I.

INTRODUCTION

Food and water are one of our primary necessities for they play a major role in our
everyday activities. They provide nutrients and electrolytes that are necessary for our everyday
living. Furthermore, these foods and water must be prepared clean and free from microorganism
because any presence of microorganism may cause bad effect in an individual systems.
Typhoid fever, also known as enteric fever, Salmonella typhi or commonly just
typhoid, is an illness. Common worldwide, it is transmitted by the ingestion of food or water
contaminated with feces from an infected person. The bacteria then perforate through the
intestinal wall and are phagocytosed by macrophages. Salmonella typhi then alters its structure to
resist destruction and allow them to exist within the macrophage. The organism is then spread
via the lymphatics while inside the macrophages. This gives them access to the
reticuloendothelial system and then to the different organs throughout the body. The organism is
a Gram-negative short bacillus that is motile due to its peritrichous flagella. The bacteria grows
best at 37°C/99°F – human body temperature.
Typhoid fever is characterized by a sustained fever as high as 40°C (104°F),
profuse sweating, gastroenteritis, and nonbloody diarrhea. Less commonly a rash of flat, rose-
colored spots may appear.
Classically, the course of untreated typhoid fever is divided into four individual
stages, each lasting approximately one week. In the first week, there is a slowly rising
temperature with relative bradycardia, malaise, headache and cough. A bloody nose (epistaxis) is
seen in a quarter of cases and abdominal pain is also possible. There is leukopenia, a decrease in
the number of circulating white blood cells, with eosinopenia and relative lymphocytosis, a
positive diazo reaction and blood cultures are positive for Salmonella typhi or paratyphi. The
classic Widal test is negative in the first week.
In the second week of the infection, the patient lies prostrated with high fever in
plateau around 40°C (104°F) and bradycardia (Sphygmo-thermic dissociation), classically with a
dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This delirium
gives to typhoid the nickname of "nervous fever". Rose spots appear on the lower chest and
abdomen in around 1/3 patients. There are rhonchi in lung bases. The abdomen is distended and
painful in the right lower quadrant where borborygmi can be heard. Diarrhea can occur in this
stage: six to eight stools in a day, green with a characteristic smell, comparable to pea-soup.
However, constipation is also frequent. The spleen and liver are enlarged (hepatosplenomegaly)
and tender and there is elevation of liver transaminases. The Widal reaction is strongly positive
with antiO and antiH antibodies. Blood cultures are sometimes still positive at this stage. (The
major symptom of this fever is the fever usually rises in the afternoon up to the first and second
week.)
In the third week of typhoid fever a number of complications can occur.
Diagnosis 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 blood cultures.
The term "enteric fever" is a collective term that refers to typhoid and paratyphoid.
Flying insects feeding on feces may occasionally transfer the bacteria through poor
hygiene habits and public sanitation conditions. Public education campaigns encouraging people
to wash their hands after defecating and before handling food are an important component in
controlling spread of the disease. According to statistics from the United States Center for
Disease Control, the chlorination of drinking water has led to dramatic decreases in the
transmission of typhoid fever in the U.S.
A person may become an asymptomatic carrier of typhoid fever, suffering no
symptoms, but capable of infecting others. According to the Centers for Disease Control
approximately 5% of people who contract typhoid continue to carry the disease after they
recover. The most famous asymptomatic carrier was Mary Mallon (commonly known as
"Typhoid Mary"), a young cook who was responsible for infecting at least 53 people with
typhoid, three of whom died from the disease. Mallon was the first apparently perfectly healthy
person known to be responsible for an "epidemic".
Many carriers of typhoid were locked into an isolation ward never to be released in
order to prevent further typhoid cases. These people often deteriorated mentally, driven mad by
the conditions they lived in.
II. PERSONAL DATA

Name: Mr. AM T. A

Age: 6 years old

Gender: Male

Address: M.H. Del Pilar, Cupang proper, Bataan

Birth Date: June 14, 2003

Place of Birth: Balanga, Bataan

Civil Status: Single

Nationality: Filipino

Religion: Christian

Chief Complaint: High Grade Fever

Date of Admission: July 23, 2009

Time of Admission: 11:03 PM

Attending Physician: Dr. R. Escudero

Final Diagnosis: Typhoid Fever; Acute Bronchitis

 III.Medical History

a. Past Medical History

Mr. AM T. A is fully vaccinated. He received a dose of BCG and Measles

vaccination and three doses of DPT, OPV, and Hepa B. Also, he had the vaccine for
typhoid fever. When he was 10 months old, he was admitted at Women's Hospital because
of high grade fever. After days of spending in the hospital, his physicians told his mother
that they may go home. A day before discharge he experienced vomiting and frequent
bowel movement with liquid in consistency. They found out that he had gastroenteritis.
Mr. AM T. A's usually experience colds, cough and fever. During these
situations, his mother never tried to administer OTC drugs rather going to their physician
immediately.
He has no allergies on food and he's not fond on buying and eating street
foods like fish ball, squid ball, etc.

b. Present Medical History

On July 23, 2009, at exactly 11:03 PM, Mr. AM. T. A was admitted at
Bataan St. Joseph Hospital due to high grade fever. He was diagnosed to have typhoid
fever. His mother questioned his situation for he already had vaccine against typhoid fever
and the doctor told her that its normal. He was also diagnosed to have acute bronchitis.

c. Family Medical History

Upon interview, it revealed that his mother is currently diagnosed with

diabetes. His grandfather on his mother side is hypertensive. Almost his relatives on his
mother side are with asthma. His brother is diagnosed with sepsis at birth last April 2009.
Developmental Milestones

Erik Erickson developed a theory called “Theory of psychosocial

development” in which it stresses the importance of our culture as well as our society
in the development of an individual in his personality. He divides his theory in 8
stages in which only five of these eight are applicable to childhood.
At Mr. AM T. A's case, he falls on the 4th stage of Erickson's theory, the
“Industry versus Inferiority”. This stage tends to reveal that the child belongs to this
is enjoying doing something with his/her friends. Also this stage is the time for
developing and overcoming in experiencing the said low esteem.
Mr. AM T. A is studying at Cupang Elementary School and is currently
Grade I. In his case he tends to create a good relationship with his classmates. In his
diet, he doesn’t usually eat street foods because he was afraid of doing so. But then
his schoolmates tend to encourage him, and try to eat a certain dish. Even though he
knows that eating that food will cause harm; he followed his schoolmate and ate that
food.
Because of that, he and his classmate experienced and admitted to
hospital with same diagnosis. They were 38 in a class and 15 of them are diagnosed.
IV. Activities of Daily Living

Activity Before Hospitalization During Hospitalization

Diet >Usual diet child has >restriction to fatty foods

Almost whole day of

11:00pm – 06:00am
Rest sleeping as a way of resolving
7 hrs of sleep with afternoon nap
boredom

Elimination
1. Urination 5-8 times a day 5-8 times a day
2. Defecation once a day once a day

Hygiene
1. Tooth brushing 3 times a day 3 times a day
2. Bathing once a day >tepid sponge bath
 VI. ANATOMY AND PHYSIOLOGY

GASTROINTESTINAL TRACT (GI TRACT) / DIGESTIVE TRACT

♥ the system of organs within multicellular organisms that takes in food, digests it to extract
energy and nutrients, and expels the remaining matter.

♥ Ingested food is converted into a form that can be absorbed into the circulatory system for
distribution to and utilization by the various tissues of the body.

FUNCTIONS

▪ingestion

-is the consumption of a substance by an organism. In animals, it normally is

accomplished by taking in the substance through the mouth into the gastrointestinal tract,
such as through eating or drinking. In single-celled organisms, ingestion can take place
through taking the substance through the wall. Besides nutritional items, other substances
which may be ingested include medications, recreational drugs, and substances
considered inedible such as foreign bodies or excrement. Ingestion is a common route
taken by pathogenic organisms and poisons entering the body. Ingestion can also refer to
a mechanism picking up something and making it enter an internal hollow of that
mechanism.

▪ digestion

-is the mechanical and chemical breaking down of food into smaller components,
to a form that can be absorbed, for instance, by a blood stream. Digestion is a form of
catabolism.

In mammals, food enters the mouth, being chewed by teeth, and broken down by
the saliva from the salivary glands. Then it travels down the esophagus into the stomach,
where acid begins physical break down of some food, and chemical alteration of some.
The "leftovers" go through the small intestine, through the large intestine, and are
excreted during defecation
 ▪ absorption

The digested food can now pass into the blood vessels in the wall of the intestine through
the process known as absorption. The small intestine is the site where most of the nutrients from
ingested food are absorbed. The inner wall, or mucosa, of the small intestine is lined with simple
columnar epithelial tissue. Structurally, the mucosa is covered in wrinkles or folds called plicae
circulares, which are considered permanent features in the wall of the organ. They are distinct
from rugae which are considered non-permanent or temporary allowing for distention and
contraction. From the plicae circulares project microscopic finger-like pieces of tissue called villi
(Latin for "shaggy hair"). The individual epithelial cells also have finger-like projections known
as microvilli. The function of the plicae circulares, the villi and the microvilli is to increase the
amount of surface area available for the absorption of nutrients.

Each villus has a network of capillaries and fine lymphatic vessels called lacteals close to
its surface. The epithelial cells of the villi transport nutrients from the lumen of the intestine into
these capillaries (amino acids and carbohydrates) and lacteals (lipids). The absorbed substances
are transported via the blood vessels to different organs of the body where they are used to build
complex substances such as the proteins required by our body. This is called assimilation. The
food that remains undigested and unabsorbed passes into the large intestine.

▪ defecation

-is the final act of digestion by which organisms eliminate solid, semisolid or liquid waste
material (feces) from the digestive tract via the anus. Humans usually defecate from three times a
week, up to three times a day.[1] Waves of muscular contraction known as peristalsis in the walls
of the colon move fecal matter through the digestive tract towards the rectum. Undigested food
may also be expelled this way; this process is called egestion.
 Upper gastrointestinal tract

The upper gastrointestinal tract consists of the mouth, pharynx, esophagus, stomach, and
duodenum proximal to the ligament of the buccal cavity, which contains the openings of the
salivary glands; the tongue; and the teeth.

oral cavity
-anterior cavity of the digestive tract enabling ingestion of food; it also aids in breathing.
salivary glands
-each of the three pairs of organs secreting a liquid (saliva) that contains a digestive
enzyme; it is used to moisten food to facilitate its ingestion.
tongue
-flexible muscular structure of the oral cavity; it helps in tasting, masticating and
ingesting food, and also facilitates speech.
pharynx
-muscular membranous channel connecting the nasal cavity to the larynx and the oral
cavity to the esophagus; it enables breathing, ingestion of food and speech.
esophagus
-muscular membranous channel of the anterior section of the digestive tract; it allows
food to reach the stomach.
stomach
-dilated section of the digestive tract; it stores, stirs and mixes food with the gastric juices
it secretes before emptying it into the duodenum.

Lower gastrointestinal tract

The lower gastrointestinal tract comprises the most of the intestines and the anus.
liver
-viscera secreting substances, including bile, that help digestion and break up certain
toxins contained in the blood.
gallbladder
-small reservoir where bile secreted by the liver gathers before emptying into the
 duodenum during digestion. Bile helps in the digestion of fatty substances.
vermiform appendix
-tubular extension of the cecum; this appendage is occasionally the site of appendicitis, a
severe inflammation.
pancreas
-digestive gland connected to the duodenum; produces secretions and hormones
(especially insulin).
small intestine
-narrow section of the digestive tract, about 20 ft long, between the stomach and cecum,
where a part of digestion and food absorption occurs.
ileum
-terminal part of the small intestine between the jejunum and cecum.
jejunum
-middle section of the small intestine between the duodenum and the ileum; the majority of
nutrients are absorbed here
duodenum
-anterior section of the small intestine; secretions from the liver and pancreas, as well as food
partially digested in the stomach, empty into it.
large intestine
-last wide section of the digestive tract, about 5 ft long, where the final stage of digestion and
elimination of waste occurs; it includes the colon and the rectum.
cecum
-anterior part of the large intestine; it receives food particles from the ileum.
ascending colon
-first segment of the colon; it absorbs water from food residue before it is excreted.
descending colon
-third segment of the colon; it stores waste before it is eliminated
transverse colon
-second segment of the colon (middle section of the large intestine). The right colon (the
ascending colon plus half the transverse colon) mainly enables absorption of water.
sigmoid colon
-fourth segment of the colon; it carries waste to the rectum.
rectum
-terminal section of the large intestine preceding the anus.
sphincter muscle of anus
-muscle ensuring the contraction and relaxation of the anus and enabling defecation.
anus
-terminal orifice of the digestive tube controlled by a sphincter enabling ejection of fecal
matter.
VII.PATHOPHYSIOLOGY

Ingestion of food or
water
with feces (fecal-oral
route)

Salmonella typhi

Survives the acidity of

the stomach

intestine

Payer's patches

macrophages

Survive within the

macrophages

Reticuloendothelial
system

liver spleen gallbladder Bone

marrow

Lymphatic channels

multiply in
bloodstream
 VIII.PHYSICAL ASSESSMENT

1. Vital Signs

VITAL SIGNS FINDINGS ANALYSIS

Temperatue 38.9 C Febrile
Pulse rate 88bpm Normal
Respiratory Rate 28bpm Normal

2. General Survey

CRITERIA FINDINGS ANALYSIS

Anthropometric Measurements Height: 3'9” Overweight

Weight: 45kgs

Level of Conciousness Conscious Awake and responsive

Coherence Coherent to stimuli

Orientation Oriented to time and place

Not confused with time and date
Development Appears older than age Appears older than age
Nutririon Weighs is not normal with her
height and age Overweight

3. Skin

CRITERIA FINDINGS ANALYSIS

General Color (-) jaundice Normal
Face Flushed face Due to high grade fever
Texture Smooth Good hygiene
Turgor Good
Moisture Moistened
 4. Head

CRITERIA FINDINGS ANALYSIS

Configuration Normocephalic Normal
Fontanelles Closed Normal
Hair Smooth and shiny Normal
Scalp Without dandruff Normal
Sclera Anicteric Normal

5. Ears

CRITERIA FINDINGS ANALYSIS

External Pinnae Normoset Both ears are present
Symmetrical with no gross Both ears equal
abnormalities and tenderness

External Canal Cerumen not impacted with clean Evidence of good hygiene

Gross Hearing Symmetrical sense of hearing in Normal

both ears

6. Nose

CRITERIA FINDINGS ANALYSIS

Nasolabia Fold Symmetrical Normal anatomical finding
Septum Midline Normal anatomical finding
Sinuses Non-tender Normal
 7. Mouth

CRITERIA FINDINGS ANALYSIS

Lips Dry Due to decrease fluid intake
Tongue Midline Normal anatomical finding
Teeth Complete Normal
Speech Intact Able to speak clearly

8. Neck

CRITERIA FINDINGS ANALYSIS

Trachea Midline Normal anatomical finding

9. Abdomen

CRITERIA FINDINGS ANALYSIS

General Normal Normal antomical finding
Palpation Non-tender Normal

10. Back and Extremeties

CRITERIA FINDINGS ANALYSIS

EXTREMETIES:
Peripheral Puse Normal Normal
Range of Motion Normal ROM
Muscle Tone and Strength Equal
Spine Midline Normal
 IX. LABORATORY FINDINGS / DIAGNOSTIC PROCEDURE

Hematology Result Normal Interpretation

OLD UNIT SI UNIT OLD UNIT SI UNIT

12-15 gm% F 120-150 g/l F

Hemoglobin 15.0 gm% 150 g/l Normal
14-17 gm% M 140-170 g/l M

37-47 vol% F 0.37-47 F

Hematocrit 45 vol% 0.45 Increased
40-50 vol% M 0.40-0.50 M

5,000-
WBC Count 6,300/mm3 6.3x10 9/l 5-10x 10 9/l Normal
10,000/mm3

Segmenters 60% 0.60 55-65% 0.55-0.65 Normal

Lymphocytes 39% 0.39 25-35% 0.25-0.35 Increased

Eosinophils 01% 0.01% 2-4% 0.02-0.04 Decreased

150,000-
Platelet Count 318,000/mm3 318x10 9/l 150-400x 10 9/l Normal
400,000mm3
 Urinalysis Result Normal
Color Yellow clear to a dark amber
Appearance Clear clear
Reaction Alkaline neutral
pH 7.5 pH 6.5 – 7.4 pH
Specific Gravity 1.010 1.003–1.035 (g·cm−3)
Pus cell 2-4 /hpf <4
RBC 0-2 /hpf
Epithelial cell rare
Crystal a, phosphate-rare
Sugar negative Negative (absent)
Albumin negative negative
Typhidot Result Interpretation
IgM Positive Acute typhoid fever

IgG Positive (in the middle stage of

infection)