CASE

PRESENTATION
By: GROUP 2
INITIAL DATABASE
 NAME: MS. X
 AGE: 31
 GENDER: FEMALE
 CIVIL STATUS: SINGLE
 NATIONALITY: FILIPINO
 RELIGION: BAPTIST
 EDUC ATTAINMENT: COLLEGE GRADUATE
 OCCUPATION: KINDER TEACHER
 CHIEF COMPLAINT:
 FINAL DIAGNOSIS: DENGUE FEVER WITH WARNING SIGNS OF UTI
 ATTENDING PHYSICIAN: DR. CARLO BRAVO
 DATE/TIME OF ADMISSION:
 HISTORY OF PRESENT ILLNESS

DIAGNOSIS OF ILLNESS WHICH

STARTED AS GENERALIZED
BODY PAIN WITH FEVER.
POSITIVE ANOREXIA, AFEBRILE
X 3 DAYS. THIS AM, NOTED
WITH EPISTAXIS.
HISTORY PRESENT ILLNESS
 Onset and nature of symptoms

- “last last week pa”

 Duration of symptoms

- “mga 1 week”
 Exact location of distress or symptoms

- “sa hawak nya trangkaso”

 Character of Complaint

- “Gi trangkaso ko niya naulian rapod pagkahuman nagbalik napod kay galain napod akong paminaw”
 Activity involved when problem occurred

- “wala man, wa pod koy gekaon og gi inom”

 Phenomena/ Symptoms assoc. With C/CX

- “wala na pod, mao rato sakit sa akong likod”

PAST HEALTH HISTORY
 Prior illness throughout development including
 - “wala maam, kani ra”
 Immunization
 - “oo complete”
 Allergies
 - sea food
 Accidents/ Injuries
 -Motorcycle accident “naka bangga mi og iro”
 Previous Hospitalizations
 - “Wala, di man kaayo ko masakiton jud”
 Check-ups?
 - “wala”
LABORATORY AND DIAGNOSTIC TESTS
HEMATOLOGY A
Components  Results  Normal Value  Indication 
Platelet count  137 125-350  A complete blood count (CBC) is a blood test. It
x 10^q/L gives your provide information about your blood and
overall health. CBCs help provides diagnosed,
Mean Platelets Volume (MPV) 12.50 6.5-12.0 fL
monitor and screen for a wide range of diseases,
(H)
condition, disorders and infections. According to the
Hemoglobin  95 (L) 115-175 g/L results shown, high mean Platelets Volume indicates
Hematocrit  0.29 (L) 0.35-0.50 that the platelets are larger than what's considered
normal as newly made platelets are larger than older
Red Blood Cells 4.34 3.80-5.80 platelets, so a high number indicates or may signal
x10^12/L that the bone marrow's
Mean Corpuscular Volume (MCV) 65.70 (L) 82.0-100.0 Making a lot of new platelets as the older (smaller)
x10^12/L platelets are being destroyed at an increased rate
which means or possibly indicates that the bacterial
Mean Corpuscular Hemoglobin (MCH) 21.90(L) 27 34. pg infection cause by E.coli has become invasive. A low
hemoglobin indicates that the body's ability to
Mean Corpuscular Hemoglobin Concentration 333 316-354 g/L produce RBCs is affected by the diseases and when
(MCHC) the body isn't getting enough oxygen. It makes the
Red Blood Cell Distribution Width(RDW) 0.143 0.110-0.160 individual feel very tired and weak. A low hematocrit
in a stable patient suggest recovery from disease . A
White Blood Cells  10.42(H) 3.50-9.50 low mean Corpuscular means RBCs are smaller than
x10^ 9/L normal and  may indicate microcytic anenila caused
by Iron deficiency. A low mean Corpuscular
Neutrophils  0.36(L) 0.40-0.75 Hemoglobin indicates that the hemoglobin
Lymphocytes  0.45 0.40-50 production is less than normal which may lead to
anemia. A high WBC indicates an infection or
Monocytes  0.18(H) 0.03-0.10 inflammation in the body. A low neutrophil level
Eosinophils 0.01 0.004-0.08 indicates the body can't figthyiff bacteria. Lastly, a
high monocyte indicates an infection as the body
Basophy 0?01 0.00-0.10
creates more monocytes to fight the invader.
LABORATORY AND DIAGNOSTIC TESTS
Date Urinalysis Results Indication
Color Dark Yellow Ordering a urinalysis for a patient who is
possibly diagnosed with both a urinary tract
Transparency Clear infection (UTI) and dengue hemorrhagic fever
Sugar Negative serves as a crucial diagnostic tool to gather
valuable information about the patient's
Protein 1+ condition. Urinalysis helps in assessing the
pH 7.5 presence of a UTI by analyzing urine samples
Specific gravity 1.010 for the presence of bacteria, white blood cells,
red blood cells, and other markers of infection.
Blood 3+ UTIs can occur concurrently with dengue
Leucocytes Negative hemorrhagic fever due to compromised
immune function, prolonged hospital stays, or
Bilirubin Negative the use of invasive medical procedures,
May 09, 2023  making it important to identify and treat these
Ketone Negative
infections promptly. Additionally, urinalysis
Nitrite Negative aids in evaluating renal function, as dengue
Urobilinogen 3.2 nmol/L hemorrhagic fever can cause kidney
12:34pm involvement and renal dysfunction. By
Pus cells 0-2 /hpf detecting abnormalities such as proteinuria or
RBC 5-10 /hpf hematuria, urinalysis provides vital insights
into the patient's overall health status and aids
Epithelial cells RARE in determining appropriate treatment strategies
Bacteria FEW for both the UTI and dengue hemorrhagic
fever, ensuring comprehensive care for the
individual.
DOCTOR’S Date/Time
05/05/23
Progress Notes
(+) fever x 3 days
Doctor’s Order
> admit under the service of Dr. Copia
Rationale
- preferred to Dr. Copia for proper medical
ORDERS 5:30 PM (-) cough
(-) colds
 
 
management of present condition
 
> consent to care - secure consent to care is ordered upon admission to
  ensure legality of any procedure to be applied by the
  institution
   
> diet no dark colored foods - no colored foods for diet, to monitor stool for signs
  of internal bleeding (black stools)
 
> v/s q & H -Monitor vital signs to frequently check patients
  condition/ status
   
> Dx. CBC, BT, UA -Diagnostic Tests requested for diagnosis and proper
Dengue test treatment
S. Creatinine, Na; K+  
Sars Cov 2  
CXR- PA  
   
> IVF: PNSS 1L x 120 cc 1hr to run 1st 200 cc as FD - IVF administered to ensure/treat/
  Fluid balance esp. electrolytes & prevent dehydration
  to supplement body needs
   
> meds:  
>Paracetamol 500 g 1 tab q 4H PRN > Paracetamol can help reduce fever associated with
  various conditions, including infections, colds, and flu.
  > Omeprazole may be prescribed to alleviate
> Omeprazole 40 g 1 cap OD symptoms of indigestion, such as stomach pain,
  bloating, and discomfort, when no specific cause or
  ulcer is identified.
  >Tranexamic acid is primarily used for its hemostatic
  properties in controlling or preventing excessive
> Tranexamic acid 500 g IV now bleeding in specific medical situations.
   
  > Watch out /monitor patient for bleeding episodes,
> watch & refer for bleeding episodes, hypotension, narrow hypotension, and narrow pulse to prevent
pulse pressure complications and to provide, immediate treatments
  as these are signs of DSS
   
  > refer and call AP accordingly for efficient and
> AP aware then call collaborate treatment and care for the pt.
> refer accordingly
DOCTOR’S 05/06/23
9:15 AM
Va: pus- 25-50
RBC- 50-100
> start ceftriaxone sulbactam (trilactam) 1.5 gm Vial IV. - to treat Pt’s UTI;
9/2 Ceftriaxone-sulbactam is often prescribed for
ORDERS  
(+) episodes minimal
 
 
the treatment of intra-abdominal infections,
including peritonitis (inflammation of the lining
of the abdominal cavity), intra-abdominal
  abscesses, and biliary tract infections.
 
> continue monitoring to 9/2 > to monitor progress of dengue & watch out for
  complications esp. Bleeding.
> include pt INR an next blood extraction - to monitor patients to check Pt’s clotting
  factors
 
> tranexamic acid 500 mg IV q 8H PRN for active - to treat bleeding
bleeding  
   
   
> IVF TF: PNSS Tl @ 100cc/hr x 3 bottles - to prevent dehydration, to replenish lost
electrolytes

05/07/23 Dx. Cefriaxone Sulbactan
9:45 AM  
No active bleeding
 
 
 
 
 
 
(+) bruising @ antecubital area
> start hirudoid cream apply 3x a day on area of hematoma
> repeat VA >D3 of Ceftriaxone +Sulbactan
 
 
 
 
> IVF TF:
PNSS 1L @ SC 80 cc/hr x 4 bottles
> for treatment of superficial bruising and hematoma
>Ceftriaxone-sulbactam is often prescribed for the
treatment of intra-abdominal infections, including
peritonitis (inflammation of the lining of the
abdominal cavity), intra-abdominal abscesses, and
biliary tract infections.
> to monitor progress of UTI
> to continue treatment
> to present dehydration to replace water, sugar salt
or electrolytes

05/08/23   > continue management > to continue proper treatment and care for the
11:30 AM     patient
     
> no bleeding > IVF TF: > to prevent dehydration, to replenish lost
PNSS 1L @ 50cc/hr x 4 bottles electrolytes
   
   
> refer accordingly > to monitor progress of dengue hemorrhagic fever
> continue CBC monitoring OD and to watch out for complications.
ANATOMY AND PHYSIOLOGY OF
URINARY SYSTEM
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
INDEPENDENT NURSING INTERVENTIONS

 Encourage patient to increase fluid intake

 Monitor vital signs
 Provide comfort measures
 Encourage rest and sleep
 Monitor and manage urinary symptoms
 Educate on self-care measures
 Promote nutrition
 Monitor for complications
 Document and communicate
 Provide comfort to relieve pain
 Monitor Input and Output
 Assess patients level of pain. 1-10 rating scale.
   INSPECT
Skin, hair and Nails > Skin is brown
> Hair is black and evenly
distributed
> No cyanosis noted
> Superficial bruising and
hematoma is present and
noted
PALPATE PERCUSS AUSCULTATE
> Skin is intact and feels    
warm when touched
> Capillary refill of less
than 2 seconds both upper
and lower extremities

Head > Normocephalic      

> No drooping on one side
of the face
> Facial features are
symmetrical
 

REVIEW OF SYSTEMS
Eyes > Eyes appear moist with > No lesion, lumps,    
ping conjunctiva inflammation, tenderness or
> Eye movements are edema visible around
symmetrical client’s eyes
> No usual discharges and
drainage observed
> Does not wear corrective
lenses
> No lesion, lumps,
inflammation, tenderness or
edema visible around
client’s eyes
> Eyes are dark brown
 
 Ears > External ears have no > External ears have no    
lesions or lumps noted lesions or lumps noted
> No drainage discharges > Ears were symmetrical
or information are noted and in level with the outer
> Able to hear clearly on cantus of eyes
both ears of claimed by  
the patient
> Ears were symmetrical
and in level with the outer
cantus of eyes
> No hearing devices used
 

REVIEW OF SYSTEMS
Mouth, Throat and Nose > Was able to perform      
assessment on patient’s
mouth and throat
> There is loss of taste as
claimed by the patient
> Nose is located at the
center of the face
> Proportioned and evenly
colored
> No nasal flaring noted
> No significance scars or
lesions observed
> No visible swelling,
deformity and tenderness
observed