CASE 1

Adrienne Alve
Michelle Mae P. Castro
Lourd Benzardas Anto Nixon
Bess D. Rompal
Risa Mae A. Salgado
Shannie Faith L. Zalavarria
 .
History and Physical Examination was done during
the 2nd day of patient’s hospitalization.
DATE AND TIME OF INTERVIEW July 28, 2020 at 3:00 PM

SOURCE OF INFORMATION Patient

RELIABILITY 95%

REFERRAL None
Chief Complaint:

Fever and
Tea-colored
urine
 IDENTIFYING DATA

Patient S.M, 23 year old male, born on February 14,

1997, single, Filipino, Roman Catholic, a Pedicab
Driver from Brgy. Pawing Palo Leyte was admitted
for the first time on July 26, 2020 at 5pm at
Eastern Visayas Regional Medical Center.
 HISTORY OF PRESENT ILLNESS
5 days prior to admission patient developed recurrent
moderate to high-grade fever with a temperature of 38-39°C
associated with myalgia and throbbing headache localized in the
frontal region with a pain rating scale of 5 out of 10. He took
Paracetamol 500mg 1 tablet for fever affording temporary relief.
The patient also experienced weakness and fatigue of which he
thought was due to his fever.
 HISTORY OF PRESENT ILLNESS
This was later associated with epigastric pain with a pain
rating scale of 8 out of 10, without radiation, associated with
nausea, vomiting and diarrhea, which he stated as defecating to
watery stools of about 5 times.
2 days prior to admission, the patient noticed small flat red
spots on his chest and abdomen. Fever still persisted with a
temperature of 38-39°C. The patient continued taking Paracetamol
500 mg 1 tablet every four hours but does not offer relief.
 HISTORY OF PRESENT ILLNESS
1 day prior to admission, the above symptoms still persisted,
but now he noted his urine to be dark yellow in color and
decreasing in volume from urinating of about 200 ml in volume it
is now decreased to 50-100 ml. This prompted the patient to
submit himself for admission.
 PAST MEDICAL HISTORY

2017-
No diagnosed
allergy
(+) dengue with
at 7 year oldtowardsUTIat EVRMC
admitted treated with
foodtransfused
and
Adult
with 4 U platelet
unrecalled
medications None Allergies
concentrate
antibiotic
Negates Illness
(+) mumps, measles
other and chicken pox (date and age
comorbidity
unrecalled)
Childhood Surgical
IIllnes Operations
 FAMILY HISTORY
Parents still alive and well.
2nd in a brood of 5. All siblings apparently well.
Negates any heredofamilial disease such as asthma, hypertension, diabetes,
kidney diseases, heart problems and cancer.

Family Member Age Gender Health Status

Father 60 Male Apparently well

Mother 58 Female Apparently well

Older sibling 27 Male Apparently well

3rd sibling 22 Male Apparently well

4th sibling 20 Male Apparently well

Youngest sibling 18 Female Apparently well

 PSYCHOSOCIAL HISTORY
Patient is a high school graduate currently working as a pedicab
driver earning Php 300-400/day. He lives with his family in a 1-
storey house, located near the river. Their house is made of wood
with a water-sealed toilet. The water used for drinking was from
LMWD and was taken in without any boiling or treatment. They
store their water for drinking in used mineral water bottles and
water cans which they wash at least once every two weeks.
 PSYCHOSOCIAL HISTORY

The family uses wood for cooking and usually stores their food in
plastic containers. The family receives their electricity from LEYECO.
He usually wakes up at 5am eats breakfast usually composed and
fish and rice then goes to work.
 PSYCHOSOCIAL HISTORY
He usually wakes up at 5am eats breakfast usually
composed and fish and rice then goes to work. Since
he is a pedicab driver and is always on the road, the
patient is fond of eating street foods like bopis and
kwek-kwek near the market where he usually waits for
his customers.
 PSYCHOSOCIAL HISTORY
He admits that due to his livelihood he then neglects
to wash his hands every time he eats, and this has
been his habit for quite some time. The patient also
stated that he usually only drinks 1500 ml of water
while he is working since he has only as short time for
break.
 PSYCHOSOCIAL HISTORY

He is a smoker for 10 pack year and occasional alcoholic

beverage drinker. He negates exposure to flood but with
rodents at home and there are stagnant waters at their
neighborhood.
 PSYCHOSOCIAL HISTORY

The patient usually defecated to formed brown stools once a

day and urinates about 4 times per day of about 200 ml per
voiding. He denies any use of illicit drugs.
REVIEW OF SYSTEMS
General: Negates weight loss. Has fever, has body malaise
since the onset of illness. Has weakness and fatigue.
Skin: No dryness of the skin, no itchiness, no redness, no
discoloration of hair and nails. No recurrent skin lesions ,
no rashes.
Head: No lightheadedness, no dizziness, has throbbing
headache with a PRS of 5/10, no head trauma
Eyes: No excessive tearing, no blurring of vision, does not wear
eyeglasses, no discharges. No pain, no itchiness, no diplopia,
Ears: No hearing loss, no tinnitus, no vertigo, no pain, no discharges
Nose and sinuses: No nasal stuffiness, No colds, no anosmia, no
itchiness, no pain, no epistaxis
Throat and Mouth: No sore throat, no toothache, no sore tongue, no
bleeding gums, no dentures, no pain, no dysphagia, no hoarseness
Neck: No torticollis, no pain, no mass, No stiffness in
the neck
Breast: No lumps, no pain, no discharge
Respiratory: No dyspnea, no orthopnea, no
hemoptysis, no cough, no pleuritic chest pain
Cardiovascular: No palpitations, no easy fatigability ,
no paroxysmal nocturnal dyspnea
Abdomen: Has anorexia since onset of illness, has
localized sharp abdominal pain (on the epigastric
region with a PRS of 7/10). No dysphagia, no bowel
movement changes, has melena and defecates once a
day with formed brown-colored stool that is firm in
consistency. No pain during defecation
Urinary: Patient usually urinates 3-4 times per day (approximately
200ml to 300ml per void). No dysuria, no hematuria, no urinary
frequency, no flank pains. Patient noted his urine to be dark yellow
in color and decreasing in volume
Genital: No itching, no sores, no discharges
Musculoskeletal: Has myalgia, no arthralgia, no swelling or edema,
no bone pain
Peripheral Vascular: No intermittent claudication, no recurrent
pain on extremities, no numbness, no cramps, no edema.
Psychiatric: No mood swings, no tension, no anxiety, no
depression, no suicidal tendencies.
Neurologic: No recurrent headache, no dizziness, no loss of
consciousness, no numbness, no seizures, no history of head
trauma, no paresthesia, no tremors, no paralysis
Hematologic: No easy bruising, no gum bleeding, has history of
blood transfusion
Endocrine: No polydipsia, no polyuria, no polyphagia, no heat or
cold intolerance, no hyperhidrosis
PHYSICAL EXAMINATION
 Patient was examined lying down, awake,
conscious, coherent, cooperative, and is
oriented to time, place and person. He has good
eye contact and has no unremarkable facies. He
is well-groomed, well-developed with a
mesomorph physique. Patient is in respiratory
distress with the following vital signs:
 VITAL SIGNS RESULTS INTERPRETATION
Blood Pressure 80/60 mmHg HYPOTENSIVE
Heart Rate 118 bpm TACHYCARDIC
Temperature 38.9 oC FEBRILE
Respiratory Rate 19 cpm NORMAL
O2 saturation 98% NORMAL
INTEGUMENT
 Skin: No active skin lesions,, brown complexion, warm, moist,
with good turgor and mobility. No peripheral cyanosis, small red
flat spots found on the chest and abdomen, no petechiae, no
ecchymoses, or jaundice
 Hair: black, short, straight, evenly distributed, fine hair.
 Nails: Good capillary refill <2 sec. Without clubbing or cyanosis.
Smooth with no ridges nor breaks.
HEAD
 Skull: normocephalic, atraumatic with symmetric
contour.
 Scalp: has no dandruff, no lumps or lesions.
 Face: symmetric with no involuntary movements, no
masses or edema
EYES
 Eyebrows : fine, black, symmetric with evenly distributed hair.
 Eyelashes : black, evenly distributed, and oriented outwards
 Eyelids : symmetrical, lid margins intact with adequate lid closure. No
ptosis, no edema and no periorbital tenderness.
 Conjunctiva: pinkish in color. With conjunctival suffusion
 Sclera : Slightly icteric , no spots or hemorrhages.
 Cornea :clear and transparent. No ulcerations, scars or opacities.
 Pupils: round, symmetrical, 2mm in diameter and briskly reactive to
direct and consensual light stimulation.
 EOM: Full extraocular movement, with normal conjugate gazes and with
good convergence. No nystagmus.
EARS
 Ears are symmetrical with no discoloration. Mobile,
firm and non-tender auricles. With No active lesions on
both ears with visible cerumen
NOSE :symmetrical. No alar flaring, (-) nasal
discharge, NO deviation of septum and sinus
tenderness noted. Turbinates not inflamed..
MOUTH and THROAT
• Lips: dry. No angular deviations or cold sores. no lumps,
no ulcers, no cheilosis
 Mucous membrane : No bleeding or sores are noted.
 Gums : pale. No bleeding. no swelling or ulcerations on
gums margins,
 Tongue: dry and has no ulceration and papillary atrophy.
 Tonsils: not enlarged. Uvula at midline. No inflammation
NECK: Trachea at midline, jugular vein not engorged, thyroid gland
not palpable, Lymph nodes not swollen, and no stiffness of the
neck noted. Carotid upstrokes are brisk and no bruit noted. No
lesions nor scars noted. JVP of 5cm from the sternum. (-) NVE
BREAST: symmetrical. Everted nipples. No
lumps, discolorations, or discharges.
CHEST and LUNGS
 Inspection: Symmetrical chest expansion. No bulging, no
retractions.
 Palpation: Confirmed symmetrical chest expansion.
Unimpaired tactile fremitus, no masses or tenderness.
 Percussion: Resonant on all lung field.
 Auscultation: Bronchovesicular breath sounds in all lung
fields. No adventitious breath sounds. No crackles, no rales,
no pleural friction rub.
HEART
 Inspection: Adynamic precordium. No visible precordial
pulsation.
 Palpation: No thrills or heaves. PMI is located at 5TH ICS with a
distance of 6 cm from the midclavicular line and a diameter
of 2.5 cm.
 Auscultation: Heart rate is tachycardic, regular in rhythm and
synchronous with the radial pulse. Absent bruit, murmurs
and pericardial friction rub.
ABDOMEN
 Inspection: Abdomen is full and symmetrical. No visible scars. No
localized bulging. No striae & prominent dilated veins. Peristaltic
waves not noted. No visible pulsations noted. No visible organs or
masses noted.
 Auscultation: Normoactive Bowel Sounds. No bruits and friction rubs.
 Palpation: no palpable mass, with tenderness on epigastric region
upon palpation. No guarding and muscle rigidity. No abdominal
masses palpated. Spleen was not palpable.
 Percussion: (-) tenderness. Tympanitic in all quadrants. Liver edge
palpable 3 cm below subcostal margin. Liver span was 14 cm in the
right midclavicular line. Splenic span of 8 cm. Negative for Kidney
Punch Sign.
EXTREMITIES : Both upper and lower extremities are symmetrical
and warm. No varicosities or stasis changes. Has bilateral calf
muscle tenderness. Legs are non-edematous. No evidence of
deformity. Full range of motion of the joints of the upper and
lower extremities. Peripheral pulses are palpable and regular in
rhythm.
 Poplitea Posterior Dorsalis
Pulse Brachial Radial
l Tibial Pedis

Right 1+ 1+ 1+ 1+ 1+
Left 1+ 1+ 1+ 1+ 1+
BACK and SPINE: No abnormal deviation, no retractions, no
bulging, no muscle wasting, no hair tufts, no dimpling noted, no
paravertebral tenderness or mass. (-) KPS on both sides.

GENITOURINARY: No lesions and no unusual discharges. No pain

upon palpation. Patient is circumcised. No phimosis.
ANUS, RECTUM, AND PROSTATE
 No perirectal lesions or fissures. External sphincter tone
intact. Rectal vault without masses. The walls of the mucosa are
smooth. Prostate gland is about 2.5 cm in length, is smooth,
firm and non-tender with palpable median sulcus. Melena on
the gloved finger.
 NEUROLOGIC
EXAMINATION
I. HIGHER CEREBRAL FUNCTIONS

Patient is alert, attentive and oriented to

person place and time; has clear fluent speech with
normal comprehension; able to provide clear
account of historical and recent events MMSE
performed is 30, normal
CRANIAL NERVES RESULT
I Olfactory Patient is able to smell coffee.
Visual acuity is 20/20 OU; visual fields
II Optic
are both intact.
Pupils are both round equally reactive to
II&III Optic and Occulomotor
light and has normal accommodation
III, IV, & VI Occulomotor, Trochlear, and Abducens EOM is intact; good convergence.
Normal sensation of the skin over the
forehead, maxilla, and mandible normal
V Trigeminal
corneal reflex, temporal and masseter
strength intact.

Patient was able to wrinkle forehead,

VII Facial close eyes tightly, puff out cheeks ; no
lagging; no weakness; and symmetric

Patient was able to hear whispered voice

VIII Acoustic
and hear rubbing of hair on both ears

IX&X Glossopharyngeal and Vagus Patient was able to swallow and cough
Patient was able to shoulder shrug and
XI Spinal Accessory head rotation to opposite sides against
resistance.
Symmetrical tongue protrusion and
XII Hypoglossal
good tongue strength.
MOTOR FUNCTION
Good muscle bulk and tone. All muscles with 5/5 strength; Good
adduction, abduction and grip, extension and flexion.

Wrist Finger Hip Knee Knee Ankle Ankle

extension abduction flexion flexion extension flexion extension
Deltoid Biceps Triceps

LEFT 5 5 5 5 5 5 5 5 5 5
RIGHT 5 5 5 5 5 5 5 5 5 5
SENSORY FUNCTION
Normal sensation in all areas of dermatome as to pain, light
touch and vibratory sense. Intact 2- point discrimination, position
sense, stereognosis and graphesthesia.

CEREBELLAR FUNCTION
(+) rapid alternating movement, (+) finger to nose test, (+) heel
to shin test. Normal gait and balance with (-) rombergs test and no
pronator drift.

REFLEXES
Reflexes are 2+ and symmetric at the biceps, triceps, wrist, knees
and ankles. (-) Ankle clonus; (-) Babinski reflex.
 SALIENT
FEATURES
CLINICAL PROFILE:

Identifying data: PHYSICAL FINDINGS:

 23 Y.O
 MALE  BP: 80/60 mmhg
 FILIPINO  HR: 118 BPM
 ROMAN CATHOLIC
 TEMP: 38. OC
 BRGY PAWING PALO
 SINGLE  (-) WT LOSS
 BODY MALAISE
History of Present Illness:
 WEAKNESS AND FATIGUE
• MODERATE TO HIGH-GRADE FEVER OF 38-39’C  THROBBING HEADACHE
• MYALGIA  LOCALIZED SHARP ABDOMINAL PAIN ON THE
• FRONTAL THROBBING PRS 5/10
EPIGASTRIC REGION WITH A PRS OF 7/10)
• WEAKNESS AND FATIGUE
• EPIGASTRIC PAIN PRS OF 8/10 WITHOUT RADIATION  HAS MELENA
• NAUSEA, VOMITING (3X/DAY AT ABOUT 100/VOMIT)  NOTED HIS URINE TO BE DARK YELLOW IN
• DIARRHEA (5X/DAY) COLOR AND DECREASING IN VOLUME
• SMALL FLAT RED SPOTS ON CHEST AND ABDOMEN  MYALGIA
• DARK YELLOW URINE
• DECREASED URINARY OUTPUT (50-100ML)
 HAS HISTORY OF BLOOD TRANSFUSION
 WITH CONJUNCTIVAL SUFFUSION
Psychosocial History:  SLIGHTLY ICTERIC SCLERA
• SOURCE OF DRINKING WATER IS FROM LMWD, TAKEN IN  WITH TENDERNESS ON EPIGASTRIC REGION
WITHOUT BOILING OR ANY TREATMENT UPON PALPATION.
• FOND OF EATING STREET FOOD (BOPIS AND KWEKKWEK)  ENLARGED LIVER (14 cm @ R MCL)
• NEGLECTS HAND WASHING PRIOR EATING
• PRESENCE OF RODENTS AT HOME
• SMOKER: 10 PACK YEARS
• OCCASIONAL ALCOHOLIC BEVERAGE DRINKER
 pivot

FEVER
DIFFERENTIAL
DIAGNOSIS
TYPHOID FEVER (ENTERIC)
 High grade fever 38-39°C
 Vomiting 3x about 100 ml per episode
 Myalgia
 Throbbing headache in the frontal area with PRS of 5/10
 Anorexia since onset of illness
 Diarrhea of 5 episodes
 Small red flat spots on the chest and abdomen
 Weakness and Fatigue
 Abdominal Pain
 Tea-colored urine
 Enlarged liver (palpable 3cm below subcostal margin; 14 cm RMCL)
 Water used for drinking is straight from the faucet and taken in without any
treatment or boiling
 Fond of eating street foods (Bopis and kwek-kwek)
 Neglects hand washing prior eating
 Has melena
 Residing in an epidemiologically endemic area
 Presence of rodents at home
 DENGUE HEMORRHAGIC FEVER WITH COMPLICATED
ACUTE RENAL FAILURE
 No known exposure to stagnant water
 No flushed face noted during the first 2-
 Moderate to high grade fever 38-39°C
7 days
 Myalgia
 Liver tenderness
 Frontal throbbing headache (PRS 5/10)
 Small flat red spots (dengue rash is
 Weakness and fatigue
characterized as a maculopapular or
 Epigastric pain PRS of 8/10 withut
macular confluent rash over the face,
radiation
thorax, and flexor surfaces, with islands
 Nausea
of skin sparing. Petechiae spots on full
 Vomiting of 3 episodes at 100ml per
body except face, from day 3-4. May
episode
turn hemorrhagic. Rash disappears
 Diarrhea (5 times per day)
under pressure)
 Tea colored urine
 No joint pain noted
 Decreased urinary output (50-100ml)
 No retroorbital pain
 Body malaise
 No petechiae
 Hypotension (80/60 mmHg)
 No bleeding gums
 Conjunctival suffusion
 No epistaxis
 Slightly icteric sclera
 No hematuria
 No altered taste sentation
 HEPATITIS A
 Nausea
 Has anorexia since onset of
illness
 Vomiting 3x about 100 ml per
 No alterations in olfaction and
episode
taste
 Myalgia
 Persistent constitutional
 Throbbing headache in the frontal
prodromal symptoms
area with PRS of 5/10
 Negates weight loss
 Slightly icteric sclera
 Has melena instead of clay
 High grade fever 38-39°C
colored stools
 Current temperature of 38°C
 No liver tenderness
(Febrile)
 Epigastric pain instead of RUQ
 Tea-colored urine
pain
 Enlarged liver (palpable 3cm
below subcostal margin; 14 cm
RMCL)
 Fond of eating street foods
 LEPTOSPIROSIS
 Moderate to high grade fever of 38-
39°C
 Myalgia
 Frontal throbbing headache PRS 5/10
 Weakness and fatigue
 No exposure to flood
 Epigastric pain PRS of 8/10 without
radiation  No known exposure to rodents
 Nausea  No chills
 Vomiting of 3 episodes at about 100 ml  No jaundice
per episode  No red eyes
 Diarrhea (5 times per day)  Rash usually found over the legs
 Decreased urinary output (50-100ml)
from day 4-6, hemorrhagic
 Body malaise
 Conjuntival suffusion  No lymphadenopathy
 With tenderness on the epigastric  No muscle rigidity
region upon palpation
 Has melena
 Slightly icteric sclera
 Liver span of 14 cm suggesting
hepatomegaly
DIAGNOSTICS
 WORK-UP FOR TYPHOID FEVER
TEST INTERPRETATION
Culture • standard for diagnosis of typhoid fever has long been culture isolation of the organism. Cultures are widely
considered 100% specific.
• Blood, intestinal secretions (vomitus or duodenal aspirate), and stool culture results are positive for S typhi
in approximately 85%-90% of patients with typhoid fever who present within the first week of onset. They
decline to 20%-30% later in the disease course. In particular, stool culture may be positive for S typhi several
days after ingestion of the bacteria secondary to inflammation of the intraluminal dendritic cells. Later in
the illness, stool culture results are positive because of bacteria shed through the gallbladder.
Specific serologic • Widal test used to measure agglutinating antibodies against H and O antigens of S typhi. Neither sensitive
tests nor specific,
• Indirect hemagglutination, indirect fluorescent Vi antibody, and indirect enzyme-linked immunosorbent
assay (ELISA) for immunoglobulin M (IgM) and IgG antibodies to S typhi polysaccharide, as well as
monoclonal antibodies against S typhi flagellin,

CBC • are moderately anemic, have an elevated erythrocyte sedimentation rate (ESR), thrombocytopenia, and
relative lymphopenia.

Coagulation studies • slightly elevated prothrombin time (PT) and activated partial thromboplastin time (aPTT) and decreased
fibrinogen levels.
• Circulating fibrin degradation products commonly rise to levels seen in subclinical disseminated
intravascular coagulation (DIC).
 TEST INTERPRETATION
Liver function test • Liver transaminase and serum bilirubin values usually rise to twice the reference range.
• serum alanine amino transferase (ALT)–to–lactate dehydrogenase (LDH) ratio of more than 9:1 appears
to be helpful in distinguishing typhoid from viral hepatitis. A ratio of greater than 9:1 supports a diagnosis
of acute viral hepatitis, while ratio of less than 9:1 supports typhoid hepatitis
Electrolytes • Mild hyponatremia and hypokalemia are common
C-reactive protein • elevated C-reactive protein levels (>40 mg/L)
• combination of absolute eosinopenia, elevated aspartate aminotransferase levels, and elevated C-
reactive protein levels (>40 mg/L) have been shown to be a positive predictor of S typhi and S paratyphi
bacteremia.
Imaging Studies • Radiography: Radiography of the kidneys, ureters, and bladder (KUB) is useful if bowel perforation
(symptomatic or asymptomatic) is suspected.
• CT scanning and MRI: These studies may be warranted to investigate for abscesses in the liver or bones,
among other sites.
Histologic Findings • hallmark histologic finding in typhoid fever is infiltration of tissues by macrophages (typhoid cells) that
contain bacteria, erythrocytes, and degenerated lymphocytes. Aggregates of these macrophages are
called typhoid nodules,
 TO RULE-OUT THE DIFFERENTIAL DIAGNOSIS

TEST INTERPRETATION
Imaging studies • Ultrasound scanning is the investigation of choice in patients suspected of having acute
cholecystitis. Sonograms typically show pericholecystic fluid (fluid around the gall bladder),
distended gall bladder, edematous gallbladder wall, and gall stones.
• CT criteria for appendicitis include an enlarged appendix (greater than 6 mm in diameter),
appendiceal wall thickening (greater than 2 mm), peri-appendiceal fat stranding, appendiceal wall
enhancement, the presence of appendicolith (approximately 25% of patients). In ultrasound
demonstrates a mildly dilated appendix with preservation of the expected multilayered appearance
of bowel.
• most amebic liver abscesses will be found in the right lobe. Imaging modalities include ultrasound
which might show around, hypo-echoic mass, CT scan can identify a low-density mass with peripheral
enhancing rim, and MRI typically shows low signal intensity on the T1-weighted image and high signal
intensity on T2-weighted image, which are fairly sensitive but without absolute specificity for an
amebic liver abscess.
 TEST INTERPRETATION
CBC • Elevated white blood cells (WBC) with or without a left shift is classically present, but up to one-third
of patients with acute appendicitis will present with a normal WBC count.
• amebic liver abscess will typically have evidence of leukocytosis

Liver Function • amebic liver abscess will typically have evidence of elevated serum
Tests transaminases, alkaline phosphatase
TREATMENT AND
MANAGEMENT
 Administration of appropriate antibiotic therapy prevents severe
complications of enteric fever and results in a case–fatality rate of <1%
The initial choice of antibiotics depends on the susceptibility of the S.
Typhi and S. Paratyphi strains.
 Drug-susceptible typhoid fever treatment:- Fluoroquinolones are the
most effective class of agents [ciprofloxacin – (500 mg bid (PO) or 400
mg q12h (IV) for 5-7 days)].
[Fluoroquinolones should no longer be used for treatment of enteric fever with
patient who are infected with DSC strains and ciprofloxacin-resistant]

• Patients infected with DSC strains of S. Typhi or S. Paratyphi should be treated

with ceftriaxone or azithromycin.
• Patients infected with MDR enteric fever effectively treated with Ceftriaxone,
cefotaxime, and (oral) cefixime, [also for DSC and fluoroquinolone-resistant
strains]
 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 a fluoroquinolone, depending
on the susceptibility profile (at least 10 days or for 5 days after fever
resolution).
 PREVENTION AND CONTROL
Two typhoid vaccines are commercially available:

• Ty21a, an oral live attenuated S. Typhi vaccine (given on days 1, 3, 5, and 7, with
revaccination with a full 4-dose series every 5 years)
• Vi CPS, a parenteral vaccine consisting of purified Vi-polysaccharide from the
bacterial capsule (given in a single dose, with a booster every 2 years).

[Typhoid vaccine is not required for international travel, but it is recommended for
traveller to areas where there is a moderate to high risk of exposure]

• Avoiding food that is raw or undercooked

• Drinking only bottled water or water that has been boiled
• Thoroughly washing your hands each time before eating
• Avoiding raw fruits and vegetables that cannot be peeled.
• Avoiding eating foods and beverages purchased from street vendors.