Case 18 questions 1-12

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Question 1

A patient has just returned from a trip to Singapore with work. He has fever, blanching rash and muscle ache. He rubs his eye during the consultation which results in pain. What is the most likely causative agent?

  1. Plasmodium ovale
  2. Leishmania donovani
  3. Dengue virus
  4. Rhinovirus
  5. Cryptosporidium

The correct answer is option c, dengue virus

Dengue virus- Correct, this patient is presenting with signs of dengue virus. Travel to endemic region as well as blanching rash points you in the direction of DV
Plasmodium ovale- Wrong, P. ovale would present with fevers and rigours.
Leishmania donovani- Wrong, leishmaniasis isn’t endemic to South East Asia.
Rhinovirus- Wrong, as common as this is, his travel to Singapore and blanching rash point you towards DV.
Cryptosporidium- Wrong, cryptosporidium is a fungal infection which typically presents with diarrhoea.

Question 2

You’re the FY1 covering A&E and you’re asked to see a patient complaining of stomach pain and persistent vomiting. The patient is wearing a guayabera (common shirt worn in countries in South America, Puerto Rico for example). He’s come to visit his daughter studying at Newcastle university.

Upon further examination he has a high fever, a positive tourniquet test and 3cm hepatomegaly. You suspect a case of dengue. How would you treat this patient?

  1. Send home with fluid balance chart and to come back if worsens
  2. Send home to rest and take ibuprofen for pain
  3. Admit immediately and send to ICU
  4. Admit and monitor, giving IV fluids
  5. Admit and give IV artemisinin combination therapy (ACT)

The correct answer is option d, Admit and monitor, giving IV fluids

3. Admit and monitor, giving IV fluids- Correct, he has dengue with warning signs, so taking him in and giving fluids would be the most appropriate management at this point.
1. Send home with fluid balance chart and to come back if worsens- Wrong, this patient has dengue with warning signs. He could progress into DHF so sending him home wouldn’t be the best.
2. Send home to rest and take ibuprofen for pain- Wrong, same for 1, and if you give him NSAIDs his bleeding risk rises dramatically.
3. Admit immediately and send to ICU- Wrong, this is the management of DHF, at this point this would be too far.
5. Admit and give IV artemisinin combination therapy (ACT)- Wrong, this is the treatment of malaria.

Question 3

A 45 year old male presents to A+E with a 2-day history of fatigue, malaise, diarrhoea and arthralgia. He also reports his urine has been dark in color. He has no past medical history and takes no medications. He returned from a holiday in Morrocco 4 weeks ago but has no other significant travel history.

On examination, he is hemodynamically stable, alert and orientated. Observations are in normal range. However, he is icteric and exhibits tenderness in the right upper quadrant with hepatomegaly felt on deep palpation.

Which investigation is most likely to reveal the underlying diagnosis?

  1. Malaria thin and thick film
  2. CMV IgG and IgM
  3. Hepatitis A IgG and IgM
  4. JEV IgG and IgM
  5. CSF tap

The correct answer is option c, Hepatitis A IgG and IgM

Hepatitis A IgG and IgM- Correct, this patient has come back from an endemic region and is experiencing symptoms of acute hepatitis.
Malaria thin and thick film- Wrong, malaria doesn’t usually present with diarrhoea and dark urine
CMV IgG and IgM- Wrong, this patient isn’t presenting with typical CMV
JEV IgG and IgM- Wrong, JEV presents with headache and mild fever, and is mainly found in Asia.
CSF tap- Wrong, this might be abnormal if they’ve progressed to acute liver failure, but it doesn’t point towards a diagnosis.

Question 4

A 22 year old student comes back from a elective placement in Taiwan complaining of high fever, stick neck and headache. He said he lied about his vaccinations because he’s scared of needles and starts visibly shaking and passes out when the phleb comes to take a sample.

What would be the best investigation to diagnose his condition?

  1. Malaria thick and thin film
  2. Serum JEV IgM
  3. Liber biopsy for hypnozoites
  4. Stool sample and culture
  5. Serum dengue IgM

The correct answer is option b, Serum JEV IgM

Serum JEV IgM- Correct, this patient is presenting with a severe acute case of JEV characterised by headache, stuff neck and seizure.
Malaria thick and thin film- Wrong, this patient is present with a severe case of JEV. Malaria doesn’t present with stiff neck unless it’s at the cerebral stage which is not in this time zone.
Liber biopsy for hypnozoites- Wrong, this isn’t routinely done.
Stool sample and culture- Wrong, lack of GI symptoms means you probably wouldn’t see anything untoward after stool sample.
Serum dengue IgM- Wrong, it is possible this patient also has dengue, but the seizure and stuff neck points more towards JEV.

Question 5

A 44 year old Venezuelan mother of 2 comes with a glowing tan to the GP with mild fever, backache and nausea. You reassure her that it’s probably a bug and to go home and wait it out.

2 days later you get a call from A&E about the same patient. She was brought in with high fever, jaundice and bleeding from her nose, mouth and eyes.

What test is most likely to give you diagnosis?

  1. Serum dengue IgM
  2. Liver function tests, specifically ALT, AST and ALP
  3. Malaria thick and thin film
  4. Serum American trypanosomiasis IgM
  5. Serum yellow fever IgM

The correct answer is option e, Serum yellow fever IgM

Serum yellow fever IgM- Correct, this patient is presenting with severe yellow fever characterised by a few days of mild YF which progresses to jaundice, fever and bleeding from the eyes, nose and mouth.
Serum dengue IgM- Wrong, the bleeding would definitely suggest HDF, but with addition of jaundice this and the hinting of coming back from Venezuela points towards yellow fever.
Liver function tests, specifically ALT, AST and ALP- Wrong, whilst this would be helpful in looking at the function of the liver in this patient, it wouldn’t give you the diagnosis
Malaria thick and thin film- Wrong, this patient isn’t presenting with malaria symptoms
Serum American trypanosomiasis IgM- Wrong, even though she’s come back from an endemic area, jaundice and bleeding from the face is typical of yellow fever.

Question 6

A family come to the GP after their son is smaller than the rest of his class. He was fine up until a year ago when he’s stalled. They boy reports of stomach cramps and greasy stool.

What is the most likely causative agent?

  1. Anxiety
  2. Giardia lamblia
  3. Entamoeba histolytica
  4. Plasmodium knowlesi
  5. Cryptosporidium parvum

The correct answer is option b, Giardia lamblia

Giardia lamblia- Correct, Giardiasis is a common cause of failure to thrive in children, as well as a history of greasy stool.
Anxiety- Wrong, this could be correct but there isn’t enough history here to make that diagnosis
Entamoeba histolytica- Wrong.
Plasmodium knowlesi- Wrong, no features of malaria at all in this case
Cryptosporidium parvum- Wrong, could be correct, but more likely to be Giardia infection

Question 7

A healthy 39 year old man with rheumatoid arthritis (and is on immunosupression for this) is being seen in the clinic after a diagnosis of cryptosporidiosis. What is the most appropriate treatment?

  1. Nitazoxanide
  2. Salt and fluid replacement
  3. No treatment needed
  4. Immunosuppression
  5. Metronidazole

The correct answer is option a,Nitazoxanide

Nitazoxanide- Correct, this is the correct treatment for cryptosporidium in those who are immunocompromised.
Salt and fluid replacement- Wrong, this would be good management in a healthy, immunocompetent person.
No treatment needed- Wrong, fluid and salt replacement is ideal but you could get away with this I suppose.
Immunosuppression- Wrong, he is already immunosuppressed.
Metronidazole- Wrong, not a treatment of cryptosporidium.

Question 8

A patient has been diagnosed with hypertension. The doctor gives them a prescription for ramipril, for the patient to take once a day. The patients does this everyday until they die, although they never really understood why.

What is this an example of?

  1. Adherence
  2. Concordance
  3. Compliance
  4. Covenanting
  5. Temporalisation

The correct answer is option c, Compliance

Compliance- Correct, the patient is doing as their told and therefore complying.
Adherence- Wrong, adherence is a patient taking medication if their own accord, for example an inhaler when they’re breathless.
Concordance- Wrong, concordance is an agreement between a doctor and a patient for a plan, the patient doesn’t really understand and is just doing as they’re told here
Covenanting- Wrong, not sure this word even exists.
Temporalisation- Wrong, a method when a patient gives themselves an arbitrary timelines before they present.

Question 9

What is the mechanism of action of albendazole?

  1. Affects neurotransmission
  2. Paralyses worn larvae
  3. Blocks glucose uptake
  4. Acetylcholine receptor agonist
  5. Causes oxidative phosphorylation

The correct answer is option c, Blocks glucose uptake

Blocks glucose uptake- Correct, albendazole blocks the uptake of glucose causing the death of the worm.
Affects neurotransmission- Wrong, this is the MOA for Piperazine
Paralyses worn larvae- Wrong, this is the MOA for Prazinquantel
Acetylcholine receptor agonist- Wrong, this is the MOA of Levisole.
Causes oxidative phosphorylation- Wrong, this is the MOA of Niclosamide.

Question 10

Which of the following are the correct 7 F’s of intestinal parasite transmission?

  1. Faeces, Flies, Food, Fluids, Fingers, Fields, Fomites
  2. Faeces, Flies, Food, Fluids, Fingers, Fornicaries, Fomites
  3. Faeces, Flies, Fluids, Fingers, Fields, Fomites
  4. Faeces, Flies, Food, Fluids, Fingers, Fields, Flooring
  5. Faeces, Flies, Food, Fluids, Fertiliser, Fields, Fomites

The correct answer is option a,Faeces, Flies, Food, Fluids, Fingers, Fields, Fomites

Faeces, Flies, Food, Fluids, Fingers, Fields, Fomites- Correct
Faeces, Flies, Food, Fluids, Fingers, Fornicaries, Fomites- Wrong, fornicaries agree not one of the 7.
Faeces, Flies, Fluids, Fingers, Fields, Fomites- Wrong, only 6 here.
Faeces, Flies, Food, Fluids, Fingers, Fields, Flooring- Wrong, even though flooring can be, it’s not one of the 7 recognised Fs.
Faeces, Flies, Food, Fluids, Fertiliser, Fields, Fomites- Wrong, fertiliser isn’t omg of the Fs.

Question 11

What is the treatment of uncomplicated Plasmodium faliciparum malaria?

  1. Paracetamol
  2. Quinine
  3. IV artesunate
  4. Clindamycin
  5. Artemisinin Combination Therapy (ACT)

The correct answer is option e, Artemisinin Combination Therapy (ACT)

Artemisinin Combination Therapy (ACT)- Correct, this is 1st line treatment of uncomplicated malaria.
Paracetamol- Wrong, paracetamol would help with the fever and pain it won’t treat the cause
Quinine- Wrong, this is still used, but ACT is preferred.
IV artesunate- Wrong, this is treatment of more severe forms of malaria
Clindamycin- Wrong, this isn’t used.

Question 12

Steroids cause supression of the hypothaamic-pituitary axis as an adverse drug reaction.

What type of adverse drug reaction is this?

  1. Augmented
  2. Bizarre
  3. Chronic
  4. Delayed
  5. End of use

The correct answer is option c, chronic

Chronic- Correct, long term steroid exposure suppresses the HPA axis.
Augmented- Wrong, predicted reactions based off pharmacology of the drug, e.g. bradycardia with beta blockers.
Bizarre- Wrong, unexpected reaction such as anaphylaxis.
Delayed- Wrong, example of this is a reaction that happens 6 hours after admission.
End of use- Wrong, an example of this is withdrawal from drugs.

Credits

  • 1-12 (James Lee, 4th year),