viral men in go encephalitis

8/2/2019 Viral Men in Go Encephalitis

1/13

VIRALMENINGOENCEPHALITIS


2/13

Chapter 2 A. Patients Profile Name : Angeline Natividad Ursos

Age/Sex : 6 years old/ Female Civil Status : Single Address : Purok 2, Bayugan 2, San Francisco, Agusan Del Sur Nationality : Filipino Religion : UCCP

Occupation : Child Birth date : January 20, 2006 Birth Place : Agusan Del Sur Weight : 17kgs. Name of Mother : Mary Jane Ursos

Name of Father : Alfredo Basigan Admission Date/Time : January 28, 2012 at 6:53pm Admitting Physician : Dr. Joemel P. Dacula MD Admitting Diagnosis : CNS infection probably Bacterial

Meningitis


3/13

B. Family Background:

Patient Angeline Ursos is a 6 years Old girl. Bornon January 20, 2006 and is the second child of Mary

Jane Ursos and Alfredo Basigan who happens to beseparated. Her Grandparents, Mr. and Mrs. Ursos andMr. and Mrs. Basigan both have a common heredo-familal disease which is hypertension. She has 3

siblings, Dicken Ursos who is 7 years old and currentlya Grade 1 student in their home town, Bunny JaneUrsos who is 4 years Old and the other one is her 2

years old brother from her mothers second family.Angeline was unfortunately the only one who got thistype of disease.


4/13

C. Effects of Present disease to self/family:

According to her grandfather, Mr. Benedicto Ursosthey really didnt expect Angelines condition at all

because as young as she is, she has still a lot ofplaying and studying to do. He also added that italready came to a point that they already gave uptowards her condition because as they can observed,

it seems that there is no more cure even though theyprovide all of the prescriptions given. And that theirwere a lot of times that they attempted to ask the

doctors to discharge their patient even if she is not yetwell. But with a strong faith in God, not a single daythat they didnt wish that Angeline would soon recoverfrom her illness in Gods time.


5/13

D. History of Past Illness:

Patient Angeline Ursos was never been

hospitalized before. She only had feverand cold. And as added by her grandfather who took care of her since she was

2 years old up to now, she has alsoexperienced chicken pox when she was 2years old and got mumps when she was 4

years old. But no other serious illnessback then.


6/13

E. History of Present Illness:

Weeks prior to admission, patientexperienced fever and several episodes ofLBM, vomiting and convulsions. 4 days prior toadmission, patient still experienced the samesymptoms. Then her grandfather decided to

admit Angeline in their provincial hospital andwas then diagnosed with bacterial meningitis.She was admitted for 4 days but because the

hospital doesnt have enough facilities to helptreat Angelines condition, they were referred toSouthern Philippines Medical center (SPMC).

Further tests were done and still they have the


7/13

F. Assessment

Vital Signs

February 14, 2012

Temperature:39.2C

Blood Pressure:100/80mmHg

Pulse Rate:130bpm

Respiratory RatE:44cpm

February 15, 2012

TEMP:40.4CBP:100/80mmHg

PULSE RATE:145bpm

RESPIRATORY:40cpm


8/13

Nervous System

Patient is very lethargic. Positive of nuchal rigidity as well askernings sign. With Glasgow coma scale (GCS) ranging from7-9.

Cardiovascular System

Patient has several episodes of tachycardia having Pulse Rate

ranging from 130-145 beats per minute. Her pulsations are verystrong and fast.

Gastrointestinal System

Patient is on OTF feeding at 1,400. Has a dry mucousmembrane including the tongue. Her gums have poor conditionand she has a lot of damaged teeth. Negative of abdominaldistention.


9/13

Genitor-Urinary System

Patient is voiding freely with urine output

of 500cc per shift. She has also episodesof LBM with a tea-colored watery stool.

Musculo-Skeletal System

Patient is lying on bed and is positive of

decorticate and decerebrate posturing.Has very poor muscle tone andmovement. Not able to flex joints freely.


10/13

Integumantary System

Patient has flushed, warm to touch and very dry skin. Haspaleness coloration of the upper and lower nails. With capillaryrefill timing of 2-3 seconds.

Respiratory System

Productive cough noted with crackling sounds heared upon

ausculatation Positive episodes of tachypnea. Has respiratoryrate ranging from 30-44 cycles per minute. With 02 inhalationvia face mask at 6 liters per minute.

Psychosocial System

Patient is lethargic. Unable to respond to interviews andinstructions given. But she has a very supportive grand fatherand aunt to assist her.


11/13


12/13


13/13

viral men in go encephalitis

Documents