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Case study:
Dengue

2. TABLE OF CONTENTS
1. Introduction
2. Objectives of the study
-general objectives
-specific objectives
3. Theoretical framework
4. Nursing health history
-demographic data
-history of present illness
-past medical history
-family history
-social history
-environmental history

3. -genogram
5. Gordon’s level of functioning
6. Physical assessment
7. Laboratory exams
8. Anatomy and physiology
9. Pathophysiology
10. medical/surgical intervention
11. Drug study
12.nursing care plan
12. Discharge plan
12. Bibliography
INTRODUCTION
This case is a about a 13 years old boy who was admitted at Capitol medical center on
September 21, 2012 with a chief complaint of fever and was diagnosed with dengue.
Dengue fever is a disease cause by a family of viruses that are transmitted by ‘’Aedes’’
mosquitoes. This mosquito transmits the disease by biting an infected person and then biting
someone else. The mosquitoes that transmit dengue live among human and breeds in
discarded tires, flower pots, old drums and water storage containers close to human dwellings.
Unlike the mosquitoes that cause malaria, dengue mosquitoes bit during the day.
Symptoms such as headache, fever, exhaustion, severe joint and muscle pain, swollen glands
(lymphadenopathy), and rash. The presence (the "dengue triad") of fever, rash, and headache
(and other pains) is particularly characteristic of dengue fever

4. MANILA, Philippines -- Global warming may have contributed to a 43 percent rise in the
number of dengue cases in the Philippines for the first half of the year. The biggest increase in
the country was seen in Metro Manila, where there was an almost 200 percent increase. "The
increase in the number of dengue cases may be attributed to the constantly changing climate
brought by global warming as well as congestion in urban areas,"
World Health Organization officials earlier this year warned climate change was increasing the
incidence of dengue fever and other infectious diseases in the country. There is no known cure
or vaccine for dengue fever, which is transmitted by the white-spotted mosquito.
OBJECTIVES OF THE STUDY
General objectives
 the main goal of the study is for me to have an additional knowledge related to
pneumonia and to develop my skills in assessing a patient with pneumonia
Specific objectives

5.  interpret data gathered from the patient identify and explain etiology of the underlying
condition
 discuss the anatomy and physiology of the related disease
 trace the pathopysiology of the disease
 explain how the theoretical framework relates to the patients present condition
 discuss the Gordon’s pattern of functioning and physical assessment obtained
 classify the drugs being taken by the patient
 carry out interventions that were discussed in the nursing care plan
THEORETICAL FRAMEWORKS
Environmental theory
Florence nightingalewasbornon May 12 1820. She wasthe founderof modern nursingandthe first
nursingtheorist. Alsoknownas"The Ladywiththe Lamp She was the firstto propose nursingrequired
specificeducationandtraining. HercontributionduringCrimeanwariswell-known.
Assumptions of nightingale’s theory
 Natural laws
 Mankindcan achieve perfection
 Nursingisa calling
 Nursingisan art and a science
 Nursingisachievedthroughenvironmentalalteration
 Nursingrequiresaspecificeducationalbase
 Nursingisdistinctandseparate frommedicine
Nightingale’s canons: major concepts

6.  Ventilationandwarming
 Light,Noise
 Cleanlinessof rooms/walls
 Healthof houses
 Bedand bedding
 Personal cleanliness
 Variety
 Chatteringhopesandadvices
 Takingfood. What food?
Nightingale'sdocumentscontainherphilosophical assumptionsandbeliefsregardingall elementsfound
inthe metaparadigmof nursing. These canbe formedintoa conceptual model thathasgreatutilityin
the practice settingandoffersa frameworkforresearchconceptualization
4-digm
Nursing
Nursingisdifferentfrommedicine andthe goal of nursingisto place the patient inthe bestpossible
conditionfornature toact.
Nursingisthe "activitiesthatpromote health(asoutlinedincanons) whichoccurinany caregiving
situation. Theycanbe done byanyone."
Person
People are multidimensional,composedof biological,psychological,social andspiritualcomponents.
Health
Healthis“not onlyto be well,buttobe able touse well everypowerwe have”.
Disease isconsideredasdys-ease orthe absence of comfort.
Environment
"Pooror difficultenvironmentsledtopoorhealthanddisease".

7. "Environmentcouldbe alteredtoimprove conditionssothatthe natural lawswouldallow healingto
occur."
In a relationtothe patient,
In the case of the patientwhereinshe manifesteddengue,itcanbe correlatedwiththe theoryof
nightingale where inthe environmentof the patientisafactor leadingtorecovery,havingaclean
environment,well organizedhouse,nurturingenvironmentandtakingfruitsandvegetables,the body
couldrepairitself.
NURSING HEALTH HISTORY
A. personal history
Name: MT
Age:13
Address: cordero8th
avenue grace park Caloocancity
Birthday: July25, 1999
Sex: male
Civil status:single
Religion:romanCatholic
Attendingphysician:Dr.Naidas
Admissiondiagnosis: systemicviral illnessruledoutdengue fever
Admissiondate: September21,2012
Chief complaint:Fever
B. history of presentillness
4 daysprior to admissionpatienthadcolds.1 dayprior to admissionpatient wasnotedtobe
febrile at(40. O C) paracetamol wasgivenandthe patientconsultedalocal clinicandwas
diagnosedwithacute tonsillopharyngitis.Co-amoxiclavwasprescribepatientwasable totake
medicationfor3 days
C. past medical history

8. Patientwashealthybut he hadbeenadmittedtothe hospital several timesbefore.Hislast
admissionwasonFebruary2012 due to scarletfever.Andhe alsohasbronchial asthma.Andhis
vaccinationwasunrecalled
D. personal/social history
Patientisnowingrade 7. He liveswithhismother,fatherandhissiblings. The patientisaNon-
smokerandNon-alcoholicdrinker.He wasalsoinclinedtosportslike basketball,andsometimes
he playsbadmintonforpasttime. He lovestoeatchickenandpork but he hatesvegetables.
E. Environmental history
Patientlivesinanurbanarea whichisnot crowdedbutsomehow semi-polluted
F. Familyhealth history
Patient‘sfatherwhoresidesinCaloocantogetherwithhis Familydoesn’thave anyhistoryof
otherdiseasesaside fromhypertension whichwere treatedbymedicationsprescribedbytheir
physician.Similarly, theyhave alsostatedthatthe familyisnotsports-inclinedandhasnot
practicedmuch of theiractive lifestyle.Usuallytheyspendtheirtime atworkand at home
watchingtelevisionandmoviesandenjoyoccasionaldrinking. Onthe otherhand,hermother
whogrewup in Caloocan hada historyof diabetesandasthma.
GORDON’S PATTERN OF FUNCTIONING
Pattern Before hospitalization During hospitalization Analysis
1. Health
perception
maintenance
The patienttakes
vitaminsandbut
doesn’teatvegetable.
The patienthave
regularcheckupsyearly
withhisphysician
The clienthealthis
goodthe feverresided,
but the rasheson his
skinwere still there.
Andhisfamily
informedthe nurse on
dutywhenthe client’s
temp.Increased.
Thepatientcanmanage
hishealth,heinformedthe
nursewheneverhefeels
somethingwrong,andit
reallyhelpsthemedical
staffstotreathim.
2. Nutritional
metabolic
pattern
Eat 3 mealsperday
and sometimestake
midnightsnacks.And
consume 5-6 glassesof
waterper day
He’sonDFAandNDCF,still
eats3timesaday.Andhe
hadanon-goingIVfluid.
Andtakes 600ccofwater
perday
There are nomany
changesinpatient’s
nutritional and
metabolicpattern.And
the clienthasproper
dietandfluidintake
3. Elimination
pattern
The patientdefecates
once a daywithoutany
discomfortanditis
well formed.he usually
urinates 4 or 5 timesa
day withoutanypainor
discomfort
The clientstill urinates
4 to 5 timesa day and
defecatedonce aday
There are nomany
changesinpatient’s
eliminationpattern
4. Activity and Have no regular The patientliesonbed There isminimal

9. exercise pattern exercise buthe plays
basketball and
badminton.
mostof the time,and
not allowedtomobilize
as much due hisIV.
activitiesdue tohis
hospitalization
5. Sleepand rest
pattern
The clientsleep’s6to 7
hrs withoutdifficulties.
Usuallysleeps11pmto
5 am.
The clienthasno
choice butto sleep and
rest,but he has
difficultyof sleeping
because of the nurses
and doctorsrounds
The clientssleeping
routine hasbeen
changed.Patientssleep
was disturbedbecause
of the nursesand
doctorsrounds
6. Cognitive and
perceptual
pattern
Patientisalertandwell
oriented
Patientseasily
understandsand
cooperateswell
There are nochanges
inclient’scognitiveand
perceptual pattern.The
clientcanexpress
himself butdoesn’t
communicateswell
7. Self-perception
and self-
maintenance
The patientisserious
and familycentered
The patientisnot that
approachable butvery
cooperative,he is
alwayssurroundedby
his family
The patientsisirritable
because of her
condition,butcan
cooperate withthe
others
8. Role relationship
pattern
The patientisthe
youngestson.Andhe
liveswithhismother,
fatherand brothers
The patientisalways
accompaniedbyhis
oldestbrother,andhis
relativesvisitsonce in
awhile
The patientis
independentbut
somehow dependson
hisbrotherdue to his
condition
9. Sexuality
reproductive
the patientisnot
sexuallyactive
The patientdoesn’t
performanysexual
activities
There isstill nochanges
inthe patient’s
sexualityreproduction
10. Coping/stress
tolerance
The patientdoesn’t
encountermuch
problem,and his
alwayshappy
the patientseems
boredand somehow
unhappy,andhe plays
laptopto entertain
himself
The clientisnot
comfortable because
he is hospitalizedand
wantedtogo home
soon
11. Valuesand
beliefs
The clientisa roman
catholic.he goesto
mass everySunday
withhisfamily,and
pray everynightbefore
goingto sleep
The clientsstill have
time to prayevery
nighttogetherwithhis
brother
The clientisreligious
and eventhoughhe is
hospitalizedhe had
time pray
PHYSICAL ASSESSMENT
General findings Normal Findings Analysis
height 4’5-5’3 5’2 Height is in the normal
range
weight 45.3-49.8 54 Weight is not in the

10. normal range
temperature 36.5-37.5 36.6 Temperature is in the
normal range
Pulse rate 60-100 80 Pulse rate is in the
normal range
Respiratory rate 12-20 20 Respiratory rate is in
the normal range
Blood pressure 90/60 to 130/90 100/70 Blood pressure is in the
normal range
Area assessed Technique Normal
findings
Findings Analysis
A. Skin
Color Inspection Lightbrown,
tannedskin
(mayvary
accordingto race)
Light brown in
color, has pink
rashes
Due to dengue
Moisture Inspection/palpation Skinnormallydry Normally dry Normal
Temperature Palpation Normallywarm Warm to touch Normal
Texture Palpation Smoothand soft smooth and soft Normal
Turgor Palpation Skinsnapsback
immediately
Skin snaps back
immediately
Normal
Skin appendages
Nails Inspection Transparent,
smoothand
convex
Transparent,
smoothand
convex
Normal
Nailsbed inspection Pinkish Pinkish Normal
Nailsbase Inspection Firm Firm Normal
Hair distribution Inspection Evenlydistributed Evenlydistributed Normal
Color Inspection Black to light
brown
black Normal
Upperextremities Normal
Arms Palpation/inspection Warm to touch
and tenderness
Warm to touch
and tenderness
Normal
Palmsand dorsal
surface
Palpation/inspection Pinkishand
slightlyrough
Pinkishand
slightlyrough
Normal
Shoulders Inspection Performw/oany
difficulty
Perform w/o any
difficulty
Normal
Elbows Inspection Performwithout
any difficulty
Perform without
any difficulty
Normal
Skull Inspection
Generallyround Generallyround
Normal
Eyes

11. Eyes Inspection
Nonprotruding Nonprotruding
Normal
Eyebrows Inspection Symmetrical in
size, extension,
hair texture and
movement
Symmetrical in
size,extension,
hair texture and
movement
Normal
Eyelashes Inspection
Evenlydistributed Evenlydistributed
Normal
Eyelids Inspection
Same color as skin Same color as skin
Normal
Conjunctiva Inspection
Transparentwith
lightpinkcolor
Transparentwith
lightpinkcolor
Normal
Sclera Inspection Colorwhite Colorwhite Normal
Ears
Inspection Free of Lesions,
discharge or
inflammation
Free of Lesions,
discharge or
inflammation
Normal
Hearingacuity Inspection Clientnormally
hearswordswhen
whispered.
Clientnormally
hearswordswhen
whispered.
Normal
Nose Inspection Nose inthe
midline;no
discharges;no
bone or cartilage
deviationnoted.
Nose in the
midline; no
discharges; no
bone or cartilage
deviation noted.
Normal
neck Inspection/palpation
No visiblemassor
lumps;
symmetrical;no
jugularvenous
distension.
No visiblemassor
lumps;
symmetrical;no
jugularvenous
distension.
Normal
Lymphnodes inspection
May notbe
palpable;non-
tenderIF
PALPABLE;less
than 1cm in size.
May notbe
palpable;non-
tenderIF
PALPABLE;less
than 1cm in size.
Normal
Thyroid Inspection
Normallynon-
palpable; no
nodulespalpable
Normallynon-
palpable; no
nodulespalpable
Normal
Thorax
Lungs Auscultation Normal

12. Illustrate
voluntarysound
Illustrate
voluntarysound
Cardiovascular Inspection
Pulse visible;no
liftor heaves.
Pulse visible;no
liftor heaves.
Normal
Abdomen inspection
Skincoloris
uniform, no
lesions;some may
have presence of
striae or scars
Uniformcolorto
the rest of the
skin
Normal
lowerextremities Inspection
Equal in size; no
edema; no
crepitus
Equal in size; no
edema; no
crepitus
Normal
LABORATORY EXAM
HEMATOLOGY
Latest report
September 23, 2012
Test Actual findings Normal findings Analysis/interpretation
Hemoglobin 163 g/l 135-160 The no. of hemoglobin
increasedindicationof
poor oxygensupply
Hematocrit 0.48 0.40-0.48 normal
Erythrocytes 5.59 10’12/l 4.5-5.0 The no. of erythrocytes
increasedindicates that
the red bloodcellsare
carryinglessoxygen
than normal
MCV 87.70 fl 80-96 Normal
MCH 29.20 pg 27-33 Normal
MCHC 33.30 g/dl 33-36 Normal
Total WBC 3.4 10’g/l 5.0-10.0 The no. of WBC count
decreasedindicationof
vulnerable topotential
seriousinfection which
isdengue

13. Nuetrophils 0.37 0.55-0.65 The no. of neutrophils
decreased resultedto
underlyingcondition
whichisdengue that
affectsthe cell
production
Lymphocytes 0.53 0.25-0.40 The no. of lymphocytes
increased because of
the infection
Monocytes 0.06 0.02-0.06 Normal
Stabs 0.04 0.01-0.05 Normal
Platelet count 230 150-440 Normal
Previous
September 22, 2012
Test Actual findings Normal findings Analysis/interpretation
Hemoglobin 146 135-160 Normal
Hematocrit 0.44 0.40-0.48 Normal
Erythrocytes 4.98 4.5-5.0 Normal
MCV 87.30 80-96 Normal
MCH 29.30 27-33 Normal
MCHC 33.60 33-36 Normal
Total WBC 4.1 5.0-10.0 The no. of WBC count
decreasedindicationof
vulnerable topotential
seriousinfection which
isdengue
Nuetrophils 0.65 0.55-0.65 Normal
lymphocytes 0.25 0.25-0.40 Normal
Monocytes 0.06 0.02-0.06 Normal
Stabs 0.03 0.01-0.05 Normal
Platelet count 213 150-440 Normal
ANATOMY AND PHYSIOLOGY

14. BLOOD
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients
and oxygen to the cells and transports metabolic waste products away from those same cells.
PHYSICAL CHARACTERISTIC
Brightred (oxygenated) darkred/purplish(unoxygenated). Muchmore dense thanpure water. pH
range from 7.35 to 7.45 (slightlyalkaline). Slightlywarmerthanbodytemperature38.Celsius. Typical
volume inadultmale 5-6 literstypical volume inadultfemale 4-5liters typically8% of bodyweight
COMPONENTS OF BLOOD
The bloodisconsideredtobe the onlyfluidtissue inthe body.Itiscomplex connective tissue inwhich
formedelementsare suspendedinanonlivingfluidmatrix calledplasma.The plasmaisthe liquidpartof
the bloodand isapproximately90%water.
3 formedelementsinthe blood
1. Erythrocytes- responsibleforbloodgastransport
2. Leukocytes –defendsbodyfrominfectionordisease
3. Platelets- neededfornormal bloodclotting
(in this case, platelets are the ones mostly affected by the dengue virus so this will be our focus)
Blood cell formation/hematopoieses (platelets)
Hematopoiesesoccursinthe redbone marrow or the myeloidtissue.Redbone marrow isfound
chieflyinflatboneslikethe skull,pelvis,the ribs,sternum, humerusandfemur.All of the formed
elementsarise fromacommontype of stemcell calledhemocytoblastwhichresidesinthe redbone
marrow

15. The hemocytoblaststemcellsdevelopintolymphoid or myeloid stem cells. Myeloid stem cells
by thenwill developedasplateletsorotherformedelementsdependingonthe response of the
changingbodyneedsanddifferentstimuli.Like anyotherformedelementsinthe blood,platelet
production is stimulated by the hormones. The hormone thrombopoietin accelerates the
production of platelets but only little is known about how this process is regulated
PLATELETS
Plateletsare notcellsinastrict sense.Theyare fragmentsof bizarre multinucleatedcellsof
megakaryocytes.Theyappearasdarklystainedandirregularlyshaped.The nominal plateletcountis
150,000 – 500,000 percubic millimeter.
PHYSIOLOGYOF PLATELETS
Plateletsare responsible fornormal bloodclotting.If we are goingtolive withoutit,asingle cut
wouldleadusout todeath.There isa processcalledhemostasiswhereinplateletshave amajorrole.
Hemostasismeansstoopingof bleeding.Ithappenswhenabloodvessel breaksorinjured.Hemostasis
occurs inthree major phaseswhichoccurin rapidsequence.
1. Vascularspasmsoccur – the immediate responseof the bodytobloodvessel injury
2. Plateletplugforms –whenthe endotheliumisbroken,the collagenfibersare exposedthat
leadstoclingingof the plateletstothe damage site andmakingthemsticky.Platelets
releasedmore chemicalsthatattract more plateletstothe site of damage.
3. Coagulationeventoccurs
A. Injuredtissuesreleasedtissuefactors(TF),substancesthatplaysanimportantrole
inclotting.
B. PF3 whichisa phospholipid,coatsthe surfacesof the platelets,interactswiththe TF,
VitK, calciumionsandotherproteinclottingfactor
C. Prothrombinactivatorforconversionof prothrombinto thrombinwhichisan
enzyme.
D. Thrombinjoinsfibrinogenproteinstoformlonghairlike moleculesof insoluble
fibrinwhichformanetlikemeshwork’s thattrapsRBCs and formsthe basisof the
clot.
PATHOPHYSIOLOGY (BOOK-BASED)
Predisposingfactors
 Geographical area:
Caloocancity
Precipitatingfactors
 Environmental conditions
(stagnantwateras breedingsites)
 Dengue carriermosquitoes
 Activity(student)

16. Replicationof virusinmosquitoes’salivary
glands
Bite to skinfromdengue carriermosquito(itchinessandredness
at the bite area)
Virusdisseminatesrapidlyinthe bloodstimulatingWBCsandB
lymphocytesandproducesantibodiesandmacrophagesMacrophagesperformsphagocytosis;denguevirus
replicateswithinthe cells,antibodiesattachtoviral
antigents
Entry to the spleen Release of cytokinesandother
plateletactivatingfactorsthat
stimulatesWBCsandpyrogen
release
Entry to the bone
marrow
DENGUE
s/s:
 Highgrade fever
 Flushedskin
 Headache
 Pinkrashesonthe skin
If Treated:
 HYDRATION: IV
infusion; increased
fluid intake
 Drug therapy:
antipyretic
(Paracetamol)
Dengue virusisinoculatedinthe bloodwith8-14 days incubationperiod
If not treated:
Complicationssuch:
 Intense bleeding
 Severe hypertension

17. DRUG STUDY
DRUG MECHANISM
OF ACTION
INDICATION CONTRAINDICATION SIDE
EFFECTS
NURSING
RESPONSIBILITIES
Paracetamol
(biogesic)
500mg/tab 1
tab PRN
Produce
analgesia by
blocking pain
impulses by
inhibiting
prostaglandin
synthesis in
the CNS or of
other
substances
that sensitize
pain receptors
to stimulation.
The drug may
relief fever
through
central action
in the
hypothalamic
heat regulating
center.
Relief of
fever, minor
aches and
pains
Anemia, cardiac and
pulmonary disease.
Hepatic or severe renal
disease
Allergic skin
reactions and
GI
disturbances
Assess for allergy
Reassess the Pt’s
vital signs

18. NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
‘’ Anginitko
po’’as
verbalizedby
the patient
Objective:
-flushskin
-skiniswarm
to touch
V/stakenas
follows:
Temp:38.2
PR-80
RR-20
BP-120/80
Hyperthermia
relatedto
dengue
Short term
goal:
After 30 mins
of nursing
intervention
the patientwill
maintaincore
temperature
withinthe
normal range
witha temp:of
36.5-37.5
Independent:
-Establish
rapport
-encourage
pt’sto increase
fluidintake
-provided
surface cooling
such as TSB
and removing
of extra
clothing
Dependent:
Give
paracetamol
(biogesic) as
prescribe by
the physician
-togain pt’s
trust
-toprevent
dehydration
because
increasedin
temperature
causesfluid
losssuch as
sweating
-topromote
core coolingby
helping
reducedbody
temperature
Paracetamol
are classified
as analgesics
and
antipyretics
whichacts on
the
hypothalamus
to regulate
normal body
temperature
Short term
goal:
After30 mins
of nursing
intervention
the patient
was
maintained
core
temperature
withinthe
normal range
witha temp:of
36.5-37.5

19. Discharge plan
DISCHARGE PLANNING
Discharge PlanningDiet:
Encourage nutritiousfoodslike vegetables,meatandfruits.>Instructthe familymemberstogive the
clientproteinrichfoodssuchas meat,fish,eggsandnuts,vitaminKrichfoodssuch as greenleafy
vegetables,vitCrichfoods(guavaandtomatoesandothercitrusfruits),carbohydratesrichfood(breads
and rice)
Medications:
Give acetaminophenincase the temperaturesincreases.
Give oresol toreplace fluidinthe body.
Remindtotake the prescribedmedicine,havingawrittenreminder of the correctmedication,time to
take,and the rightfrequencyof the medicine onthe wayhome toestablishassurance of medication
compliance.
Don’tgive aspirinandNSAID’s,theyincrease the riskof bleeding.Anymedicines
That decrease plateletcountshouldbe avoided.

20. Exercise:
Instruct to avoidexcessive activitiesthatmayresulttostress. Justadvisedtoperformrange of motions
and repetitive bodymovementsforpromotionof optimum
Treatment:
Currently, no medications are available to treat dengue hemorrhagic fever.
> Increasedoral fluidintake.
>Admissiontoanintensive care unit>Intravenousfluidsandelectrolytes
>Oxygentherapy>Transfusionsof bloodandplateletsasneeded>BedrestOut-PatientFollow-UpCare
>Instruct the family memberstohave acheck-upor toconsultphysicianonce a while tomonitor
patient’sconditionandfordetectionof recurrencesandothercomplicationsthatmayarise on to
it.HealthTeaching:(forprevention)>D- discussthe possible source of infection of the disease.>E-
educate the family/patientonhowtoeliminate thosevectors.>N- Neverstockedwaterinacontainer
withoutcover.>G- Gallon,containerandtiresmusthave properwayof disposal.>U- Use insecticidesat
home to kill orreduce mosquito
Bibliography
books
 Principles of Anatomy and Physiology
Gerard J. Tortora (Author), Bryan H. Derrickson
 Laboratory Manual for AnatomyandPhysiology[Spiral-Bound]
Connie Allen (Author), Valerie Harper (Author)
 Nurse's Pocket Guide (NANDA) 11th Edition
Google
 http://www.scribd.com/doc/67121235/Dengue-Discharge-Plan
 http://www.google.com.ph/#hl=fil&sclient=psy-
ab&q=discharge+plan+for+dengue&oq=discharge+plan+for+de&gs_l=serp.1.1.0l4.1547.11675.0
.14554.34.20.0.7.7.1.432.4670.0j1j9j3j3.16.0...0.0...1c.1.8kw1RkLWqF8&pbx=1&bav=on.2,or.r_g
c.r_pw.r_qf.&fp=953ad84da23aef2c&biw=1024&bih=677
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