Client Presentation

This is a case of L.C.C. a 35 years old male client that lives at B115 Golden City, Taytay Rizal. He was a Filipino citizen born on May 18, 1977 with no known allergy. The patient was admitted on August 16, 2012 with a chief complaint of fever and medical history of muscle strain-unrecalled. The patient is positive of smoking 15packs per year and drinking of alcohol two bottles of beer a day. There is a family history that his father has a coronary heart disease and mother and brother have Diabetes Mellitus.

One week prior to admission the patient experience pharyngitis and pneumocystis. Five days prior to admission the patient is having a fever associated with generalized pruritic rash clustered as small dots, headache and vomiting. Consult was done prior to request and CBC was normal. He was given antihistamine for the rash. Persistence of symptoms prompted consults the companys physician. He was advised for admission hence consulted at our institution. The patient feels pain in his joint that radiates to knee and then to hip. No abdominal pain, diarrhea, cough and dyspnea noted. Some of the remarkable laboratory results were positive of protein in urine, bile quali: +1, eosinophils of 14/L(NV: 80 - 440/l ) and monocytes of 9/L (NV: 120 880/l). Laboratory results as of august 16, 2012, lymphocyte 4500/ (NV: 1000 - 5500/l), eosinophils of 14/L(NV: 80 - 440/l ), monocytes of 9/L (NV: 120 - 880/l), Neutrophils 3.1x10*9/L(2.0 - 8.0 x 10*9/L), RBC 4.3 million cells/ l (NV:Male: 4.7 to 6.1 million cells/l), platelet 275,000/ l (NV: 150,000 - 350,000/l).

On August 17, 2012 the researcher received the patient in a supine position with an intravenous fluid PNSS 1L x 100ml/hour on his left peripheral line. The patients diagnosis is systemic viral infection with a diet of diet as tolerated. Vital signs taken during 0800h and 1200h. The medical resident on duty visited the patient at 0645h. At 0800h the patients vital signs are T - 36C, P 69 bpm, R 21 cpm, BP 100/70 and painscale of 0/10. Medyo Makati ung katawan ko as verbalized by the patient. At 1200h the patients vital signs were T- 36, P 66bpm, R 21, BP 120/70 and pain scale of 3/10 on his armpit. The concern of patient about his rashes was verbalized. He was given 2 medications: Nexium (Esomeprazole) tab 40mg 1 tab OD PO and Biogesic (Paracetamol) 500mg 1 tab PRN (37.8C) PO. The researcher took the patients intake and output and the result was: intake of 1750ml, urine of 480ml and zero stools. The researcher instructed the patient to scratch lightly if the rashes are itchy.

On August 18, 2012 the researcher received the patient supine position while watching television, conscious, coherent and ambulatory. He has a contraption of intravenous fluid in Left peripheral line PNSS 1L x 100ml/hr. The patient manifest rashes in his extremities and now it are itchier and the patient is slightly irritated. The researcher understands the feeling of the patient and instructed to slightly scratch. Ayan naglabasan na talaga, Makati talaga siya as verbalized by the patient. The complete blood count was taken at 0730h when the researcher gets the vital signs of the patient. The results for vital signs at 0800h Temperature of 37.2C, pulse rate of 67 bpm, respiration of 16 cpm and blood pressure of 130/90 and for 1200h temperature 37.4 C, pulse rate of 65 bpm, respiration of 18 cpm and blood pressure of 130/90. The intake from 0600 to 1400 is 1000ml; the urine is 960ml and zero stools. The penicillin Benzylpenicillin was given when the nurse and researcher do rounds. At 0930h the nurse let the researcher come

with him to give the patient Alerta Loratidine (antihistamine) 10mg. Nexium and Biogesic are still prescribed by the doctor.

For interventions, the researcher instructed the patient to increase fluid intake