 1.025

Pus Cells: 5-10/hpf

Red Blood Cells: 0-2 hpf

Microscopic Examination Amorphous Urates: Few

Epithelial cells: Rare

Mucus threads: Rare

Bacteria: Few

Date: August 03

Time: 8:10 AM

PLT Flags

WBC: 4.4 L 103 /mm 3 < 5.0-10.0 > MCV: 82 Um3 < 80- 47 >

RBC: 4.46 103 /mm3 < 4.20-6.30 > MCH: 25.9 L Pg < 26.5-33.5 >

HGB: 11.6 L g/dL < 12.0-18.0 > MCHC: 31.6 g/dL < 31.5-35.0 >

HCT: 36.5 L % < 37.O-51.0> RDW: 12.9 % < 10.0-15.O >

PLT: 417 103 /mm3 < 142-424 > MPV: 6.5 Um3 < 6.5-11.0 >

PCT: .270 % < .100-.500 > PDW: 11.2 % < 10.0-18.0>

Mean Corposcular Volume MCV

-Increased in macrocytic anemia

-Decreased in microcytic anemia

Mean Corpuscular Hemoglobin MCH

-Increasd in macrocytic anemia

-Decreased in microcytic anemia

Mean Copuscular Hemoglobin Cocentration MCHC

-Decreased in severe hypochromic anemia

WBC Flags

% LYM: 56.3 H % < 17.0-48.0 > # LYM: 2.4 103/mm3 <1.2-3.2 >

%MON: 4.1 % < 4.0-10.0 > #MON: 0.1 L 103/mm3 < 0.3-0.8 >

%GRA: 39.6 L % < 43.0-76.0 > #GRA: 1.9 103/mm3 <1.2-6.8>

Lymphocytes-Increased with infectious mononucleosis, viral and some bacterial infections, hepatitis-Decreased with aplastic anemia, SLE, immunodefficiency includung AIDS

Monocytes

-Increased with viral infections, parasitic disease, collagen and hemolytic disorders

-Decreased with use of corticosteroids, RA, HIV infection

Date: August 5,2010

Time: 10:42 AM

PLT Flags: G2

WBC: 6.9 103/mm3 < 5.0- 10.0 > MCV: 82 Um3 < 80-97 >

RBC: 4.65 103/mm3 < 4.20-6.30 > MCH: 26.1 Lpg < 26.5-33.5 >

HGB: 12.1 g/Dl < 12.0-18.0 > MCHC: 31.9 g/dL < 31.5-35.0 >

HCT: 37.9 % < 37.0-51.0 > RDW: 13.0 % < 10.0-15.0 >

PLT: 223 103/mm3 < 142-424 > MPV: 6.6 Um3 < 6.5-11.0 >

PCT: .147 % < .100- .500 > PDW: 11.4 % < 10.0-18.0 >

WBC Flags

% LYM: 53.6 H % < 17.0-48.0 > # LYM: 3.6 H 103/mm3 < 1.2-3.2 >

% MON: 8.1 % < 4.0-10.0 > #MON: 0.5 103mm3 < 0.3-8.0 >

% GRA: 38.3 L % < 43.0-76.0 > #GRA: 2.8 103/mm3 < 1.2-6.8 >

Date: August 5,2010

Time: 9:54 PM

PLT Flags

WBC: 12.0 H 103/mm3 < 5.0-10.0 > MCV: 80 Um3 < 80-97 >

RBC: 4.18 L 103 /mm3 < 4.20-6.30 > MCH: 26.2 L pG < 26.5-33.5 >

HGB: 11.0 L g/dL < 12.0-18.0 > MCHC: 32.7 g/dL < 31.5-35.0 >

HCT: 33.5 % 103/mm3 < 37.0-51.0 > RDW: 13.2 % < 10.0-15.0 >

PLT : 354 103/mm3 < 142-424 > MPV: 6.2 L Um3 < 6.5-11.0 >

PCT: .219 % < .100-.500 > PDW: 11.5 % < 10.0-18.0 >

WBC Flags: G1 G2

%LYM: 57.5 H % #LYM: 6.9 H 103/mm3 < 1.2-3.2 >

%MON: 11.9 H % #MON: 1.4 H 103/mm3 < 0.3-0.8 >

%GRA: 30.6 L% #GRA: 3.7 103/mm3 < 1.2-6.8 >

MISCELLANEOUS LABOARTORY EXAM

DENGUE LINE TEST

Specimen: BLOOD

Date: August 3,2010 August 5,2010

Result: IgM = Negative Result: IgM= Positive

IgG= Negative IgG= Negative

IgM

-Increased Waldenstroms Macroglubenemia, parasitic infections, hepatitis

-Decreased in Aggamaglubenemias, some IgG and IgA myelomas, chronic lymphatic luekemia

IgG

-Increased in IgG myeloma, following hyperimmunization, autoimmune disease states, chronic infections

-Decreased in congenital and acquired hypogammaglubenemia, IgA myelomas, Waldenstroms macroglobunemia, some malabsorption syndrome, extensive protein loss

COURSE IN THE WARD

DOCTOR’S ORDER NURSES NOTES

08-02-20101:40>Please admit to ROC under my service-Dra. Constantino>Please secure consent for admission and management>Monitor I and O, V/S q shift>DAT>Diagnostics:CBC, UA>Chest X-ray PAL

Therapuetics:IVF: D5NaCl 1L at 60cc/hr Cefuroxime 750 mg IV q 12 hours ST due 3:00PMSalbutamol nebule, 1 nebule plus 1cc NSS q 6

Paracetamol 120/5ml, 5ml q 4 hrs. For temperature greater than or equal to 37.8

>AP performed >Refer accordingly08-02-2010>For CBC, with APC and Dengue Line Test tommorow AM

Febrile 38.5

08-02-20102:00 PM>Admitted a 2 y/o female patient with chief complains of cough and fever T-38.6. An IVF of D5 0.3 NaCl regulated at 60 gtts/min. was hooked in her left arm.She was admitted under the service of Dr. Rowena Constantino. Orders were made and carried out.CBC and UA was done and chest X-ray PA-L was requested. Skin testing was done for Cefuroxime, due at 3:00 PM. A dose of 750mg via IV will be given if negative for skin test. At 2:45 PM, Salbutamol plus 1cc NSS first dose will be given. The SO was instructed to give Paracetamol at 4:30PM and was encouraged to increase OFI with strict precaution of the patient, to give the patient with foods rich in Vit.C. At 2:50 PM, vital signs were monitored. The patient is febrile T- 38.5. Paracetamol was given and instructed SO to do TSB and increase OFI of the patient as tolerated. Comfort measures was provided and instructed SO to report any untoward sign and symptoms. The patient was kept rested.Cefuroxime was started and other needs were attended. At 3:20 PM the patient is afebrile T-36.9. Same

08-04-201010:34 AM> Ambroxol 15mg/5ml, 5ml 2x a day

IVF is infusing taken and recorwell. The patient is for CBC with APC and Dengue Line Test tommorow morning. Vital signs were taken and recorded. Due meds were given. Other needs were attended and kept comfotable.

08-03-20108:20 AM

> Received patient lying on bed awake with intact IVF. Responsive. Seen and examined by AP. Vital signs were taken and recorded. Patient is febrile T- 39.5. I and O was measured. The SO was instructed to report any untoward signs and symptoms. Due meds were given- Paracetamol 5ml. Other needs were attended and was provided with quiet environment to rest. At 10:00 PM, the patientis afebrile. Vital signs were taken. Iand O was measured. At 2:00 AM, the patient is febrile T- 38.3. Paracetamol was given. Provided quiet environment and other calls were attended. Kept rested.

08-04-2010

Still with fever episodes Good appetite Positive crackles on both lungs

08-05-20109:30AM> For repeat RBC, with APC now>For repeat Dengue Line Test

Positive MP rashes in all extrenities

Positive fever, chills IgM positive-Dengue Test

>Shift IVF to D5LR 1L at 70cc/hr>Ascorbic Acid 100mg/5ml 2x a day>Please monitor V/S including BPq4 hrs.

8:10 AM

>Received patient lying on bed with ongoing IVF of D5 0.3 Nacl 1L at 600 cc level. Concious and responsive. Afebrile. Vital signs were taken and recorded. I and O was measured. She was seen and examined by Dr. Constantino and new orders were made and carried out. Ambroxol 15mg/5ml,5ml was given. Other needs were attended and kept rested. At 3:30 PM, received lying on bed with same IVF, infusing well at 200cc level. Vital signs were taken and recorded. Patient is afebrile. I and O was measured. Calls were attended. Due meds were given. Provided cool and quiet environment and kept rested. At 6:10 PM, above IVF was consumed and same IVF was hooked.

08-05-2010

>Cetirizine 25mg/5ml, 1ml q 12 hrs.>for repeat CBC with APC at 10 PM

9:00PM>12Kgs.>Paracetamol 120mg IV now>Oxygen inhalation at 6 cpm>For Hgb, Hct, APC at 2PM>Increase IVF rate to 80cc/hr.

Positive chills Positive noted circumval cyanosis Negative seizure

08-06-2010 MP rashes Fever 39.8

At 8PM, vital signs were taken and recorded. Patient is afebrile T-36.8. I and O was measured. At 10PM, patient is febrile. Paracetamol was given as ordered by ROD. TSB was done continuously till temperature subsided;SO was instructed to do so if temperature exceeds 37.8. clothings were loosened to facilitate further relief from heat. Provided a cool and quiet environment. Oxygen inhalation via facemask was administered by ROD. Patient was kept rested and comfortable. Needs were attended and was endorsed accordingly.