LABORATORY

July 01, 2016

Hematology
Hemoglobin
Hematocrit
RBC
WBC

148
0.45
4.95
10.7

Segmenters

0.84

Lymphocytes

0.15

REFERENCE VALUE
SIGNIFICANCE
Normal
(M) 140-160 GMS/L
Normal
(M) 0.42-0.52
Normal
(M) 4.5-5.5X10 /L
High
5-10X 10 /L

Basophil

0.03-0.05

Low

0.02-0.06

Low

0.550.65
0.250.35

Eosonophil

0.000.01

Stab Cell

0.030-0.05

Bands

1-5%

Monocytes

0.01

TEST

RESULT

UNIT

REFERENCE RANGE

Creatine

35.00

Umal/L

Adults: 45-104
Neonate: 27-87
Infant: 14-34
Child: 23-68

July 04, 2016

Chest AP/L
Both lung fields are clear.
Heart is not enlarged.

IMPRESSION:

NEGATIVE CHEST PA.

July 06, 2016

TEST

RESULT

UNIT

REFERENCE RANGE

SIGNIFICANCE

Creatine

35.00

Umal/L

Adults: 45-104
Neonate: 27-87
Infant: 14-34
Child: 23-68

NORMAL

On the 3rd (July 02, 2016) prior to admission Male X still with fever and headache decrease
vomiting 2 episode every day. Patient consulted with a private pediatrician and CXR was
requested which revealed normal chest.
According to the mother on July 4, 2016 one day prior to admission patient became hysterical
described as shouting, gets agitated easily and has flight of ideas .
Tuesday on the 5th day of July 2016 Male X brought in the JRRMMC, ER pediatric via stretcher
accompanied by his mother with chief complaint of headache. Patient was conscious and
coherent but with weak in appearance. He was examined by Dr. Tan.
He was diagnosed to have CNS infection and was given Acyclovir 250mg TIV q8 and
paracetamol 250mg TIV q4 for fever >37.8 degree Celsius.

D. Family History
(-) DM

(-) Cancer

(-) Heart disease

(-) Allergies

(+) PTB, maternal

(+) Asthma

(+) HPN, paternal

(-) Accidents

PATIENT'S PROFILE

Name: Male X
Age: 11 years old
Gender: Male
Address: Malabon City
Date of Birth: October 16, 2004
Place of Birth: Nugan- lying-in
Nationality: Filipino
Religion: Catholic
Civil Status: Single
Occupation: None
Date of Admission: July 05, 2016
Place of Admission: JRRMMC
Admitting Diagnosis: CNS infection

PHYSICAL EXAMINATION

Latest VS are as follows: T: 38 degree Celsius

BP: 110/70 mmHg

PR:

89 bpm

R: 22 cpm

General Survey: Conscious and incoherent.

HEENT: Head is symmetrical and proportion to the body, (-) nasal discharge, with complete
teeth
Neck: No cervical lymphadenopathies, symmetrical
Chest/ Lungs: Symmetral chest expansion, normal breath sound and no retractions
Heart: Upon inspection, no visible thrills or heaves observed.
Abdomen: soft, flat, no palpable mass, normal bowel sounds
Extremities: (-) swelling, (-) tenderness, pulse are full and equal, no cyanosis, no edema.

July 07, 2016

Examination: HEAD, Cranial
TECHNIQUE: Multiple axial CT images of the brain without contrastr were obtained using the
standard department protocol.
Findings:
No abnormal parenchymal density changes are seen.
No demonstrable extra-axial fluid collection noted.
There is mild dilatation of the ventricles.
The cortical sulci show normal configuration.
The gray- white matter interface is intact.
No midline shifting seen.
Visualized posterior fossa structure, pineal region , orbits, petromastoids, paranasal, sinuses
and bony calvarium are intact.

IMPRESSION:
Mild communicating hydrocephalus.

July 07, 2016

SPECIMEN: CSF #1
Examination: GRAM'S STAIN
GRAM'S STAIN: NO MICROORGANISM SEEN

July 07, 2016

SPECIMEN: CSF #5
EXAMINATION: BACTERIAL ANTIGEN DETERMINATION

NEGATIVE FOR:

Streptococcus pneumoniae
Streptococcus Group B
Haemophilus influenzae B
Neisseria meningitis B/E. coli K1
Neisseria meningitis ACY/W135

July 07, 2016

TEST: ENZYME IMMUNOASSAY Japanese Encephalitis IgM
SPECIMEN: SERUM
REFERENCE RANGE:
NEGATIVE: <4.0
EQUIVOCAL: < 4-6
POSITIVE: >6
RESULT: 3.89 ( NEGATIVE )

NURSING CARE PLAN

July 08, 2016
ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

Subjective:
" Parang mainit
siya, as
verbalized by the
mother".

Eleveted body
temperature
related to
bacterial
infection as
manifested by
Temperature of
38 degree
Celsius, warm to
touch and
weakness.

After 1 hour of
nursing
intervention the
patient's body
temperature 38
degree Celsius
will decrease to
37.5 degree
Celsius.

Monitored vital
signs.

After 1 hour of
nursing
intervention goal
was met with
temperature of
37.3 degree
Celsius.

Objective:
BP: 110/70
mmHg
T: 38
PR: 79 bpm
RR: 22 cpm:
Warm to touch
Weakness

Provided tepid
sponge bath.
Instructed the
mother not to
used alcohol.
Remove excess
clothing and
covers.
Advised the
mother to
increased male x
fluid intake.
Educated and
advised support
system (relative)
to do the TSB
when patient
feels hot.
-luke warm water
only.
-makae sure that
armpits and
groins were
included in doing
TSB.

DISCHARGE PLANNING.
Medications
Take home medication as prescribed by the Physician.
Report any side effects & adverse reactions as indicated by the healthcare provider.
Check with physician about administration of other medications
Environment/Exercise
Instruct patient to stay in calm, quiet environment.
Home environment must be free from slipping or accident hazards.
Reinforce the need to continue exercises at home. Active ROM exercisesincrease muscle mass, tone,
& strength pressure joint mobility & improve cardiac & respiratory function.
Encourage/advise patient to use/wear a clean cotton T-shirt to prevent contact between the skin &
shoulder harness & to promote absorption of perspiration.
Treatment
Inform relatives to have a follow-up check up after 1- 2 weeks.
Inform relatives to return after 1 week for removal of sutures.
H Health Teachings
Encourage client to have warm bath to soothe & reduce pain..
Instruct to promote adequate fluid intake.
Discourage patient to participate in strenuous activities that might precipitate
stress and trauma.
Identify community and rehabilitation support, e.g., certified, home care service,
homemaker services, as needed. Facilitates transfer to home, supports
independence, and enhances coping.
O Observable Signs and Symptoms
Instruct relative to monitor & report promptly the signs of complications (e.g.,
uncontrolled pain) to the physician.
D Diet/ Nutrition
Stress importance of well-balanced diet, such as protein-rich foods, and
adequate fluid intake. Provides needed nutrients for tissue regeneration/healing,
aids in maintaining circulating volume and normal organ function, and aids in
maintenance of proper weight.
Instruct to increase fluid intake.
Inform patient that there are no restrictions in the diet.