Cagayan State University- Carig Campus

College of Medicine and Surgery

CASE #2

MEDICINE DE CURIE: JANUARY 09, 2018

PRESENTED BY:

MED III-C

GROUP 2

BASIR, HUJEFFI
FANSOFKAR, URFA
CONAG, RICH MARK
JAVIER, JONALYN MIGUEL
CAMPOS-BACCAY, APRIL
DACAYO, JODEX
SMITH, KURT

PRECEPTOR:

DR. SHERYL CELINO-BAJET

MEDICAL WARD DECURIE A.Y.’17-‘18

PATIENT’S GENERAL DATA:

Name: AB
Age: 21 y/o
Birthdate: June 23, 1996
Sex: Male
Religion: Roman Catholic
Address: Peñablanca, Cagayan
Educational Attainment: High school Graduate
Number of Admission/s: 3
Present Hospital of Admission: CVMC
Date of Admission: January 03, 2018
Informant: Patient
Reliability: 100%

CHIEF COMPLAINT:

Pain verbalized as “Masakit i tyan ku” pointing specifically at Epigastric area

HISTORY OF PRESENT ILLNESS:

2 weeks prior to admission, around afternoon and while at rest, patient felt sudden pain on the
Epigastric area which he described as crushing and gnawing. He rated the pain 6 out of 10 (0 being of no
pain and 10 being of most debilitating). He said it was distressing and he could not do any other activity
thus relied to rest and sleep to recuperate.

For two weeks the pain was frequent during the day and was accompanied by intermittent fever
spike (up to 39OC) during most days with which he would usually medicate through Oral Paracetamol
500mg tablet. Symptom of Headache was also a complaint which is exacerbated by productive cough
and colds.

1 week prior to admission the Epigastric Pain with Intermittent fever was continuous. He rated
the pain 7 out of 10. It was unmanageable for him because he had to be confined at home for rest and
sleep. Activities of daily living (ADL) were also difficult because he was too tired to get up of bed and was
mostly anxious which he verbalized as “hindi ako malma sa pagaalala kung ano ang sakit ko”. He would
also vomit whenever he eats and became weak and lethargic. He did not consult any medical advice nor
had taken any other drugs to allay condition due to financial constraints.

1 day prior to admission, upon waking up, patient’s Epigastric pain was rated 8 out of 10, crushing
with apparent movement limitation and difficulty in talking or listening. He also had Fever (up to 40OC),

MEDICAL WARD DECURIE A.Y.’17-‘18

chills, headache and myalgia. According to him, when his mother when came for assistance, she
noticed some patchy red spots visible on his entire anterior (chest and abdomen) and posterior trunk.
These were non-painful/ non-itchy spots. Cough and colds were also present and persistent. The patient
was also described as grossly pale and could not tolerate eating due to nausea and vomiting

January 03, 2018 at 8:00am, Pt. was admitted to CVMC upon proper assessment and ROD’s
recommendation.

PAST MEDICAL HISTORY

Patient AB was said to have been diagnosed with Rheumatic Heart Diseases in 2013. He was first
confined at Doctor Meneses Hospital Clinic last 2013 due to complaints of persistent fever, joint pains
and recurrent sore throat. After series of tests he was diagnosed with RHD and has been on
maintenance drug injections monthly.

The patient said he stopped taking the medication in 2016 dueto financial constraint and stayed
in Manila for a year. During those times he had occasional signs of fever, joint pains and DOB but said he
was able to survive through sufficient rest and sleep.

November 2016 after coming back home to Peñablanca Cagayan, he was rushed to CVMC due
to intolerable signs of RHD hence admitted for 5 days.

No other noted diseases or confinement before and after the abovementioned dates.

PERSONAL AND SOCIAL HISTORY:

Patient AB is single and describes himself as hardworking member of the family. He is a high
school graduate and often helps father in farm works. He started smoking at age 13 but stopped two
years after. He occasionally drinks during gatherings but with no illicit drug use.
He prefers eating raw foods like “kilawin” fish or meat and said weekly consumed it as a meal
however eats whatever is served. He has no know allergies on foods or drugs.

FAMILY HISTORY:

The patient is the eldest in a brood of 2. His Father (47y/o) works as a farmer and Mother (46
y/o) is a plain housewife. There was no history of illnesses and hospitalization in any member of the
family.
No known hereditary, familial or childhood diseases from both sides like Asthma, no allergies to
any food or drugs.

Paternal Maternal
Ca - -
HPN - -
DM - -
Heart Dse. - -

MEDICAL WARD DECURIE A.Y.’17-‘18

 REVIEW OF SYSTEMS:

General: Easy fatigability, fever with chills; ADL -mildly impaired; Pain on movement.
Skin: (+) rashes (non purulent, reddish, macular)

HEENT:
Head: (+) headaches, no dizziness, no head trauma
Eyes: No blurring of vision, no redness and irritation
Ears: Hearing is good. No complaints of ear pain, ear discharge and tinnitus
Nose and Sinuses: No epistaxis, polyps and nasal discharge
Throat (Mouth & Pharynx): No mouth sores, dysphagia
Neck: No lumps, tenderness and stiffness
Respiratory: (+) shortness of breath; (+) Cough and colds
Cardiovascular: No chest pain, cyanosis, palpitations, edema or paroxysmal nocturnal dyspnea
Gastrointestinal: Epigastric pain; loss of appetite, diarrhea; Nausea and vomiting
Urinary: Dark coloured urine and oliguria
Musculoskeletal: (+) Myalgia; No complaints of joint pain, joint tenderness or swelling
Psychiatric: (+) Anxiety; No history of depression
Hematologic: No history of bleeding disorders or easy bruising
Neurologic: Conscious and coherent. Oriented to time, person, and place
Endocrine: No known thyroid disorders, heat or cold intolerance

PHYSICAL EXAMINATION:

General: The patient is lying flat on bed, D5W 500 CC at 250cc during interview; on DAT
He is conscious and coherent. Oriented to time, place and person.

Vital Signs: BP 100/80 mmHg

HR: 88bpm
RR: 19cpm
Afebrile (36.5 degrees)

Skin: Skin dry and warm to touch, +rose spots

Head: patient’s hair is dry, scalp is free of any lesion
Eyes: Icteric sclera; the pupils are equal in size, round, and reactive to light and accommodation
Ears: The patient has no bone conduction and sensory hearing loss; (-) lesions and abnormal discharge
Nose and Sinuses: septum is in the midline, mucosa is moist, (-) nasal discharge
Mouth: lips are dark pink and moist, (-) cyanosis

MEDICAL WARD DECURIE A.Y.’17-‘18

 Neck: (-) tracheal deviation, (-) cervical lymph node enlargement
Respiratory: (-) abnormal muscle retraction of the intercostal spaces
Musculoskeletal: In normal alignment
(-) deformities of the head and neck, spine, ribs and pelvis
(-) joint enlargement or tenderness
(-) tremors, tingling sensations
Cardiovascular: Good S1 and S2, no murmur
Abdomen: I: non bulging, no protrusions, flat and symmetrical A: (+) borborygmi , P: Tympanic mostly
on airfilled parts, no ascites P: soft and nontender; no pain on palpation.
Extremities: (-) edema, (-)cyanosis, (-) varicosities
Nervous system: Glasgow coma scale score= 15 Eye opening=4 Verbal response=5 Motor response=6
DTR: +2- somewhat diminished

ASSESSMENT AND PLAN

1. Pain (epigastric). Patient complains of Crushing and gnawing epigastric pain rated as 8/10 causing
limited movements and inattentiveness.
 Advise small frequent meals
 Avoid intake of foods that could further exacerbate pain such as coffee and spicy food.

2. Episodes of dyspnea. Patient complains uneasiness of breathing at rest.

 Administer oxygen as needed.
 Encouraged to elevate the head of the bed
 Teach on breathing exercises
 Advise to report persistence of dyspnea

3. Fever and chills. Patient reported undocumented rise in body temperature accompanied by chills.
 Advise for paracetamol intake as needed.
 Encourage for a tepid sponge bath
 Instruct to opt for light-clothing
 Encourage increased fluid intake
 Encourage to report persistence of fever.

4. Tobacco abuse. The patient is a known smoker of 5 cigarette sticks a day

Plan:
 Encourage smoking cessation.
 Encourage any other diversionary activities.
 Provide health teachings about the possible effects of cigarette smoking in the body.

5. Sanitary practices. Toilet outside the house being shared with other neighbors.
Plan:
 Emphasized importance of hand washing
 Encourage exclusive use of toilet only to household members.
 Emphasized cleanliness of CR at all times.
 Encouraged regular cleaning of surroundings.

6. Food and water consumption. Patient is not picky on what and where to eat.
 Health teachings on proper handwashing especially before eating

MEDICAL WARD DECURIE A.Y.’17-‘18

  Encouraged to eat home cooked food only.
 Avoidance of street food
 Proper food preparation and handling
 Encouraged shift from deep-well source of drinking water to commercially prepared distilled
water.
 Boiling of drinking water if no other means for a treated water source.
7. Health maintenance. Patient solely rely on self-medication before seeking consult.
 Advise importance of prompt consult when feeling unwell
 Encourage hospital-based treatment rather that self-medication.

DIFFERENTIAL DIAGNOSES:

Salient features:
 Prior vomiting  Rose spots on  Loss of appetite
 Prior diarrhea abdomen  Borborygmi
 Fever and chills  Easy fatigability
 Epigastric pain  Myalgia
1. Viral Hepatitis A
HAV infection is the most prevalent hepatotropic virus. This virus is also responsible for most
forms of acute and benign hepatitis; although fulminant hepatic failure can occur, it is rare. HAV is
responsible for acute hepatitis only. HAV is an RNA virus, a member of the picornavirus family. It is heat
stable and has limited host range—namely, the human and other primates.
HAV is highly contagious. Transmission is almost always by person to- person contact through
the fecal–oral route. Often, this is an anicteric illness, with clinical symptoms indistinguishable from
other forms of viral gastroenteritis, particularly in young children.
Rule In Rule Out
Fever Jaundice
Epigastric pain Oliguria
Vomiting & Nausea Rose spots
Dark colored urine Cough and colds
Icteric sclera Diarrhea
2. Malaria
Malaria is an acute and chronic illness. Malaria is caused by intracellular Plasmodium protozoa
transmitted to humans by female Anopheles mosquitoes. Malaria also can be transmitted through blood
transfusion, use of contaminated needles, and transplacentally from a pregnant woman to her fetus.
The principal areas of transmission are Africa, Asia, and South America. P. falciparum and P. malariae are
found in most malarious areas.
Rule In Rule Out
Fever with chills Shortness of breath
Nausea & Vomiting Oliguria
Anorexia Rose spots
Epigastric pain Dark coloured urine
Myalgia Jaundice
Headache
Diarrhea

MEDICAL WARD DECURIE A.Y.’17-‘18

3. Dengue Fever

Dengue fever is a mosquito-borne tropical disease caused by the dengue virus. It is a mosquito-
borne single positive-stranded RNA virus of the family Flaviviridae; genus Flavivirus. Dengue is spread by
several species of mosquito of the Aedes type, principally A. aegypti. The alternative name for dengue,
"breakbone fever", comes from the associated muscle and joint pains. Symptoms typically begin three
to fourteen days after infection.
-
Rule In Rule Out
Fever with chills Rose spots
Cough Icteric sclera
Myalgia Sore throat
Anorexia Arthralgia
Nausea & Vomiting Retro-orbital pain
Diarrhea

DISCUSSION:

ENTERIC (TYPHOID) FEVER

OVERVIEW

 there are an estimated 27 million cases of enteric fever, with 200,000–600,000 deaths annually.
 systemic disease characterized by fever and abdominal pain and caused by dissemination of S.
typhi or S. paratyphi. Serotypes A, B, and C—have no known hosts other than humans.

 Most commonly, food-borne or waterborne transmission results from fecal contamination by ill
or asymptomatic chronic carriers. A high incidence of enteric fever correlates with poor
sanitation and lack of access to clean drinking water.

 Health care workers occasionally acquire enteric fever after exposure to infected patients or
during processing of clinical specimens and cultures.

RISK FACTORS
 include contaminated water or ice, flooding, food and drinks purchased from street vendors,
raw fruits and vegetables grown in fields fertilized with sewage, ill household contacts, lack of
hand washing and toilet access.
CLINICAL COURSE
Enteric fever is a misnomer, in that the hallmark features of this disease—fever and abdominal pain—
are variable.
 fever is documented at presentation in >75% of cases
 abdominal pain is reported in only 30–40%.

INCUBATION PERIOD
 S. typhi averages 10–14 days but ranges from 5 to 21 days, depending on the inoculum size and
the host’s health and immune status.

MEDICAL WARD DECURIE A.Y.’17-‘18

  The most prominent symptom is prolonged fever (38.8°–40.5°C; 101.8°–104.9°F), which can
continue for up to 4 weeks if untreated.
 S. paratyphi A is thought to cause milder disease than S. typhi, with predominantly
gastrointestinal symptoms.

DIAGNOSIS
 Clinical presentation of enteric fever is relatively nonspecific, diagnosis needs to be considered
in any febrile traveler returning from a developing region, especially the Indian subcontinent,
the Philippines, or Latin America.
 Other than a positive culture, no specific laboratory test is diagnostic for enteric fever.
 Nonspecific laboratory findings:
- Leukopenia and neutropenia
- Leukocytosis in children during first 10 days
- Moderate elevation of liver function test and muscle enzyme levels.

 The definitive diagnosis of enteric fever requires the isolation of S. typhi or S. paratyphi from
blood, bone marrow, other sterile sites, rose spots, stool, or intestinal secretions.

TREATMENT ENTERIC (TYPHOID) FEVER

 initial choice of antibiotics depends on the susceptibility of the S. typhi and S. paratyphi strains
in the area of residence or travel.
- Drug-susceptible typhoid fever
 Fluoroquinolones (most effective) class of agents,
 Ofloxacin therapy (short-course)
- DCS S. typhi
 Ceftriaxone, azithromycin, or high-dose ciprofloxacin

Patients with persistent vomiting, diarrhea, and/or abdominal distension should be hospitalized
and given supportive therapy as well as a parenteral third-generation cephalosporin or fluoroquinolone,
depending on the susceptibility profile. Therapy should be administered for at least 10 days or for 5 days
after fever resolution. The 1–5% of patients who develop chronic carriage of Salmonella can be treated
for 4–6 weeks with an appropriate oral antibiotic. Treatment with oral amoxicillin, TMP-SMX,
ciprofloxacin, or norfloxacin is ~80% effective in eradicating chronic carriage of susceptible organisms.
However, in cases of anatomic abnormality (e.g., biliary or kidney stones), eradication often requires
both antibiotic therapy
and surgical correction.

PREVENTION AND CONTROL

 Immunization against S. typhi
 2 Typhoid Vaccines: 1. Ty21a (oral live attenuated S.typhi ) 2. Vi CPS (parenteral vaccine)
 Projects on adequate sewage disposal and water treatment
 Importance of proper hand washing
 Proper food handling and preparation. Discourage consumption not home cooked food

MEDICAL WARD DECURIE A.Y.’17-‘18