Rubie Ann G.
Tillor September 19, 2020
Clinical Clerk (IM-Ward)
This is a case of a 26-year-old female with a chief complaint of fever.
Salient points:
HISTORY PHYSICAL EXAM
15 days PTC, patient was noted to have intermittent fever
with Tmax 39°C associated with sweating, colds, VITAL SIGNS: RESULTS INTERPRETATION
malaise, and decrease in the amount of her daily activities. BP 100/60 mmHg NORMOTENSIVE
No consult was done. She self-medicated with Bioflu 1 tab CR 80 bpm NORMAL
BID and Tempra 500 mg/tab 1 tab every 8 hrs., which RR 24 bpm TACHYPNEIC
offered temporary relief. Temperature 38 ºC FEBRILE
SO2 98% NORMAL
10 days PTC, fever, cold, and malaise persisted. Patient also
developed productive cough with yellowish phlegm. There
RESULTS INTERPRETATION
was note of nausea and one episode of vomiting of
Wt 49 kg
previously eaten meals, & decreased appetite. She also
HT 165.1. cm
experienced intermittent diffuse abdominal pain VAS 4/10.
BMI 18 Mildly
Still no consult was done and patient opted for bed rest.
underweight
However, she shifted her medications to Cetirizine 1 cap
with unrecalled dosage TID, Carbocysteine 1 cap TID,
Paracetamol + Caffeine 500 mg + 65 mg 1 tabq4 and GENERAL SURVEY: Awake, ambulatory, not in CPD, appropriately
Aluminum Hydroxide + Magnesium Hydroxide + Simeticone dressed, oriented to time, place and person.
all of which offered temporary relief.
SKIN: No rashes, warm to touch, skin turgor not noted
7 days PTC, patient was noted to have pinpoint, HEENT: Anicteric sclerae, pale conjunctivae, no alar flaring, non-
erythematous, nontender, non-pruritic, and blanchable hyperemic tonsils, no cervical lymphadenopathies
rashes on her abdomen.
CHEST, LUNGS & HEART: Symmetric chest expansion, no costal
3 days PTC, fever plateaued at 39-40 °C, patient also had retractions, resonant lung fields, bronchovesicular breath sounds
watery, blood-streaked stools 3-4 times a day (approx. 2
cups), with persistence of abdominal pain. Tea-colored ABDOMEN: Flat, no lesions, striae, scars, normoactive bowel
urine was noted and frontal headache VAS 6/10. There was sounds, smooth liver edge, liver span at 13 cm at R MCL, 8 cm at
a note of disappearance of rashes this time. No consult was RSB (hepatomegaly); non-palpable spleen, direct tenderness at
done and no medications or ORS taken. epigastric area and RUO
On the day on consult, fever Tmax of 40 °C, watery, blood- PELVIC: Grossly female external genitalia, no masses or lesions,
streaked stools (2 cups) and headache VAS 6/10 persisted. Speculum exam showed pinkish cervix, no masses, no
Patient took Rexidol but offered no relief, thus this discharges, bleeding or lesions noted. Internal exam revealed
prompted the patient for consult. close cervix, no cervical motion, tenderness, Bimanual exam
showed uterus anterior, midline, smooth adnexa not felt and
PERTINENT (-): Myalgia (Calf), Tenesmus, incontinence, Rectovaginal exam showed fresh blood on examining finger
weight loss, epistaxis or gum-bleeding, jaundice, seizure, (minimal), no tenderness, no hemorrhoids.
photophobia, neck stiffness/pain
EXTREMETIES: Grossly normal, no skin lesions, peripheral pulses
of grade 2, no edema noted, CRT not noted
PAST MEDICAL HISTORY:
No Hypertension, DM, Asthma NUEROLOGIC: unremarkable
No previous hospitalizations, injuries, or surgeries,
trauma, STIs, chronic and serious illnesses
(+) Allergic to peanuts and shellfish / seafood
Complete immunization (unrecalled)
FAMILY HISTORY:
No Hypertension, DM. Asthma, Malignancy
No Heredo-familial diseases
PERSONAL SOCIAL HISTORY
Housewife
Daily activities include cleaning, laundry, cooking,
taking care of children
Diet consists mainly of fish, meat, and vegetables
(pre-lockdown)
Store-bought food (post-lockdown)
Non-smoker, non-alcoholic drinker
OB-GYN HISTORY:
Menarche was at 14 years old. It was noted to be regular
with a duration of 1-2 days and consumes 2 minimally-
soaked pads per day. No dysmenorrhea was noted.
Coitarche at 18 years old with 1parter and claimed no
history of STI, uses Depo-Provera injectables for 3 years.
OB score of G2P2 (2002), delivered at WVSU-MC, no
complications noted. LMP was last August 15, 2020, PMP,
unrecalled.
ENVIRONMENTAL HISTORY
Lives with husband and 2 children. House is located
in a congested neighborhood at a relocated site.
House is made of mixed materials with only 1
bedroom. Water for drinking is bought from a local
water refilling station. Water for household use is
sourced from a communal deep well.
Food is bought from Karenderya and not stored
properly.
Garbage collection by the city garbage disposal has
been inconsistent since community quarantine
began. Sewer with stagnant water present nearby.
INTIAL IMPRESSION:
Acute Infectious Diarrhea probably due to:
A. Typhoid Fever
B. Shigellosis
C. Amoebiasis with amebic liver abscess
D. COVID-19 Suspect
SUGGESTIVE NOT SUGGESTIVE DIAGNOSTIC TESTS TO RULE OUT
A. Typhoid Fever Endemic in our country All findings reflect the CULTURE, TYPHIDOT
Poor sanitation manifestations of
Fever, diarrhea, Typhoid fever
abdominal pain,
malaise, headache, GI
bleeding
Rose spots,
hepatomegaly
B. Shigellosis Fever, malaise, loss of Rare in young STOOL CULTURE
appetite and middle-
Vomiting, dysentery aged adults
Transient fever
Watery
diarrhea
progress to
bloody
mucopurulent
stools
associated w/
tenesmus
C. Amoebiasis w./ Intestinal Amebiasis: Cannot explain STOOL EXAM, UTZ, CT, MRI
amebic liver Watery, blood- the presence
abscess streaked stools of rash
Malaise, abdominal Amebic liver
pain, fever abscess
Unsanitary common in
environment men 30-60 yrs.
Amebic Liver Abscess Old
Fever, RUQ pain,
hepatomegaly
D. COVID-19 Suspect Fever, cough, loss of RT-PCR
appetite
Diarrhea, nausea,
vomiting, anorexia,
abdominal pain &
gastrointestinal
bleeding
Patient buys food in
the karinderya
Poor sanitation
Congested
environment
DIFFERENTIAL DIAGNOSES RULE IN RULE OUT DIAGNOSTIC TESTS
A. Dengue Fever w/ warning Fever, malaise, Fever > 7 days DENGUE NS1, IgG/IgM,
signs cough step-ladder Culture
Abdominal pain, pattern
nausea, vomiting Blanchable,
transient, truncal
rash
B. Leptospirosis Flu-like illness Prolonged fever BLOOD CULTURE, PCR,
Fever No calf pain LEPTOSPIRA, IgM ELISA or
Nausea, vomiting, No jaundice MAT
abdominal pain No conjunctival
Intense frontal suffusion
headache
Hepatomegaly
Unsanitary
environment
LABORATORY FINDINGS:
CBC RESULT:
Hemoglobin 110 RT-PCR NEGATIVE
Hematocrit 0.30 TYPHIDOT SALMONELLA Typhi IgM +
RBC Count 4.37
WBC Count 5.0
Platelet 150 RESULTS NORMAL VALUES
Count pH 7.51 7.35-7.45
MCH 28
MCV 90 pCo2 26.6 35-45
MCHC 33.1
Neutrophil .60 pO2 103 75-100
Lymphocyte .34
Monocyte .02 O2 98.7% 98-100%
Eosinophil .01
Basophil 0 HCO3 18 22-26
INTERPRETATION:
NORMOCHROMIC, NORMOCYTIC
ANEMIA INTERPRETATION: Respiratory Alkalosis with secondary
OTHER LABORATORY FINDINGS:
Metabolic Acidosis
STOOL EXAM NOPS, Soft brown
STOOL CULTURE + Growth of S. typhi
ELECTROLYTES:
Na 124.5
K 2.93 CRP >6
BUN 2.77 ESR 67
Cre 55.47 Procalcitonin 2.2
a
ALT 300 PT 12.5
AST 100 INR 100%
INTERPRETATION:
HYPOKALEMIA
HYPONATREMIA
Serum b-hCG Negative
Chest X-ray Normal
WORKING IMPRESSION: (BASED ON LABORATORY FINDINGS + PE + HISTORY)
Acute Infectious Diarrhea secondary to Typhoid Fever with moderate dehydration
Electrolyte imbalance (Hyponatremia, Hypokalemia), secondary;
Mild Normocytic, Normochromic Anemia probably secondary to gastrointestinal bleeding;
COVID-19 RT-PCR Negative
RATIONALE:
Typhoid fever was confirmed by Stool culture with positive growth of S. typhi, also by TYPHIDOT
salmonella typhi IgM positive PLUS the presentation of the patient which strongly suggests typhoid
fever. The patient was also COVID-19 negative because of the negative RT-PCR result.
MANAGEMENT:
IMMEDIATE:
GOALS: Secure ABCs
Do ABCs of Resuscitation Establish IV line
Do Fluid Resuscitation Put patient on NPO, complete bed rest
Establish Diagnosis Address moderate dehydration
500-1000ml Plain NSS
Start Paracetamol 300 mg IV Q4H PRN for
fever
After addressing the dehydration, you may now RT-PCR
request other laboratories to establish the Serologic Tests: Typhidot, Dengue
working diagnosis IgM/IgG, Leptospira IgM/IgG
CBC
ABG
CXR
Serum electrolytes (Na, K, Cl)
Stool Exam, Culture, and Sensitivity
Blood Culture
BUN/Creatinine
Admit to Clean Ward if RT-PCR is negative
Decide to Admit for COVID-19
Skin test prior to empiric antibiotic
Start on empiric antibiotics
Prompt Antibiotic Therapy o ceftriaxone 2-3g IV q24h, or
o azithromycin 1g IV q24h, or
o ciprofloxacin 400mg IV q12h, or
o ofloxacin 400mg IV q12h
Hyponatremia is expected to normalize
Address HYPONATREMIA, HYPOKALEMIA once IV hydration therapy is started
Plan to incorporate KCL in IVF
Request 2 unit (s) PRBC of patient’s blood
type RESULT: typhoid ulcers from rectum up to
descending colon; some ulcers are eroding
Request Colonoscopy
adjacent blood vessels that might have caused
lower GI bleed of px (Typhoid Colitis)
WORKING DIAGNOSIS:
Lower gastrointestinal bleeding secondary to Typhoid colitis;
Moderate normocytic normochromic Anemia, secondary;
Acute Infectious Diarrhea secondary to Typhoid fever with moderate dehydration;
Electrolyte imbalance (Hyponatremia, Hypokalemia) secondary; COVID-19 Negative
ADDITIONAL IMMEDIATE MANAGEMENT:
Start O2 supplementation at 2 lpm via nasal cannula
Transfuse 2 units PRBC after proper crossmatching
Repeat CBC and ABG post transfusion
SHORT-TERM
GOALS:
Continue supportive measures Continue adequate feeding and hydration
of the patient
Patient Monitoring Regularly monitor patient’s vital signs,
hydration status, and laboratories
Note for signs or symptoms that may
indicate the development of
complications
Switching to definitive treatment Utilize culture and sensitivity results to
modify antibiotic treatment accordingly
If the patient is afebrile for 48 hours,
stepping down to oral antibiotic may be
done
o Cefixime 200 mg 1 tab q12h for
14 days
LONG-TERM
INDICATIONS FOR DISCHARGE: Patient has defervesced
Patient is able to tolerate oral
medications
Patient has stabilized – no active bleeding
or persistent abdominal pain
GOALS:
Monitor for relapse of infection Strict compliance in taking prescribed
medications
Self-monitoring of signs and symptoms
indicative of re-infection.
Follow-up check-ups every month to
monitor culture results.
If determined to be a carrier, a prolonged
antibiotic course may be given
Identify the risk factors such as
consuming contaminated water and poor
sanitation
Practice safe eating and drinking habits Do not prepare or serve food for other
people until it is determined that you no
longer carry the bacteria.
Prevent transmission of bacteria Wash hands thoroughly with soap and
water after using the bathroom.
Ty21a: oral live attenuated vaccine given
on days 1, 3, 5, and 7, with revaccination
Typhoid Prophylaxis with a full 4-dose series every 5 years
Vi CPS: parenteral vaccine given in a
single dose, with a booster every 2 yrs.
Educate on the signs and symptoms of
infectious diarrhea and typhoid fever.
Patient and family education Educate on the importance of proper
hygienic practices and monitoring intake
of clean water and well-cooked food.
In addition, early monitoring of signs and
symptoms of S. typhi infection can
prevent complications if early
intervention are given
FINAL DIAGNOSIS:
Lower Gastrointestinal Bleeding secondary to Typhoid colitis;
Moderate normocytic normochromic Anemia, secondary; Acute Infectious Diarrhea secondary to
Typhoid fever with moderate dehydration;
Electrolyte imbalance (Hyponatremia, Hypokalemia) corrected; S/P blood transfusion; S/P colonoscopy;
COVID-19 RT-PCR Negative
REFERENCES:
Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. (2018). Harrison’s Principles of
Internal Medicine 20th edition
Philippine Society for Microbiology and Infectious Diseases. The Philippine Clinical Practice
Guidelines on the Diagnosis, Treatment and Prevention of Typhoid Fever in Adults 2017.; 2017.
http: //thepafp.org/website/wp-content /uploads /2017/05/2017-Typhoid-fever-in-Adults.pdf.
World Health Organization
Department of Health. doh.gov.
Centers for Disease Control and Prevention. (2019). Typhoid Fever and Paratyphoid Fever.
SAMPLE PRESCRIPTION:
RUBIE ANN G. TILLOR, M.D.
INTERNAL MEDICINE- INFECTIOUS DISEASE
Room 3, JS Building, Jaro, Iloilo City
Clinic Hours: MWF 10:00 AM- 2:00 PM
Contact No: 09086504598
Name: M.F.J. Age: 26 years old Sex: Female Date: Sept. 19, 2020
Address: San Pedro, Molo, Iloilo City
Cefixime 200 mg capsule #28
Sig. Take 1 capsule every 12 hours for 14 days
Rubie Ann G. Tillor, M.D.
License No: 12345678
PTR No: 98765432
RUBIE ANN G. TILLOR, M.D.
INTERNAL MEDICINE- INFECTIOUS DISEASE
Room 3, JS Building, Jaro, Iloilo City
Clinic Hours: MWF 10:00 AM- 2:00 PM
Contact No: 09086504598
Name: M.F.J. Age: 26 years old Sex: Female Date: Sept. 19, 2020
Address: San Pedro, Molo, Iloilo City
Ceftriaxone 1 g vial #2
Sig. Give 2 g IV for 24 hrs
Rubie Ann G.SANITATION
POOR Tillor, M.D.
License
No: 12345678
ENDEMICITY OF SALMONELLA IN
CONCEPT MAP: PTR No: 98765432
THE PHILIPPINES
MFJ Ingestion of
Salmonella
26/F
POOR HAND HYGIENE
(KARINDERYA)
