Dengue is transmitted by the bite of an Aedes aegypti mosquito infected with any one of the four dengue viruses.

It occurs in tropical and sub-tropical areas of the world. Symptoms appear 3 -14 days after the infective bite. Risk factors for Dengue are Age. Dengue fever is a febrile illness that affects infants, young children and adults. Gender. Both men and female can have dengue cases. Living or traveling in tropical areas. Being in tropical and subtropical areas around the world especially in highrisk areas, such as tropical Asia, Central and South America, and the Caribbean increases your risk of exposure to the virus that causes dengue fever. Dengue virus transmission occurs year-round, although the risk is highest during a recognized dengue fever outbreak.

Prior infection with a dengue fever virus. Previous infection with a dengue fever virus increases your risk of a more severe form of the disease. This is especially true for children. If you've had dengue fever before, you can get it again if you become infected with another one of the four dengue-causing viruses. Having antibodies to a virus in your blood from a previous infection usually helps protect you. But in the case of dengue fever, it actually increases your risk of severe disease dengue hemorrhagic fever if you're infected again.

After being bitten by a mosquito carrying the virus, the incubation period ranges from three to 15 (usually five to eight) days before the signs and symptoms of dengue appear. Symptoms include the following:

Headache Pain upon moving the eyes Low backache Painful aching in the legs and joints occurs during the first hours of illness Temperature rises quickly as high as 104 F (40 C) Nose-bleeding when fever starts to subside Abdominal pain

Fever and other signs of dengue last for 2 to 4 days, followed by a rapid drop in body temperature (with profuse sweating. This precedes a period with normal temperature and a sense of well-being that lasts about a day. A second rapid rise in temperature follows. A characteristic rash appears along with the fever and spreads from the extremities to cover the entire body except the face. The palms and soles may be bright red and swollen. The number of deaths due to dengue in Metro Manila has reached 77, a health official said last August 23, 2011.

Department of Health (DOH) Metro Manila Director Dr. Eduardo Janairo said Metro Manila recorded a total of 11, 260 dengue cases from January 1 to August 11, 2011, 109% higher compared to the same period last year. Janairo said Quezon City has the highest number of dengue cases, followed by Caloocan and Manila. DOHs Regional Epidemiological and Surveillance Unit (RESU) said San Lazaro Hospital, Philippine Childrens Medical Hospital, St. Lukes Medical Center, The Medical City and Bernardino General Hospital admitted the most number of dengue patients in Metro Manila.

Vomiting of coffee-colored matter Dark-colored stools Relative low heart rate (bradycardia) and low blood pressure(hypotension) Eyes become reddened Flushing or pale pink rash comes over the face and then disappears Glands (lymph nodes) in the neck and groin are often swollen

Reasons for choosing this case We, group 308, have chosen to present this case because Dengue Fever has an increasing number of cases and deaths in children in the Philippines. General Objectives: After the completion of the study, the studentnurses will be able to apply gained information in providing effective nursing intervention to clients diagnosed with Dengue Fever and apply the nursing process in rendering effective nursing care.

Specific Objectives: After this nursing case study/presentation, the student nurses will be able to: Define what is Dengue Fever Trace the pathophysiology of Dengue Fever Enumerate the different signs and symptoms of Dengue Fever Formulate and apply nursing care plans utilizing the nursing process To raise our level of awareness so that we may render the proper care in the event we encounter a similar case.

Name: Age: Gender: Civil Status: Birth date: Nationality: Religion: Address:

F.L.G. 10 years old Male Single January 1, 2001 Filipino Roman Catholic Sta. Mesa Heights, Quezon City

Educational Background: Occupation: Date of admission: Time of admission: Chief complaint: Mode of arrival:

Admitting diagnosis:

N/A Unemployed August 22, 2011 2:02 pm High Fever Wheelchair borne, accompanied by father Dengue Fever

Patients Health History According to patients mother, F.L.G. suffers from coughs, colds, and asthma. He lives with his family. Before hospitalization, F.L.G. was doing well for a 10 year old. History of Present Illness According to patients mother, when her son arrived from school, her son experienced chills, muscle weakness with muscle pain, and a slightly elevated temperature. Several days passed and fever was on and off. So they decided to bring him to St. Lukes Medical Center and admitted him on August 22, 2011 at 2:02 pm.

Patient F.L.G. has had asthma since he was 2 years of age and his last attack was in August 2011. He has neither food nor drug allergies. According to his mother, the client received BCG, Vitamin K. This is the third time that Client F.L.G. was admitted in a hospital after birth. When he was 8 years old his left elbow was fractured. The cause of the other hospitalization was not stated by the patients mother.

According to the patients mother, F.L.G.s father, 40 years old, has asthma, hypertension, and diabetes. The mother of the client, 41years old, suffers from asthma. Both of the patients grandparents have a history of diabetes, hypertension and asthma. His 3 sisters are generally healthy. According to the patients mother, only F.L.G is prone to illnesses. (-) rheumatic fever (+)HPN (-)TB (+)DM (-) mental sickness

G.Mother A.C. 65y/o HPN

G.Father D.C. 67 y/o DM, Asthma

G.Mother J.G.. 63y/o HPN, asthma

G.Father E.G. 66 y/o DM

M.C. 49 y/o HPN

L.C. 33 y/o

P.C. 38 y/o HPN

Mother A.G. 41y/o asthma

Father J.G. 40 y/o Asthma, Dm, HPN

S.G. 35 y/o HPN

I.G 29 y/o HPN, DM

LEGEND:

Female
A.G. 16 y/o Male

K.G. 14 y/o

F.L.G. 10 y/o Dengue

L.G. 7 y/o

Death

Patterns of Health

Prior to Hospitalization

During Hospitalization

Analysis and Interpretation

Health Perception-Health Management

Client F.L.G. was a 10 year old boy. The client was healthy.

According to client

Client F.L.G. can

F.L.G. he considered his function normally but condition healthy yet due to present condition, his body was weak. Client F.L.G. was diagnosed Dengue weak because of his confinement and his present condition

NutritionalMetabolic Management

Client F.L.G.s life before his confinement on the said institution was normal. The client

During hospitalization, the client was on a DAT diet but ask to avoid dark colored foods.

was on normal diet.

Client I.F.H.s nutritional and metabolic status changed due to his confinement and his medical health condition. An individuals health status greatly affects eating habits and nutritional status (Fundamentals of Nursing by Kozier &

Patterns of Health

Prior to Hospitalization

During Hospitalization

Analysis and Interpretation

Elimination Pattern

Bowel Client F.L.G. usually defecates around 1-2 times a day. The stool was brown in color and the stool was formed.

Bowel

Bowel

Client F.L.G. defecates

around 1-2 times a day. The stool was brown in color and the stool was formed.

There was no change in

consistency and amount of stool due to his present condition. Bladder There was no change in

Bladder
Client F.L.G. urine is light yellow in color. No pain when voiding. Bladder The client uses 2-5 diapers/ day. No pain when voiding

the frequency and amount.

Some drugs have side

effects that can interfere with normal elimination (Fundamentals of Nursing by Kozier & Erbs Vol.2 p. 1327).

Patterns of Health

Prior to Hospitalization Client I.F.H.s daily activities include sleeping, eating, going to school, and playing

During

Analysis and

Hospitalization
Activity, Leisure and Recreation Pattern Client F.L.G.s activities in the hospitals were limited. He can no longer play and attend school.

Interpretation
During Client F.L.G.s confinement in the hospital, there were limitations in his activities of daily living and a disruption in his leisure and recreation pattern. A number of factors affect an individuals body

alignment, mobility and daily

activity level. These include growth and development, nutrition, personal values and attitudes, certain external factors, and prescribed limitations. (Fundamentals of Nursing by Kozier & Erbs Vol.2 p. 1116).

Patterns of Health

Prior to

During Hospitalization

Analysis and Interpretation Client F.L.G.s slept and rest pattern changed when he was admitted to the hospital due to the IV that he has and the client was on q2 for his vital signs. Illness that causes pain or physical distress can result in

Hospitalization
Sleep and Rest Pattern Client F.L.G, usually sleeps for 7-8 hours, he has no difficulty falling asleep. Client F.L.G. sleeps shorter than usual; having only 2-5 hours of sleep.

sleep problems. People who

are ill require more sleep than normal and the normal rhythm and wakefulness is often disturbed. (Fundamentals of Nursing, 7th ed by Barbara Kozier, et al, p.1117).

Patterns of Health CognitivePerceptual Pattern

Prior to Hospitalization

During Hospitalization

Analysis and Interpretation

Client F.L.G. was a 10 year old boy. He can read, write, and speak.

Client F.L.G. He is a 10 year old boy. He can read, write, and speak.

There was no change in cognitive and perceptual pattern in terms of reading, writing, and speaking. Due to his present condition, there is no change to the level of patient self perception and self-concept. Illness and trauma can also affect self-concept. Other research

SelfPerceptionSelf-Concept Pattern

Client F.LG. was not moody and act like a normal 10 year old boy.

Client F.L.G. was not moody and act like the other children

shows that health conditions,

including psychosocial situations such as loss and grieving, have an impact in self-concept. Thus, selfconcept and health-related behavior are intertwined. (Fundamentals of Nursing by Kozier & Erbs Vol.2 p. 1008).

Patterns of Health

Prior to Hospitalization

During Hospitalization Client F.L.G.s family is aware from what happened to him.

Analysis and Interpretation The client needs the familys love and care due to his condition.

Role Relationship

Client F.L.G. lived together with his family. They have no family

problems.

Family roles are

especially important to people because family relationships are particularly close. (Fundamentals of Nursing by Kozier & Erbs Vol.2 p. 1009).

Sexuality-

Client F.L.G. is a 10

Client F.L.G. is a 10

Client F.L.G. is a 10

Reproductive
Pattern

year old boy and single.

year old boy and single.

year old boy and single.

Patterns of Health Coping and Stress Tolerance

Prior to Hospitalization Prior to hospitalization client F.L.G. was not stressed.

During Hospitalization

Analysis and Interpretation

This hospital confinement is not easy for F.L.G. but

Due to his condition, Client F.L.G. cant go

he is coping as best as he anywhere else. The doctor can. advised the parents of the client to just stay by the bedside and be there all the time. According to Folkman and Lazaruz, coping is the cognitive and behavioral effort to manage specific external and/or internal demands that are appraised as taxing (Fundamentals of Nursing by Kozier, p.1020).

Patterns of Health

Prior to Hospitalization

During Hospitalization

Analysis and Interpretation

Values-Belief Pattern

Client F.L.G. and his whole family were Roman Catholic.

Client F.L.G. and his Catholic. The clients mother prays for the clients health and hopes they can return home soon.

After what happened,

whole family are Roman client F.L.G. is now seeking for medical assistance. Religious effort is still a part of client F.L.G. and his familys life.

Examination Hemoglobin Hematocrit RBC WBC Differential current Neutrophils Lymphocytes Monocytes Platelet count MCV MCH MCHC Basophil eosinophils

Normal findings 13.0 - 17.0 g/L 40.0 - 52.0 % 4.70 6.10 mL/mm 4800 10800 mm 40 74% 19 48 % 39% 150000 - 400000 82 - 98 28 33 32 - 38 0-2 07

Actual findings 12.5 37.1 4.65 5080 82 10 8 224000 80 27 34

Interpretation

-Abnormal destruction of red blood cells -increased neutrophils count it indicates infection, it also cause of many inflammatory processes.

Remarks: result/s double check

Examination Hemoglobin Hematocrit RBC WBC Differential current Neutrophils Lymphocytes Monocytes Platelet count MCV MCH MCHC Basophil Eosinophils

Normal findings 13.0 17.0 40.0 52 4.70 6.10 4800 10800 40 74 19 48 39 150000 400000 82 98 28 33 32 38 02 0-7

Actual findings 13 40.5 4.96 3440 76 20 4 166000 82 26 32 -

Interpretation Decreased WBC possible causes of viral infection -results in a compromised immune system

Urinalysis Specimen: Urine

Normal findings Actual findings

Interpretation

Color Transparency Glucose Bilibrubin Ketone Specific Gravity pH (reaction) protein Urobilinogen Nitrates Blood Leukocytes Urine sediment analysis by manual microscopy Red blood cells White blood cells Epithelial cells Cast bacteria

Pale yellow to amber clear 1.010-1.040 7.35-7.45

Yellow Clear Negative Negative 15 mg/dL (+1) 1.01 6.5 Negative 1. E.U/dL Negative Negative Negative 01 01 Occasional 0 occasional

-acidic

Urine sediment analysis by manual microscopy Red blood cells White blood cells Epithelial cells Cast bacteria 01 01 Occasional 0 occasional

Examination Hemoglobin Hematocrit RBC WBC Differential current Neutrophils Lymphocytes Monocytes Platelet count MCV MCH MCHC Basophil Eosinophils

Normal findings 13.0 - 17.0 g/L 40.0 - 52.0 % 4.70 6.10 mL/mm 4800 10800 mm 40 74% 19 48 % 39% 150000 - 400000 82 - 98 28 33 32 - 38 0-2 07

Actual findings 12.4 36 9 4.6 2500 66 29 4 104000 80 27 34 1 -

Interpretation Those highlighted numbers are indicated for destruction of white blood cells which infection occurs that manifest of fever

Examination

Normal findings

Actual findings

Interpretation

Hemoglobin Hematocrit RBC WBC Differential current Neutrophils Lymphocytes Monocytes Platelet count MCV MCH MCHC Basophil Eosinophils

13.0 - 17.0 g/L 40.0 - 52.0 % 4.70 6.10 mL/mm 4800 10800 mm 40 74% 19 48 % 39% 150000 - 400000 82 - 98 28 33 32 - 38 0-2 07

13.0 38.2 4.76 2560 65 31 3 78000 80 27 34 1 -

The WBC and platelet count are the same from the previous test but there are some changes in hematocrit which destructed.

Examination Hemoglobin Hematocrit RBC WBC Differential current Neutrophils Lymphocytes Monocytes Platelet count MCV MCH MCHC Basophil Eosinophils

Normal findings 13.0 - 17.0 g/L 40.0 - 52.0 % 4.70 6.10 mL/mm 4800 10800 mm 40 74% 19 48 % 39% 150000 - 400000 82 - 98 28 33 32 - 38 0-2 07

Actual findings 12.2 35.4 4.36 2900 73 23 4 53000 81 27 34 -

Interpretation Abnormal destruction of red blood cells included the hemoglobin and hematocrit. The platelet continues to decrease occurs due to platelets destruction or impaired platelet production.

Examination Hemoglobin Hematocrit RBC WBC Differential current Neutrophils Lymphocytes Monocytes Platelet count MCV MCH MCHC Basophil Eosinophils

Normal findings 13.0 - 17.0 g/L 40.0 - 52.0 % 4.70 6.10 mL/mm 4800 10800 mm 40 74% 19 48 % 39% 150000 - 400000 82 - 98 28 33 32 - 38 0-2 07

Actual findings 13.2 39.1 4.85 3020 39 53 5 48000 81 27 34 1 2

Interpretation The decreasing of WBC and platelet count are indicated for viral infection that manifest high fever.

Examination Hemoglobin Hematocrit RBC WBC Differential current Neutrophils Lymphocytes Monocytes Platelet count MCV MCH MCHC Basophil Eosinophils

Normal findings 13.0 - 17.0 g/L 40.0 - 52.0 % 4.70 6.10 mL/mm 4800 10800 mm 40 74% 19 48 % 39% 150000 - 400000 82 - 98 28 33 32 - 38 0-2 07

Actual findings 14.0 40.2 5.14 2700 28 55 9 42000 78 27 35 2 6

Interpretation Critical low value for platelets fewer than 50,000 is at risk for bleeding episodes with minor trauma. These are more likely to have a viral infection because of the changes in platelet count it is decreasing.

Examination Hemoglobin Hematocrit RBC WBC Differential current Neutrophils Lymphocytes Monocytes Platelet count MCV MCH MCHC Basophil Eosinophils

Normal findings 13.0 - 17.0 g/L 40.0 - 52.0 % 4.70 6.10 mL/mm 4800 10800 mm 40 74% 19 48 % 39% 150000 - 400000 82 - 98 28 33 32 - 38 0-2 07

Actual findings 12.8 37.8 4.65 3400 32 51 9 50000 81 28 34 1 7

Interpretation The WBC component are destructed included the hematocrit and the platelet count still low.

Examination Hemoglobin Hematocrit RBC WBC Differential current Neutrophils Lymphocytes Monocytes Platelet count MCV MCH MCHC Basophil Eosinophils

Normal findings 13.0 - 17.0 g/L 40.0 - 52.0 % 4.70 6.10 mL/mm 4800 10800 mm 40 74% 19 48 % 39% 150000 - 400000 82 - 98 28 33 32 - 38 0-2 07

Actual findings 13.5 39.8 4.90 4400 31 56 9 63000 81 28 34 1 3

Interpretation The platelet count bit increase but not in the normal range which means the infection still there.

Examination
Hemoglobin Hematocrit RBC WBC Differential current Neutrophils Lymphocytes Monocytes Platelet count MCV MCH MCHC Basophil Eosinophils

Normal findings
13.0 - 17.0 g/L 40.0 - 52.0 % 4.70 6.10 mL/mm 4800 10800 mm 40 74% 19 48 % 39% 150000 - 400000 82 98 fl 28 33 pg 32 38 % 02% 07%

Actual findings
12.8 37.3 4.61 4500 20 66 9 81000 81 28 34 1 4

Interpretation

The circulatory system is responsible for the transport of water and dissolved materials throughout the body, including oxygen, carbon dioxide, nutrients, and waste. The circulatory system transports oxygen from the lungs and nutrients from the digestive tract to every cell in the body, allowing for the continuation of cell metabolism. The circulatory system also transports the waste products of cell metabolism to the lungs and kidneys where they can be expelled from the body. Without this important function toxic substances would quickly build up in the body.

An often overlooked part of the circulatory system is the lymphatic system. As blood passes through the capillaries, some of the fluid diffuses into the surrounding tissues. One function of the lymphatic system is to collect and recycle this fluid (called lymph). Lymph passes from capillaries to lymph vessels and flows through lymph nodes that are located along the course of these vessels. Cells of the lymph nodes phagocytize, or ingest, impurities such as bacteria, old red blood cells, and toxic and cellular waste. Finally, lymph flows into the thoracic duct, a large vessel that runs parallel to the spinal column, or into the right lymphatic duct, both of which transport the lymph back into veins of the shoulder areas where is mixes with blood and is returned to the heart. All lymph vessels contain one-way valves, like the veins, to prevent backflow. The tissues of the lymphatic system include the spleen. The spleen serves as a reservoir for blood, releasing additional blood into the circulatory system as needed. It is also involved with destruction of old cells and other substances by phagocytosis. The lymphatic system is also responsible for collecting nutrients that the digestive

The leukocytes, or white blood cells, are of three types; granulocytes, lymphocytes, and monocytes. All are involved in defending the body against foreign organisms. There are three types of granulocytes: neutrophils, eosinophils, and basophils, with neutrophils the most abundant. Neutrophils seek out bacteria and phagocytize, or engulf, them. The lymphocytes' chief function is to migrate into the connective tissue and build antibodies against bacteria and viruses. Leukocytes are almost colorless, considerably larger than red cells, have a nucleus, and are much less numerous; only one or two exist for every 1,000 red cells.

The number increases in the presence of infection. Monocytes, representing only 4 to 8 percent of white cells, attack organisms not destroyed by granulocytes and leukocytes. The granulocytes, accounting for about 70 percent of all white blood cells, are formed in the bone marrow. The lymphocytes on the other hand are produced primarily by the lymphoid tissues of the bodythe spleen and lymph nodes. They are usually smaller than the granulocytes. Monocytes are believed to originate from lymphocytes. Just as the oxygen-carrying function of red cells is necessary for our survival, so are normal numbers of leukocytes, which protect us against infection.

Platelets Platelets, or thrombocytes, are much smaller than the red blood cells. They are round or biconcave disks and are normally about 30 to 40 times more numerous than the white blood cells. The platelets' primary function is to stop bleeding. When tissue is damaged, the platelets aggregate in clumps to obstruct blood flow. Plasma The plasma is more than 90 percent water and contains a large number of substances, many essential to life. Its major solute is a mixture of proteins. The most abundant plasma protein is albumin. The globulins are even larger protein molecules than albumin and are of many chemical structures and functions. The antibodies, produced by lymphocytes, are globulins and are carried throughout the body, where many of them fight bacteria and viruses. An important function of plasma is to transport nutrients to the tissues. Glucose, for example, absorbed from the intestines, constitutes a major source of body energy. Some of the plasma proteins and fats, or lipids, are also used by the tissues for cell growth and energy.

The Blood The blood transports life-supporting food and oxygen to every cell of the body and removes their waste products. It also helps to maintain body temperature, transports hormones, and fights infections. The brain cells in particular are very dependent on a constant supply of oxygen. If the circulation to the brain is stopped, death shortly follows. Blood has two main constituents. The cells, or corpuscles, comprise about 45 percent, and the liquid portion, or plasma, in which the cells are suspended comprises 55 percent. The blood cells comprise three main types: red blood cells, or erythrocytes; white blood cells, or leukocytes, which in turn are of many different types; and platelets, or thrombocytes. Each type of cell has its own individual functions in the body. The plasma is a complex colorless solution, about 90 percent water, that carries different ions and molecules including proteins, enzymes, hormones, nutrients, waste materials such as urea, and fibrinogen, the protein that aids in clotting.

Red Blood Cells The red blood cells are tiny, round, biconcave disks, averaging about 7.5 microns (0.003 in) in diameter. A normal-sized man has about 5 l (5.3 qt) of blood in his body, containing more than 25 trillion red cells. Because the normal life span of red cells in the circulation is only about 120 days, more than 200 billion cells are normally destroyed each day by the spleen and must be replaced. Red blood cells, as well as most white cells and platelets, are made by the bone marrow. The main function of the red blood cells is to transport oxygen from the lungs to the tissues and to transport carbon dioxide, one of the chief waste products, it to the lungs for release from the body. The substance in the red blood cells that is largely responsible for their ability to carry oxygen and carbon dioxide is hemoglobin, the material that gives the cells their red color. It is a protein complex comprising many linked amino acids, and occupies almost the entire volume of a red blood cell. Essential to its structure and function is the mineral iron.

Drug name (generic and brand names)

Classification

Indication (client-based)

Dosage (clientbased)

Side effects/ Contraindications/ adverse effects precautions

Nursing responsibilities

Cetirizine hydrochloride/ Zyrtec

Antihistamine

Seasonal allergic rhinitis

10mL Somnolence, p.o. @ hs fatigue, dizziness, headache, dry mouth, nausea, vomiting

Contraindicated in Warn patient that patients drug can cause hypersensitive to drug drowsiness. or to hydroxine Remind patient not to perform hazardous activities because sleepiness is an adverse effect

Drug name Classificati Indication (generic on (clientand brand based) names)

Dosage Side effects/ Contraindication Nursing (client- adverse s/ precautions responsi based) effects bilities

Paracetam Analgesic/ ol antipyretic

Fever

p.o. T > 37.8

Leukopenia, neutropenia, jaundice, skin rash

Contrainidcated in patients hypersensitive to drug In children, dont exceed 5 doses in 24 hours.

Warn patient that drug is only for short-term use.

Drug name Classification (generic and brand names) Omeprazole/ Anti-ulcerative Prilosec

Indication (clientbased)

Dosage (clientbased)

Side effects/ Contraindication adverse s/ precautions effects Dizziness, headache, abdominal pain, constipation, diarrhea, nausea, vomiting Contrainidcated in patients hypersensitive to drug.

Nursing responsibili ties Caution patient to avoid hazardous activities if he gets dizzy.

Sympto 40 mg IV matic Od/ Q12 gstroeso phageal reflux isease (GERD) Erosive esophag itis

8/25/11 Rounds with Dr. A, the patient is afebrile, still complaining abdominal pain and decreased breath sounds on the lower lung fields. 8/25/11 @ 12:15 am Patient is undergoing CXR- PA- lateral and for repeat CBC at 2pm

8/25/11 @ 12:25 pm According to RIC notes the patient is going day on his 6th day of illness and is positive for abdominal pain but with decreased intensity with VAS 5/10, positive loose stool, IV with the itching episodes, and has input of 3640 and output with 1720 with the urine output of 1.99 cc/kg/hr. During the rounds of Dr. A the patient is awake in a mild tolerable pain, has BP of 90/60. The patient is afebrile, non-hyperemic tonsil with positive epigastric tenderness, flush, warm extrimities, and full pulse. Dengue Fever. Emptiness increase resent IVF rate, for repeat CBC at 2pm

8/25/11 @ 4 pm Dr. A updated of latest CBC result Repeat CBC tomorrow @ 6 am (8-26) Monitor patients input and output accurately 8/25/11 @ 9:30 pm According to Pedia Pulmo Notes, the patient has positive itchiness on legs, decreased abdominal pain, positive skin dryness with negative fever.

8/25/11 @ 9:40 pm According to PROD notes, patient has no reccurrence of abdominal pain and vomiting, itchiness of both arms and legs. Uneasy due to itchiness, patient is afebrile, decreased breath sounds; bibasal, without abdominal tenderness, full pulse, flushed no rashes. 8/25/11 @ 9:40 pm Doctors order is to start Cetirizine 5mg/5ml, 10 ml once a day @ bedtime and to maintain present IVF site.

8/26/11 @ 9:30 am The patient is going on day 2 of afebrile and day 7 of illness, has no recurrence of abdominal pain or vomiting. The patient improved his appetite with no recurrence of pruritis. The patient is comfortable with BP of 100/20 and heart rate of 88, afebrile. Flushed with decreased breath sounds; bibasal, no abdominal tenderness and no rashes. For repeat CBC tomorrow (8-27)

8/26/11 @ 12:52 pm Rounds of Dr. A The patient has good appetite with no recurrence of abdominal pain or vomiting; no pruritis. Patient is comfortable with no abdominal tenderness, has decreased breath sounds; bibasal, full pulse. 8/26/11 @ 2pm Decrease present IVF note to 11cc/hr and for repeat CBC tomorrow (8-27)