INFECTIOUS DISEASE

NAME: Silas Helao

GROUP: 82

PATIENT CASE REPORT

I. GENERAL BIOGRAPHICAL PARTICULARS

Patient full name: Habybulva

Age: 41 years old
Marital status: Married and has 6 kids
Professional: Business man

Clinical: S. aureus, emetic syndrome acute form, severe course and complicated by dehydration.

II. PATIENT’S COMPALINTS AT THE ONSET OF THE DISEASE

Abdominal discomfort and pain, nausea and vomiting too much, high body temperature and
weakness.

III. HISTORY OF PRESENT ILLNESS

The patient is a 41 year old business man, married and has 6 kids. He normally travels to
Kazakhstan to sell his merchandise. He lives in Moscow, but resides in country side. Previous day
ago (Sunday and today is Monday), the patient fell sick. He vomited 20 times. The onset of
vomiting was acute and he links to after he ate SHAWARMA (which is mostly a street food). The
abdomen was paining due to too much vomiting. The onset of the disease was acute. There was
no diarrhea. Increased body temp. HR bit high, AP normal, RR 19 bpm. The family members
called the ambulance which brought him to the hospital and was hospitalized. He had not been
at Kazakhstan for 2 months prior to his admission to the hospital.

IV. EPIDEMIOLOGICAL HISTORY (The source of trouble)

The patient attributes vomiting to after he has eaten SHAWARMA, which was maybe bought,
while he was without family members. If it was eaten in house, all the family members would
have been also experiencing the same problem.

V. LIFE HISTORY (PAST MEDICAL HISTORY)

The patient do not drinks and smokes as he is a devoted Muslim. He is an entrepreneur who
sells only things, hence no likely hazards due to occupational purposes. He live with his 6 kids
and wife together. He emphasized the house is of moderate standard.

The patient has not been on any medical treatments such as HIV, DM, and Hypertension etc. He
has no allergic recorded. He however, went via surgery 20 years back, for Appendicitis.

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 VI. GENERAL EXAMINATION OF THE PATIENT
At present, the patient’s condition is stable and lying at supine position and is on the drip.
The skin is clear with no patches, moderate dry with turgor. Visible mucous membranes are not
hyperemic, jaundiced nor dry. Folding of skin takes long to unfold. It is cold.

Lymphatic system: there is no lymphadenopathy in cervical, under mandible, supraclavicular

and axillary regions. Femoral region was not checked.

Respiratory system: normal breathing sounds, RR increased and there is no crepitation, rales,
wheezing or musical sounds auscultated.

CVS: normal heart sounds, no cardiac murmurs, AP not done, likely normal, pulse 99 bpm.
Digestive System: the tongue is moist and coated by whiteness. There was no pain by superficial
palpation unlike on deep palpation, the patient is complaining of moderate pain. There was no
organomegally elicited by both palpations-no splenohepatomegaly. The patient did not pass
stool since yesterday. No paldrakas’s sign.
Urogenital system: partenansky sign not done. Patient passed urine today which looks
concentrated, he said.
Nervous system: the patient is alert, communicating but speech a bit slow, oriented in time and
place, but at admission, his speech was a bit slow, but today is a bit improved. No sleeping
disturbance.

VII. PROVISIONAL (suggested) DIAGNOSIS AND SUBSTANTIATION THE DIAGNOSIS

Food poisoning (probably Staphylococcus species) acute form, severe complicated with
dehydration.

This is because of the patient is c/o: abdominal pain and cramp, increased body temperature,
too much (vomiting 20 times in the first day and 4 times in the second day) and weakness.

Clinical course: severe, the patient is exhibiting signs of too much water loss from the body
(dehydrated); he is just sleeping and his speech is slow.

Acute onset of the disease within 12 hours with Normal AP, no diarrhea and no rash.
Basic syndromes: intoxication (nausea and too much vomiting), and severe dehydration.
Epidemiological anamnesis the patient ate food bought from street.

VIII. DIFFERENTIAL DIAGNOSIS

Shigelloses, Yersioniosis, cholera, Viral Gastroenteritis, Opisthorchis, and Botulism.

IX. PLAN OF LAB DIAGONOSTICS

1. Lab diagnostic
Serological test of feces, vomitus and suspicious product, to locate the causative agent’s
enterotoxin. No need to culture the organism.

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 X. CLINICAL (final) DIAGNOSTICS AND SUBSTATIANTION OF DIAGNOSIS
Staphylococcus aureus, emetic syndrome acute form, severe complicated with dehydration,
because of patient ate a contaminated food, intoxication syndrome (nausea and vomiting 20
tome in a day), Mild decrease of skin turgor. Also, if lab findings were provided, they will show
the presence of the bacteria enterotoxin by serological test.

XI. TREATMENT
Hospitalization
Supportive care
Rehydration solution with Ringer Lactate 100ml/kg/hour IV.
Quartersalts IV to correct electrolyte
Antimicrobials: fluoroquinolones or ceftriaxone 100mg/kg/day for 2 divided doses for 5 days.
(Less antimicrobial indicated.)

After volume returns to normal and electrolytes normalize, switch the patient to oral
rehydration treatment, which is the second therapy---maintenance therapy
Continue antibiotic if need be.

XII. EPICRISIS
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XIII. PROGNOSIS
The patient has no oncological or other infectious diseases. He is middle aged. He has no HIV,
DM, Hypertension, nor on any treatment. He does not smokes and drinks alcohol. He is
responding well to medication with 24 hours from the time of admission.

Taking all those factors and put them together, the prognosis is good.

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