Case Presentation MEASLES

Case PresentationTHYPOID FEVER

Preceptor: dr. Ulynar Marpaung, Sp.A

Presenter: Elga Elaskia - 1102010087DEPARTMENT OF PEDIATRIC RADEN SAID SUKANTO POLICE CENTER HOSPITAL FACULTY OF MEDICINE YARSI UNIVERSITYPERIOD DECEMBER MARCH 16th MAY 23rd 2015

Patient IdentityName : AFFBirth Date: February 05th 2008 Age: 7 years 3 monthGender: MaleAddress: Aspol polres, Cianjur Nationality: IndonesiaReligion: Islam Date of admission : May 14th 2015Date of examination: May 14th 2015Parents IdentityFatherMotherNameMr. LMrs. DAge30 years old26 years oldJobPoliceHousewifeNationalityJavaneseJavaneseReligionIslamIslamEducationPolice AcademyHigh School (graduated)s Earning/monthApproximately Rp.2.000.000,--AddressAspol polres, Cianjur History TakingAlloanamnesis from patients mother on the date of admission, May 14th 2015.

History of Present IllnessHistory Of Past Illness

Pharyngitis/Tonsilitis-Bacillary Dysentry-Bronchitis-Amoeba Dysentry-Pneumonia-Diarrhea-Morbilli-Thypoid-Pertussis-Worms-Varicella-Surgery-Diphteria-Brain Concussion-Malaria-Fracture-Polio-Drug Reaction-Enteritis-Prenatal HistoryAntenatal careAntenatal check ups performed at the doctor in the hospital. There was no problems during pregnancy.No maternal illness during pregnancyDrugs consumption:Vitamins every antenatal careBirth HistoryLabor : HospitalBirth attendants: doctorMode of delivery: pervaginamGestation: 38 weeksInfant state: healthyBirth weight : 3400 gramsBody length: 50 cmAccording to the mother, the baby started to cry and the baby's skin is red, no congenital defects were reported

Post Natal HistoryExamination by midwifeThe state of the infant: healthy Development History

First dentition: 6 monthsPsychomotor development Head Up: 1 month oldSmile: 1 month oldLaughing: 1- 2 month oldSlant: 2,5 months oldSpeech Initiation: 4 months oldProne Position: 4 months oldFood Self: 5 6 months oldSitting: 6 months oldCrawling: 8 months oldStanding: 1 years oldWalking: 1 years old

Mental Status: Normal Conclusion: Growth and development status is still in the normal limits and was appropriate according to the patients age

History of Eating

Immunization History

Family History

Patients both parents were married when they were 26 years old and 24 years old, and this is their first marriage.There are not any significant illnesses or chronic illnesses in the family declared.

History of sibling

ChildbirthGenderAgeAge DiedSumption DiedSpontan pervaginam, gestation atermBoy6 months old--History of the disease people around the patient

There is no one living around their home known for having the same condition as the patient.

Social and Economic History

The patient lived at the house with size 20 m x 10 m together with father and mother.There are 1 door at the front side, 1 toilet near the kitchen and 3 rooms, in which 1 room is the bedroom of three of them and 1 room is for guest. There are 4 windows inside the house. The windows are ocassionaly opened during the day.Hygiene:The patient changes his clothes everyday with clean clothes.Bed sheets changed every two weeks.

Physical ExaminationDate :May 13th 2015General StatusGeneral condition: mild illAwareness: Compos MentisPulse: 120 x/min, regular, full, strong.Breathing rate: 28x/minTemperature: 38,8oC (per axilla)

17Physical Examination (contd)Antropometry Status Weight: 35 kilogram Height: 130 cm

Nutritional Status based NCHS (National Center for Health Statistics) year 2000:WFA (Weight for Age): 35/23 x 100 % = 152% (over nutrition)HFA (Height for Age): 130/124 x 100 % = 104 % (good nutrition)WFH (Weight for Height): 35/28 x 100 % = 125 % (overweight) Conclusion: The patient has good nutritional status.

Systematic Physical ExaminationHeadNormocephaly, hair (black, normal distributon, not easily removed ) sign of trauma (-), large fontanelle closed.EyesIcteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- , lacrimation -/-, sunken eyes -/-, pupils 3mm/3mm isokor, Direct and indirect light response ++/++EarsNormal shape, no wound, no bleeding ,secretion or serumenMouth Lips: Teeth: Mucous: Tongue: Tonsils: Pharynx:dryno cariesdryCoated +T1/T1, No hyperemia No hyperemia

Neck

Lymph node enlargement (-), scrofuloderma (-)

20ThoraxInspection:Symmetric when breathing , retraction (-), ictus cordis is not visible

Palpation:mass (-), tactile fremitus +/+

Percussion:Sonor on lungAuscultationCor: Pulmo:regular S1-S2, murmur (-), gallop (-)vesicular +/+, Wheezing -/- , Rhonchy -/-

Abdomen:Inspection:Convex, epigastric retraction (-), there is no a widening of the veins, no spider nevi.

Palpation:supple, liver and spleen not palpable, fluid wave (-), abdominal mass (-)

Percussion:The entire field of tympanic abdomen, shifting dullness (-)

Auscultation: normal bowel sound, bruit (-)

21AnusnormalExtremitieswarm, capillary refill time < 2 second, edema(-)SkinGood turgorLaboratory InvestigationHematology (May 13th 2015)

Widal test (May, 13th 2015)

WidalResultsNormal ValueTyphi O 1/320NegativeTyphi H1/80NegativeParatyhphi AO-NegativeParatyphi AH1/80NegativeParatyphi BO1/80NegativeParatyphi BH1/80NegativeResume..Hematology May 14th 2015 HematologyResultsNormal ValueHaemoglobin12 g/dL13-16 g/dLLeukocytes7.400/L5,000 10,000/LHematocrits36%40 48 %Trombocytes280.000/ L150,000 400,000/L WORKING DIAGNOSIS

Thypoid FeverDD/ Viral InfectionMANAGEMENT

IVFD RL 20 dpmInj. Cefotaxime 2 x 1 g IVInj. Ranitidine 2 x 30 mg IVPCT syrup 3x TabLacto B 3 x 1 SachetPROGNOSIS

Quo ad vitam: bonamQuo ad functionam: bonamQuo ad sanactionam: bonam

May 15th 2015. Second day of hospitalization, 7th day of illness

SFever (+)Phlegm (+) Diarrhea 2 timesOGeneral condition: Compos mentis.Heart rate = 112 x/minRespiratory rate = 34x/minTemperature = 37,3CCardio : S1/S2, reguler, no murmur, no gallopPulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-AThypoidP- IVFD RL, micro drip, 20 dpm.Inj. Ceftriaxone 2x1 g IVInj. Ranitidine 2x30 mg IVParacetamol syr 3 x 3/4 tabLacto B 3 x 1 SachetAmbroxol 3 x 1 cth29

30May 16th 2015. Third day of hospitalization, 8th day of illness

SFever (-)Phlegm (+) Diarrhea 1 timesOGeneral condition: Compos MentisHeart rate = 120 x/minRespiratory rate = 24x/minTemperature = 37.2CCardio : S1/S2, reguler, no murmur, no gallopPulmonary : retraction (+) vesiculer +/+, rhonchi +/+, wheezing -/-AThypoidPIVFD RL, micro drip, 20 dpm.Inj. Ceftriaxone 2x1 g IVInj. Ranitidine 2x30 mg IVParacetamol syr 3 x 3/4 tabLacto B 3 x 1 SachetAmbroxol 3 x 1 cth May 17th 2015. Fourth of hospitalization, 9th day of illness

SFever (-)Diarrhea (-)OGeneral condition: Compos mentis.Heart rate = 110 x/minRespiratory rate = 24x/minTemperature = 37CCardio : S1/S2, reguler, no murmur, no gallopPulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-ATyphoid FeverPIVFD RL, micro drip, 20 dpm.Inj. Ceftriaxone 2x1 g IVInj. Ranitidine 2x30 mg IVParacetamol syr 3 x 3/4 tabLacto B 3 x 1 SachetAmbroxol 3 x 1 cth ParemeterResultsNormal ValueMacroscopicColorYellowClearnessCloudypH7,05 8,5Density1.0051.000-1.030Protein-NegativeBilirubin- NegativeGlucose- NegativeKeton-NegativeBlood / Hb-NegativeNitrit-NegativeUrobilinogen0,1 0,1 1,0 IULeucocyte Sedimentation-NegativeLeucocyte0 1/LPBErythrocyte1 3/LPBEpitel Cell-Cylinder Cell-Crystal-EtcBacteria : -Urinalysis May 17th 2015Literature Review and DiscussionDefinitionTyphoid fever, also known as typhoid, is a commonworldwide illness, transmitted by the ingestion of food or water contaminated with the feces of an infected person, which contain the bacterium Salmonella enterica enterica serovar Typhi.The bacteria then perforate through the intestinal wall and are phagocytized by macrophages. The organism is a Gram negative short bacillus that is motile due to its peritrichous flagella. The term "enteric fever" is a collective term that refers to typhoid and paratyphoid.Etiology1. Caused by the bacterium Salmonella Typhi .

2. Ingestion of contaminated food or water.

3. Contact with an acute case of typhoid fever.

4. Water is contaminated where inadequate sewerage systems and poor sanitation.

5. Contact with a chronic asymptomatic carrier.

6. Eating food or drinking beverages that handled by a person carrying the bacteria.

7. Salmonella enteriditis and Salmonella typhimurium are other salmonella bacteria, cause food poisoning and diarrhoea

EpidemiologyThis is a highly adapted, human-specific pathogen occurring more frequently in underdeveloped regions of the world where overcrowding and poor sanitation are prevalent.

According to the best global estimates, there are at least 16 million new cases of typhoid fever each year, with 6, 00,000 deaths (Ivanoff, 1995). Between 1 - 5% of patients with acute typhoid infection have been reported to become chronic carriers of the infection, depending on age, sex and treatment regimen.

Furthermore this chronic carrier state has also been implicated in causation of carcinoma of the gall bladder.Clinical ManifestationSymptoms include:Fevers up to 103 or 104fWeaknessHeadachesPoor appetiteGeneralized aches and painsDiarrheaOccasionally a rash of flat, rose-colored spotsDiscomfortAbdominal TendernessConstipation, then diarrheaBloody StoolsNosebleedChillsDeliriumConfusionAgitationFluctuating moodsHallucinations Rose spots

High fever

Diarrhea

Aches and pains

Chest congestionSIGNS & SYMPTOMSDiagnosisDiagnosis is made by any blood, bone marrow or stool cultures and with the Widal test (demonstration of salmonella antibodies against antigens O-somatic and H-flagellar ).

In epidemics and less wealthy countries, after excluding malaria, dysentery or pneumonia, a therapeutic trial time with chloramphenicol is generally undertaken while awaiting the results of Widal test and cultures of the blood and stool.

Diagnosis of Enteric FeverWidal test

Serum agglutinins raise abruptly during the 2nd or 3rd week The widal test detects antibodies against O and H antigensTwo serum specimens obtained at intervals of 7 10 days to read the raise of antibodies.Serial dilutions on unknown sera are tested against the antigens for respective SalmonellaFalse positives and False negative limits the utility of the testThe interpretative criteria when single serum specimens are tested varyCross reactions limits the specificityTubex testA rapid diagnostic test (Tubex TF, IDL Biotech, Bromma, Sweden) can detect typhoid (but not paratyphoid) antibody in patient serum. In field trials, the Tubex TF kit had a sensitivity of 6078% and a specificity of 5889%

Time frameOccurs gradually over a few weeks after exposure to the bacteria. Sometimes children suddenly become sick.The condition may last for weeks or even a month or longer without treatment.

First-Stage Typhoid Fever The beginning stage is characterized by high fever,fatigue, weakness, headache, sore throat, diarrhea, constipation, stomach pain and a skin rash on the chest and abdominal area. According to the Mayo Clinic, adults are most likely to experience constipation, while children usually experience diarrhea. Second stage Second-stage typhoid fever is characterized by weight loss, high fever, severe diarrhea and severe constipation. Also, the abdominal region may appear severely distended.

Typhoid State When typhoid fever continues untreated for more than two or three weeks, the effected individual may be delirious or unable to stand and move, and the eyes may be partially open during this time. At this point fatal complications may emerge.

Management of thypoid FeverGeneral: Supportive care includes Maintenance of adequate hydration. Antipyretics. Appropriate nutrition.Specific: Antimicrobial therapy is the mainstay treatment.Chloramphenicol, Ampicillin, Amoxicillin, Trimethoprim & Sulphamethoxazole, Fluroquinolones In case of quinolone resistance Azithromycin, 3rd generation cephalosporins (ceftriaxone)

Avoid risky foods or drinksGet vaccinatedUse only clean waterAsk for drinks without ice unless you know where its coming fromOnly eat foods that have been thoroughly cookedAvoid raw fruits and vegetablesAvoid food and drinks from street vendorsTreatment of Thypoid Fever