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Academic case Presentation
◆ Name: Ehan
◆ Age: 6 years
◆ Sex: male
◆ Address:Boardbazar,Gazipur
◆ Religion: Islam
◆ Date & Time of Admission: 25/04/24 @02:45PM
◆ Date & Time of Examination: 29/04/24@12:00PM
◆ Informent: mother
Chief Complaints:
1. Fever for 10 days
2. passage of loose stool for 2 days
3. Decrease appetite for same duration.
:
According to the statement of the informent
mother he was reasonably well 10 days back.
Then he developed fever which was high grade
step ladder pattern & intermittent in nature.
Highest recorded temperature was 104°F. The
fever was associated with chills & rigor. Fever
was subsided by taking paracetamol. She also
complained for passage of loose watery stool
for 2 days for 6 times which was associated
with abdominal pain not associated with blood
His mother also complained that her child
took less food. His bowel habit was
normal.He had no history of travelling to
malaria,kala-azar endemic zone and no
history of contact with TB patient but
had history of taking unhygienic food and
water from outside.With these complaints
he was admitted to our medical college for
better management & further evaluation.
Continue.....
• Past History: Nothing contributory to this
Disease
.Birth History: He was born in a hospital through
NVD with no complications.
.Feeding History:- He is on family diet.
.Developmental History:- He is a developmentally
age appropriate child.
.Family History: All the members of his family are
apparently at good health.
Continue...
• Drugs History: For fever he took paracetamol.
• Personal History: He is school going child with
good academic record
• Allergic History: He has no allergy to food or drugs
• Immunization History: He was immunized as per
EPI.
• Socioeconomic History: He belongs to middle
class family & lives in house with good water
supply & well sanitation.
Continue...
His father was a buisnessman and his
monthly income was 30000 tk.
GENERAL EXAMINATION:
•Appearance: Ill-looking.
•Body Build & Nutrition: Average.
•Decubitus: On choice.
•Co-operation: Co-operative.
•Anaemia: Mild pale.
•Jaundice: Absent.
•Cyanosis: Absent.
CONTINUE...
.Clubbing: Absent.
•Koilonychia: Absent
•Leukonychia: Absent
•Oedema: Absent
•Dehydration: Absent
•Jugular venous pressure: Not Raised
•Neck Vein: Not engorged.
CONTINUE...
•Tongue:Coated
.Thyroid Gland: Not enlarged.
•Lymph Nodes: Not palpable
.Bony Tenderness: Absent
.Skin Survey:-BCG mark present & no
pigmentation
Vitals:-
.Pulse:104beats/min
•Blood Pressure: 100/50 mmHg
•Respiratory Rate: 20 breaths/min
•Temperature: 104°F
.SPO2: 98% without Oxygen
.Weight:- 12.4kg
.Height:- 102cm
.BMI:- 18.7kg/m2
• Inspection:
✓ Shape of the abdomen was normal
✓ There was no scar mark
✓ No visible peristalsis
✓ Umbilicus was inverted and centrally
placed.
• Palpation:
✓ Abdomen was tender with no
organomegaly.
continue…
•P e rc us s i o n: P e rc us s i o n no t e w a s
tympanic.
•Auscultation: Bowel sound was present.
• Inspection:
✓ Chest shape was normal
✓ Chest movement was bilaterally symmetrical.
✓ Respiratory rate was 20 breaths/mint
✓No use of accessory muscle & no intercostal
recession was present.
• Palpation:-
✓ Trachea was centrally placed
✓Apex beat was situated in left 5th intercostal
space just medial to midclavicular line
✓Chest expansion was bilaterally symmetrical
normal
✓ Vocal fremitus was normal on both side.
• Percussion: Percussion note was resonant
• Auscultation:
.Breath sound was vesicular.
.Vocal resonance normal
.No added sound.
.Inspection: There was no visible carotid &
epigastric pulsation and no cardiac impulse
were seen.
.Palpation:Apex beat was found at left 5th
intercostal space just medial to midclavicular
line. TTher was no left parasternal heave, no
thrill.
• Auscultation: 1st & 2nd heart sounds were
audible in cardiac area.No added sound
• Higher psychic function: Conscious
• Motor function : Good
• Knee jerk : Intact
• Planter response : Normal
• Sensory function : Intact
• Signs of meningeal irritation : Absent
Other systemic examinations were
performed and revealed nothing
abnormality
Ehan, 6years old boy fully immunized second
issue of non-consanguinous parents hailing from
board bazar, Gazipur was admitted to this
hospital with complaints of fever for 10 days,
Which was high grade step ladder pattern &
interm ittent in nature. Highest recorded
te m pe ra tu r e wa s 104 ° F. T h e f e ve r wa s a
ssociated with chills & rigor. Fever was subsided
by taking paracetamol.
He also complainted of diarrhoea for 2 days 6
times associated with abdominal pain not
associated with blood . Mother also
complained that her child took less food. His
bowel habit was normal.He had no history of
travelling in any Malaria, Kala-azar endemic
zone and no history of any contact with
T B p a t i e n t b u t h a d h i s to r y o f t a k i n g
unhygienic food and water from outside.On
my general examination, He was ill looking
and with average body built, pulse was 104
b p m , R e s p i ra t o r y ra t e 2 0 b / m i n a n d
temperature was 104°F. Blood Pressure
100/50 mmHg,tongue was coated.
On Alimentary system examination,umbilicus
was inverted and centrally placed. Abdomen
was tender. No organomegaly was
present.Other systemic examination was
performed but reveals nothing abnormalities.
Provisional Diagnosis: Enteric fever
• UTI
• Dengue
✓ CBC
✓ Widal Test
✓ CRP
✓ Urine R /M/E
✓ Anti dengue IgG, IgM
CBC:
❖ HB%:- 10.2gm/dl
❖ Total WBC:- 9280/cumm
❖ Neutrpphil : 44%
❖ Lymphocytes : 48%
❖ Platelet count:- 3,70,000/cumm
❖ RBC count: 4.32 Million /uL
Result : Negative
Widal Test:

Result :
TO-1:80
TH-1:320
AH-1:80
BH-1:80
CRP:- 14.70 mg/L
RBC -Nil
Pus cell – 2-3/HPF
Epithelial cell -2-3/HPF
Treatment and management at ward:
Diet-N

Inf 5% DNS(1L)
800ml l/V
@32microdrops/min

Inj.oricef(1gm)
900mg dilute with l/v fluid
with l/v slowly as infusion
drip-12 h

Inj. Amikin(100mg)
90mg l/v slowly -8h
 Treatment & Management at ward:
• Syp.Ace
• 1tsf-6h
• Supp.Ace(250mg)
• 1stick P/R-sos
Treatment during discharge:
Syp.Denvar(200mg)
1tsf ×2times-9days
. Syp.Aritone
1tsf×1time-20days
Advice:
.Take medicines regularly
•To take good nutritious diet.
•To take rest.
•Drink clean boil water.
•Hand wash before eating or preparing food
and after using toilet.
 Follow up:
•Follow up after 7 days with CBC report.
 Topic
Enteric Fever
Contents • Introduction
• Epidemiology
• Pathogenesis
• Clinical Features
• Signs
• Complication
• Diagnosis
• Treatment
• Prognosis
• Preventions
•It is a common illness in this part of
world. In this condition children usually
suffers from fever for more than 7 days
with significant sickness and prostration.
Epidemiology
• ORGANISMS: Salmonella typhi, S. paratyphi A, B, C.
• MODE OF TRANSMISSION: Faecal-oral route.
• INCUBATION PERIOD: 7-14 days.
The organisms enter the body through ingestion
of contaminated foods (street food) or drinks.
The organisms, after passing through the
intestinal mucosa enter the mesenteric lymphoid
system and then into the blood via lymphatics.
This is called Primary Bacteraemia and at this
stage the patient remains asymptomatic.
The organisms then disseminate
throughout the body, colonize and multiply
in the reticuloendothelial system. After
replication, organisms again enter the
blood causing Secondary Bacteraemia,
which coincides with the onset of
symptoms and marks the end of incubation
period.
CLINICAL FEATURES
1. Fever: Prolonged high-grade fever is the main
symptom in almost all the cases. It rises gradually
but the classical step- ladder pattern is rare
2. Abdominal symptoms: Vomiting (39%), diarrhoea
(36%) abdominal pain (21%) or
constipation (7%). Diarrhoea may occur in the
early stage of illness and may be followed by
3. constipation
4. Coated tongue (76% cases)
5• Truncal rash (rose spots): In approximately 25% of
cases,
a macular or maculopapular rash (rose spots) may be
visible
around the 7th-10th day of the illness and lesions may
appear
in crops of 10-15 on the lower chest and abdomen and
last
2-3 days
6.Other on-specific symptoms: Anorexia (70%),
7.In the second week of illness, patients
become acutely ill, lethargic and abdominal
symptoms increase in severity. Vomiting and
meningism may be prominent in infants and
young children in this stage.
Physical examination reveals -
1. High body temperature
2. Pallor
3. Coated tongue
4. Hepatomegaly
5. Splenomegaly
6. Jaundice
7. Paralytic ileus
8. Rose spots
•Sometimes, patients may present with
Irritability, confusion Delirium, stupor
(encephalopathy)
* If no complication occur, clinical features
gradually resolve within 2-4 weeks
Specimens : Blood, Bone marrow, Stool, Urine,
Pus, CSF
• 1st week : Blood culture
• 2nd week: Antibody detection by Widal test
• 3rd week: Urine culture
• 4th week: Stool culture
COMPLICATIONS

⚫ Intestinal haemorrhage ⚫ Encephalopathy,

⚫ Perforation, peritonitis & cerebral oedema
paralytic ileus ⚫Subdural empyema,
⚫ Cholecystitis, hepatitis cerebral abscess
⚫Meningitis,
⚫Hepatic abscess,
splenic abscess ventriculitis
 Respiratory System
⚫Pneumonia,
⚫Endocarditis, empyema
myocarditis, ⚫Bronchopleural
pericarditis fistula
⚫Arteritis, congestive
heart failure
⚫ DIC
Continue...
Bone and joint Soft tissue Infections
⚫ Osteomyelitis ⚫Psoas abscess,
⚫ Septic arthritis gluteal abscess
⚫ Cutaneous vasculitis
Genito-urinary system
⚫Urinary tract infection, Bone marrow-
renal abscess,
Necrosis
⚫ pelvic infections
⚫ Prostatitis, epididymitis
Treatment
•Counsel parents about the natural history of
the disease, treatment and complications
A. Supportive measures
❑ Antipyretic e.g. Paracetamol
❑ Adequate hydration e.g. more fluid intake
❑Correction of fluid and electrolyte imbalance, if
present
❑Adequate nutrition by soft, easily digestible
nutritious diet
Continue...
B. Specific treatment:
Any of the following antibiotics for 10-14 days
▪ Ceftriaxone 100 mg/kg/day, once daily
▪ Cefotaxime 80mg/kg/day, 8 hourly
▪ Amoxicillin 100 mg/kg/day orally 6 hourly
▪ Azithromycin 10 mg/kg for 7 days
Prevention
Salmonella infections are prevented mainly
by public health and personal hygiene
measures.
•Proper sewage treatment
•A safe water supply
•Hand washing prior to Food handling
•Pasteurization of milk
•Proper cooking of Poultry, eggs and meat.
Prognosis:-
•With early antibiotic therapy, prognosis
is excellent and mortality rate is < 1%
•Relapse occurs in 1-3 weeks later in 10
to 20 % cases.
References