8. a case study on typhoid fever

A 28 year old male patient was admitted to the male medicine ward with complaints of fever since 1 week, bodyache, headache, slightly yellowish sclera and watery eyes.

1. A Case Study On Typhoid
Fever
(SOAP)
-Ajita Sadhukhan
-Pharm D. 3
rd
year
-Roll No. : 1
-Enrolment No. : 150821207001

2. Definition
Typhoid or Enteric Fever is an infectious feverish disease
caused by the bacterium Salmonella typhi(Salmonella
entericaSerovarTyphi) and less commonly by
Salmonella paratyphi.
Acute generalized infection of the reticulo-endothelial
system, intestinal lymphoid tissue and the gall bladder.
The infection always comes from another human, either
an ill person or a healthy carrier of the bacterium. The
bacterium is passed on with water and foods and can
withstand both drying and refrigeration.
2

3. Patient Demographics:
Patient I.P. No.:17009875
Patient O.P. No.:17112877
Age:21 years
Weight:48 Kg
Sex:Male
Department:Male Medicine Ward
Unit:1
Date of Admission: 14. 8. 17
Date of Discharge:21. 8. 17
3

4. Reason For Admission:-Fever since 1 week
-body ache
-headache
-sclera slightly yellowish
-watery eyes
Past Medical History:NAD
Past Medication History:Patient had taken medication for fever at home.
Family history:NAD
Social history:student
Previous allergies:none
Pregnancy status: NAD
4

5. OBJECTIVES
PHYSICAL EXAMINATION:
GENERAL:Decreased appetite, yellowish urination
CVS:S1S2 normal
RS: AEBE clear
CNS:oriented
BP:110/80 mm Hg
PR:79/min
TEMP:99 F
RESPIRATION: 17/min
PA:Soft
5

6. LAB. INVESTIGATION REPORTS [first day]
LABORATORYPARAMETERS OBSERVED VALUE NORMAL RANGE UNIT
Hb 14.0 11.5-18 g%
Neutrophils 69.6 40-70 %
Lymphocytes 45 20-40 /cumm
Monocytes 04 2-10 /cumm
ESR 45 1-20 mm/hr
Platelets 348000 1.5-4 /cu mm
ALT 55 <40 IU/L
6
PS for MP:Malarial parasite not seen
WidalTest:Positive
HIV test:negative
OTHERS (2
nd
day)

7. ASSESSMENT:
PROVISIONAL DIAGNOSIS: Typhoid Fever
7

8. A 21 year old male patient was admitted to Med. ward-1 with complaints of fever
since 1 week, body ache, headache, sclera slightly yellowish and watery eyes.
Based on lab report, patient’s lymphocytes, ESR and ALT levels are abnormally
increased. WidalTest is Positive. Hence, patient was diagnosed with typhoid fever.
8

9. FINAL DIAGNOSIS:
Typhoid Fever
9

10. GOALS OF TREATMENT:10
•To reduce fever.
•To reduce body ache.
•To reduce headache.
•To reduce slightly yellowish sclera.
•To reduce watery eyes.

11. DAY 1
Temperature: 99 F
Pulse: 79/min
SPO2: 98%
B.P.: 110/80 mm Hg
R: 17/min
Adv. : CBC, PS for MP, WidalTest, HIV
11

12. Medication chart (day 1)
DRUGNAME ROUTE DOSE FREQUENCY INDICATION
Inj. Ceftriaxone +
Sulbactam
I.V. 1.5 gin 100 ml
NS
BD Totreat typhoid
fever
Inj. Ranitidine I.V. 2ml 1-1-1 To prevent
acidity
Inj. Ondanstron I.V. 4 mg TDS To prevent
emesis
Inj. NaCl+
(Optineuron)
Calcium
Pantothenate+
Cyanocobalamin +
Folic acid+
Niacinamide+
Pyridoxine + Thiamine
I.V. 3 ml 1-0-0 Electrolyte+
Calciumand
Vitamin B
complex
supplement
12

13. DAY 2
Temperature: 100 F
Pulse: 80/min
SPO2: 98%
B.P.: 110/80 mm Hg
R: 18/min
13

14. Medication chart (day 2)
14
DRUGNAME ROUTE DOSE FREQUENCY INDICATION
Tab. Paracetamol P.O. 500 mg SOS
1-0-1
Analgesic, anti-
pyretic
Inj. Ceftriaxone +
Sulbactam
I.V. 1.5 gin 100 ml
NS
BD Totreat typhoid
fever
Tab. Azithromycin P.O. 500 mg 1-0-0 typhoid fever
Inj. Ranitidine I.V. 2ml 1-1-1 To prevent
acidity
Inj. Ondanstron+ Inj.
DNS/NS
I.V. 4 mg + I pint TDS Nausea and
vomiting
Inj. NaCl+
(Optineuron)
Calcium
Pantothenate+
Cyanocobalamin +
Folic acid+
Niacinamide+
Pyridoxine + Thiamine
I.V. 3 ml 1-0-0 Electrolyte+
Calciumand
Vitamin B
complex
supplement

15. DAY 3
Temperature: 98 F
Pulse: 82/min
SPO2: 98%
B.P.: 120/80 mm Hg
R: 20/min
15

16. Medication chart (day 3)
DRUGNAME ROUTE DOSE FREQUENCY INDICATION
Tab. Diclofenac+
Paracetamol
P.O. 50mg SOS
1-0-1
Painkiller, anti-
pyretic
Inj. Ceftriaxone +
Sulbactam
I.V. 1.5 gin 100 ml NS BD Totreat typhoid
fever
Tab. Azithromycin P.O. 500 mg 1-0-0 typhoid fever
Inj. Ranitidine I.V. 2ml 1-1-1 To prevent acidity
Inj. Ondanstron+ Inj.
DNS/NS
I.V. 4 mg + I pint TDS Nausea and
vomiting
Inj. NaCl+ (Optineuron)
Calcium Pantothenate+
Cyanocobalamin + Folic
acid+ Niacinamide+
Pyridoxine + Thiamine
I.V. 3 ml 1-0-0 Electrolyte+
Calciumand
Vitamin B complex
supplement
Syp. Cyprohaptadine+
Tricholine+ Sorbitol
P.O 1 tsf 1-0-1 For allergic
reactions
16

17. DAY 4
Temperature: normal
Pulse: 86/min
SPO2: 98%
B.P.: 120/80 mm Hg
17

18. Medication chart (day 4)
DRUGNAME ROUTE DOSE FREQUENCY INDICATION
Tab. Diclofenac+
Paracetamol
P.O. 50mg SOS
1-0-1
Painkiller, anti-
pyretic
Inj. Ceftriaxone +
Sulbactam
I.V. 1.5 gin 100 ml NS BD Totreat typhoid
fever
Tab. Azithromycin P.O. 500 mg 1-0-0 Typhoid fever
Inj. Ranitidine I.V. 2ml 1-1-1 To prevent acidity
Inj. Ondanstron+ Inj.
DNS/NS
I.V. 4 mg + I pint TDS Nausea and
vomiting
Inj. NaCl+ (Optineuron)
Calcium Pantothenate+
Cyanocobalamin + Folic
acid+ Niacinamide+
Pyridoxine + Thiamine
I.V. 3 ml 1-0-0 Electrolyte+
Calciumand
Vitamin B complex
supplement
Syp. Cyprohaptadine+
Tricholine+ Sorbitol
P.O 1 tsf 1-0-1 For allergic
reactions
18

19. DAY 5
Temperature: normal
Pulse: 90/min
SPO2: 97%
B.P.: 120/80 mm Hg
RS: NAD
CVS: NAD
CNS: NAD
Adv.: CST
19

20. DRUGNAME ROUTE DOSE FREQUENCY INDICATION
Tab. Diclofenac+
Paracetamol
P.O. 50mg SOS
1-0-1
Painkiller, anti-pyretic
Inj. Ceftriaxone + Sulbactam I.V. 1.5 gin 100 ml NS BD Totreat typhoid fever
Tab. Azithromycin P.O. 500 mg 1-0-0 Typgoidfever
Inj. Ranitidine I.V. 2ml 1-1-1 To prevent acidity
Inj. Ondanstron+ Inj. DNS/NS I.V. 4 mg + I pint TDS Nausea and vomiting
Inj. NaCl+ (Optineuron)
Calcium Pantothenate+
Cyanocobalamin + Folic
acid+ Niacinamide+
Pyridoxine + Thiamine
I.V. 3 ml 1-0-0 Electrolyte+ Calcium
and Vitamin B
complex supplement
Syp. Cyprohaptadine+
Tricholine+ Sorbitol
P.O 1 tsf 1-0-1 For allergic reactions
Tab. Paracetamol P.O. 500 mg SOS
1-0-1
Analgesic, anti-pyretic
Medication chart (day 5)

21. DAY 6
Temperature: normal
Pulse: 80/min
SPO2: 99%
B.P.: 110/70 mm Hg
R: 17/min
Adv. Discharge with medication for 7 days.
21

22. DRUGNAME ROUTE DOSE FREQUENCY INDICATION
Tab. Diclofenac+
Paracetamol
P.O. 50mg SOS
1-0-1
Painkiller, anti-pyretic
Tab. Azithromycin P.O. 500 mg 1-0-0 Typhoid fever
Inj. Ranitidine I.V. 2ml 1-1-1 To prevent acidity
Inj. Ondanstron+ Inj. DNS/NS I.V. 4 mg + I pint TDS Nausea and vomiting
Inj. NaCl+ (Optineuron)
Calcium Pantothenate+
Cyanocobalamin + Folic
acid+ Niacinamide+
Pyridoxine + Thiamine
I.V. 3 ml 1-0-0 Electrolyte+ Calcium
and Vitamin B
complex supplement
Syp. Cyprohaptadine+
Tricholine+ Sorbitol
P.O 1 tsf 1-0-1 For allergic reactions
Tab. Rabeprazole+
Domperidone
P.O. 40mg 1-0-1 GERD
Medication chart (day 6)

23. Discharge Medication chart (follow up after
7 days)
DRUGNAME ROUTE DOSE FREQUENCY INDICATION
Tab. Rabeprazole+
Domperidone
P.O. 40mg 1-0-1 GERD
Tab. Azithromycin P.O. 500 mg 0-1-0 Typhoid fever
Syp. Cyprohaptadine+
Tricholine+ Sorbitol
P.O 1 tsf 1-0-0 For allergic
reactions
Tab. NaCl+
(Optineuron)
Calcium
Pantothenate+
Cyanocobalamin +
Folic acid+
Niacinamide+
Pyridoxine + Thiamine
P.O. 10 mg 0-1-0 Calciumand
Vitamin B
complex
supplement
23

24. TREATMENT PLAN:
24

25. Non-pharmacological treatment:
Some common home remedies
Mash a ripe banana along with 1 tablespoon honey and eat twice a day for a few
days.
Activity
No specific limitations on activity are indicated.
Rest is helpful, but mobility should be maintained if tolerable.
The patient should be encouraged to stay home from work until recovery.
Diet
Fluids and electrolytes should be monitored and replaced diligently.
Oral nutrition with a soft digestible diet is preferable in the absence of abdominal
distension or ileus.
25

26. Pharmacological Treatment:
26

27. INTERVENTION/POINTS TO BE
COMMUNICATED WITH DOCTOR
SERIOUS →USE ALTERNATIVE
Azithromycin + Ondansetron: Both increase QT interval on prolonged use. Avoid or
use alternative drug.
27

28. PATIENT COUNSELING:
28

29. About Disease:
It is a curable disease.
Two main typhoid fever prevention strategies:
1. Vaccination
✓Be vaccinated against typhoid while traveling to a country where typhoid is
common.
✓Need to complete your vaccination at least one week before travel.
✓Typhoid vaccines lose their effectiveness after several years so check with your
doctor to see if it is time for a booster vaccination.
29

30. 2. Avoid risky food and drinks
✓Buy bottled drinking water or bring it to a rolling boil for one minute before drinking it.
✓Ask for drinks without ice, unless the ice is made from bottled or boiled water. Avoid
Popsicles and flavored ices.
✓Eat food that have been thoroughly cooked and that are still hot and steaming.
✓Avoid raw vegetables and food that cannot be peeled like lettuce.
✓When eat raw fruit and vegetables that can be peeled, peel yourself. Don’t eat the
peelings.
✓Avoid foods and beverages from street vendors.
30

31. About Medications:
Dose of drugs
Frequency of dose
Route of administrations such as I.V, I.M., t/d, s/c, P.O., S/L.
Counselling regarding overdose (may cause toxicity), underdose
(submaximal or no response) and missing of dose of medication. E.G. If a
dose is missed, then the patient is to be advised to go for the next dose,
otherwise toxicity of drug may occur.
Contraindications
Drug interactions (drug-drug, drug-food)
31

32. Life Style Modifications:
SANITORY MEASURES:
Sanitary disposal of human faeces and maintain fly-proof latrines.
Provision of safe chlorinated water and avoid possible back-flow connections between water and
sewer systems.
Educate the community regarding the importance of hand washing especially after defecating.
Control of flies by screening, spraying with insecticides, and use of insecticidal baits and traps.
Control fly breeding by frequent collection and disposal of garbage, and fly-control measures in
latrine construction and maintenance.
Use scrupulous cleanliness in food preparation and handling; refrigerate as appropriate. Particular
attention should be directed to the proper storage of salads and other foods served cold. These
provisions apply equally to home and public eating places.
If uncertain about sanitary practices, select foods that are cooked and served hot, and fruits peeled
by the consumer.
Pasteurize or boil all milk and dairy products. Supervise the sanitary aspects of commercial milk
production, storage and delivery.
Enforce suitable quality-control procedures in industries that prepare food and drink for human
consumption.
32

33. FOOD SAFETY:
Contaminated food is another important vehicle for typhoid fever transmission.
Appropriate food handling and processing is paramount and the following basic hygiene measures must be
implemented or reinforced during epidemics:
Washing hands with soap before preparing or eating food;
Avoiding raw food, shellfish, ice; eating only cooked and still hot food or re-heating it.
NATURAL REMEDIES:
Complete bed rest is essential.
Patient should be kept on a liquid diet of orange, barley juice and milk.
Orange juice especially hastens recovery as it increases energy, promotes body resistance and increases
urinary output.
Administer warm water enema regularly.
Apply cold compress to head if temperature rises above 103
0
F
Wrap the body and legs twice with a sheet wrung in cold water and then cover it with a warm material.
The pack should be kept for an hour and renewed after every 3 hours.
Hot water bottles may be applied to the sides of the body and feet.
Fresh fruits and easily digestible foods can be given after temperature comes down to normal.
Plain water or unsweetened lemon water can be used for drinking.
Gradually start a well-balanced diet.
33

34. 34