Case No 1

62-year old patient admitted to hospital with three-day patient history of vomiting and profuse watery diarrhea

Medical History

Present Illness: 3 days ago about 2 hors after dinner in Trenčín (Slovakia) restaurant got stomach cramps, profuse diarrhea, vomiting, did not took his temperature, did not go to doctor because he has insurance in the Czech Republic. did not drink due to vomiting and diarrhea, today he returned to CR, during the whole way back from Slovakia he vomited, He had chill and shivering, feels very tired, diarrhea persisted – massive watery green stools. Driven to the hospital by paramedic, during transport lucide, cooperating. BP 90/60. At the admission room, he was not able to stand, the stomach cramps were not prominent. No drinking a day ago, he urinated for the last time yesterday. His wife called during admission and said that she drained tea from vacuum bottle, where were also pieces of glass. Denied by the patient, he did not drink tea from the vacuum bottle at all.

FHx: Father died aged 88 years of stroke, father and grand-father had problems with prostate since 75 years, mother died of pulmonary embolism after fracture of the leg at the age of 68.
EHx: Health problems started in Slovakia, a day before, when he had a dinner in the restaurant in Bratislava – soup and sausage, during the day he had two ice creams, and grapes, bought in the grocery and rinsed with utility water, then in Trenčín he had a chicken roll for dinner.
WSHx: Pensioner for 2 months, in former times he worked as technician
PMHx: common child diseases
PSHx: appendectomy, laparotomy for suspicion of post-traumatic hemorrhage into abdominal cavity
Allergies: NKDA
Medications: None
Abuse: He drinks about 7 dl bottle of wine daily, non-smoker (smokes about 5 cigars a year)

Physical Examination

Vital Signs (Vitals): T 37.5 °C, P 96/min., regular, TK 90/60, satO₂ NA
Height/ Weight: h 175 cm, m 82 kg. BMI 27 (Overweight)
General: Patient lying weakened in bed, aphonic.
Psychiatry: Oriented to person, place, and time
Skin: Pale, no rash or lesions, turgor (skin elasticity) reduced.
Head: NCAT (normocephalic atraumatic)
Eyes: PERRL, EOMI. No scleral icterus.
ENT: No nasal d/c. MMM. Oropharynx clear with no lesions/erythema. Drier coated tongue.
Neck: Supple, without thyromegaly. No carotid bruits.
Lymph Nodes: No cervical, axillar or inguinal LAD.
Lungs: CTAB (clear to auscultation bilaterally)
Cardiovascular: Pulse 96', regular. Heart sounds, S1 and S2 normal without murmur. Pulses 2+ equal on both sides, fingertips cooler.
Abdomen: flat, with upper midline laparotomy scar, soft, non-tender, non-distended. No masses. No hepatosplenomegaly. No rebound/guarding. Hyperactive bowell sounds
Rectal: Rectal exam not performed.
Extremities: No bilateral cyanosis, clubbing or edema. Calves not tender to palpation. No petechiae. Capillary refill <3 min.
Musculo-skeletal: Joints flexible without erythema.
Neurological: Cranial nerves grossly intact. No decrease in strength. No shakes. DTR 2+ symmetrical. Normal sensation throughout. Meningeal signs negative.

Laboratory Tests

Hematological examinations:

Blood count: leu 10,2, ery 6,43, Hgb 189, hct 0,552, MCV 85,9, PLT 173
Diff.: seg 80 lymfo 9 mono 8 eo 2 baso 1
Hemokoagulations: PT-time: 13.4 s PT-R: 1.00 1/1, INR: 1.01 1/1, PT-N: 13.4 s, aptt-p: 33.1 s, aptt-R: 0.95 1/1, aptt-n: 34.2 s, DDi: ! 2.75 mg/l, FEU DDimery: pozitivní
Blood group: A1 Rh+

Biochemical tests:

Urine chemistry: U-pH: 5,5 glucose +1, protein +1, blood +1
Plasma and serum chemistry: glucose 9,4, urea 31,3, creat 538, Na 130, K 3,7, Cl 91, blr 13, AST 1,1, ALT 1,08, ALP 0,69, GMT, 0,46, AMS 0,79, prealbumin 0,21, cholesterol 3,87, TG 1,96, CRP 177
Astrup: pH 7,469, pCO2 4.2, BE +1, StB 25,1, ActB 23,2

Microbiological tests:

Urine culture: - urinated urine mid-stream sample: aerobe culture non-selective - primary culture sterile, further cultivation Staphylococcus epidermidis
Blood culture BACTEC: from venipuncture: AE blood culture bottle BD BACTEC PLUS+Aerobic/F / negative, BACTEC / ANA blood culture bottle BD BACTEC Lytic 10 Anaerobic /F /: negative
Stool - rectal swab, smear primary culture for enteropathogens: Salmonella group D
antibiogram: amoxicillin/clav. C, ampicillin C, cephalotin C, chloramphenicol C, colistin C, trimetoprim/sulf. C, gentamicin C, ofloxacin C, tetracyclin C

Mikrobiologic examinations v dalším sledu:

Serology - Widal reaction (anti-Salmonella antibodies):
anti 0 9,12 (S. gr D) negative,
anti 0 4,5,12 (S. gr B) negative,
anti H d (S. Typhi) negative,
anti H b (S. Paratyphi B) negative,
anti H i (S. Typhimurium) negative,
anti H gm (S. Enteritidis) negative
Syphilis serology: RPR test negative; TPPA: negative
HIV serology: HIV-1,2 negative, p24 negative
Serologic markers of viral hepatitis: anti-HAV total neg., anti-HAV IgM neg., HBsAg neg., IgM anti-HBc neg., anti-HBs negat., anti-HCV neg.

Imaging Studies and Other Paraclinical Examinations

Hematological examinations:

Chest X-ray: Adequate finding on thoracic organs.
Abdomen ultrasonography: Normal sonographic finding on all organs including kidneys, gall bladder not differentiated.

Electrophysiologic examination:

ECG: sinus rhythm with rate at 70/min., PQ 0,16, QRS 0,11, fine brakes of QRS complex, intermediate axis, transition zone in V4, flat T into limb leads. No hypertrophy, no evidence of ischemia. No evidence of right heart strain.

Diagnostic Conclusion

Make a diagnosis.

Therapy

Propose therapy, give doses and composition of rehydrating solutions.

Task

Define the conditions for the use of antibiotics in salmonellosis.