Umanand Prasad School of Medicine & Health Sciences

Department of Clinical Sciences

Year 2018
FINAL COURSE EXAMINATION PAPER

IMED301: INTERNAL MEDICINE

Important Instructions to Students:

1. Read the questions, instructions carefully and answer the questions.

2. You are allowed an extra 10 minutes reading time (during this time, you are not allowed to write
with pen) and 180 minutes (3 Hours) to complete this paper.
3. Silent, non-programmable calculators are allowed, but not supplied.
4. Write all your answers in the answer booklet provided. If you need extra sheets, please ask from
the supervisor. Write your name, course code and student identification number in the answer
booklet and in the attendance sheet.
5. USE THE MCQ GRID TO ANSWER SECTION A
6. This Final Course Examination Paper is worth 200 marks and contributes 40% towards the total
course assessments. Students must at least score 50% in this final exam to pass the course.
7. This paper contains four (4) sections A, B, C and D. All questions are compulsory.
8. Write all your answers legibly. The marker has the right to award zero for answers that are not
legible.
9. This is a Closed Book Examination. The University views plagiarism, cheating and dishonest
practice as serious offences and if found, offenders are penalized.
Examination Paper Content
Section Question Content Marks Suggested Time
1-50 Multiple Choice 50 50 minutes

51-60 Short Answer Questions 50 40 minutes

c 61-65 Long Answer Questions 50 50 minutes

D 66-68 Cases 50 40 minutes
TOTAL 200 180 Minutes

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SECTION A: SINGLE RESPONSE QUESTION (50
MARKS) (Circle the correct answer in the MCQ grid
provided)

1. Where in the heart does the impulse originate?

A. SA node
B. AV node
C. Purkinje fibres D. Bundle of His
2. The valves of the right side of the heart are:
A. Mitral and tricuspid
B. Mitral and aortic
C. Tricuspid and pulmonary
D. Pulmonary and aortic

3. A 67-year-o'd woman is admitted to accident and emergency with pyrexia (38.1 Q

C) and a cough
productive of green sputum. The observations show a pulse rate of 101, BP 80/60 and respiratory rate
of 32. She is alert and orientated in space and time. Blood results reveal a WCC of 21, urea of 8.5 and
chest x-ray shows a patch of consolidation in the lower zone of the right lung. She is treated for severe
community-acquired pneumonia. Which of the following is the correct calculated CURB-65 score?
A. 6
B. 8
c. 4
D. 1
4. A 35yearold male, presents with fever and cough. He was well until 3 days earlier, when he suffered
the onset of nasal stuffiness, mild sore throat, and a cough productive of small amounts of clear
sputum. Today, he decided to seek physician assistance because of an increase in temperature to 38.3
0
C and spasms of coughing that produce purulent secretions. On one occasion, he noted a few flecks of
bright red blood in his sputum. The patient has no history of familial illness, hospitalizations, or
trauma.
A. Community acquired pneumonia
B. ARDS
C. Hospital acquired pneumonia
D. Chronic Obstructive Pulmonary Disorder

The next 3 questions are based on the history below (questions 5, 6, 7)

47 year old man presents with dyspnoea, fever and a wet cough (with sputum), started 4 days
ago, his doctor did an x-ray on him and found an enlargement in the whole right anterior lobe of
the lung. The laboratory findings indicated an increased WBC level.
5. What laboratory finding other than ESR will help you diagnose this patient?
A. Sputum culture
B. Blood culture
C. Sputum culture, blood culture and pleural effusion culture
D. D. MRI, patient history and urine culture
6. What is your final diagnosis?
A. Lobar pneumonia
B. Consolidation
C. Community acquired pneumonia
D. Bronchiectasis
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7. What is the most causative agent in his case?
A. Streptococcus pneumoniae
B. Staphylococcus Aureus
C. Mycoplasma pneumoniae
D. HINI virus
8. A patient presents to General Out-patients department of your hospital. The triage nurse takes the vitals
and sends the patient in with the following information: Age — 56 years, Sex — mate, BP — 140/90
mmHg. HR — 90/min, RR — 14/min, SP02 — 98% and RBS of 4.1 mmol/dl. The patient is on
Enalapril and a diuretic. Based on the information given, stage of the hypertension is:
A. Normotensive
B. Pre-hypertension
C. Stage 1 hypertension
D. D. Stage Il hypertension
9. Uncontrolled hypertension can cause all of the following except:
A. Stroke
B. Lung fibrosis
C. Myocardial infarction
D. Chronic kidney damage
10. In adults, increase in blood pressure equals to the product of increase cardiac output and total peripheral
resistance. However in elderly, increase in blood pressure equal to the product of:
A. Increase cardiac output and increase in total peripheral resistance
B. Decrease cardiac output and decrease in total peripheral resistance
C. Decrease cardiac output and increase in total peripheral resistance D. Normal cardiac output and
decreased peripheral resistance
11. Which of the following is not a major criteria in the diagnosis of rheumatic heart disease?
A. Carditis
B. Arthritis
C. Chorea
D. Fever
12. A 35 year old male presents to a hospital with a history of chest pain and palpitations. He also seems
very frail and thin. On examination you hear a loud pan-systolic murmur at the apex of the heart
which you can trace to the left axilla and posteriorly between the scapular. On more probing, the
patient reveals that he was admitted long time ago rheumatic fever. He was put on an injection which
he discontinued after few years. Based on the above account, this patient most likely has had
rheumatic heart disease and he had defaulted treatment. Which valve is most likely affected in this
patient?
A. Mitral valve
B. Tricuspid valve
C. Pulmonary valve
D. Aortic valve
13. A 58 year old male presents to emergency department with complains of dull, crushing pain behind his
sternum which radiates to his jaw and profuse sweating. He looks very anxious and is clenching his fist
over his left side chest. He also complains of dyspnoea and nausea. He reveals that he was walking
uphill when the chest pain started and that this is the first time he has experienced it. He had rested
under a tree when he first had the pain and the pain seemed to have disappeared. However, when he
started walking again, the pain returned and was very severe. Based on the information above this
patient is most likely to be suffering from:
A. Unstable Angina

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B. Stable Angina
c. NSTEMI
D. STEMI
14. According to the Canadian Cardiovascular Society Functional Classification of angina, which class
would ' angina with low levels of activity, eg walking 50 — 100 meters on the flat, walking one
flight of stairs, with marked restriction of activity" be place:
A. Class I
B. Class Il
C. Class Ill
D. Class IV
15. A 65 year old male with a history of pulmonary hypertension presents with symptoms of right heart
failure, fatigue and dyspnoea. He also has positive Carvallos sign and on auscultation you hear a
blowing holosystolic murmur. This patient is likely to have:
A. Tricuspid regurgitation
B. Mitral stenosis
C. Tricuspid stenosis
D. Mitral regurgitation
16. A 21 year old male presents to emergency department with low grade, intermittent fever and a
systolic murmur. On examination you also find petechiae on anterior chest, oral mucosa and soft
palate. On examination of the extremities you notice dark linear lesions on the nail bed. On further
questioning the patient he reveals he has had a dental extraction few days ago. The diagnosis most
probably is that of:
A. Pneumonia
B. Pulmonary embolism
C. Endocarditis
D. Septicaemia
17. A modified Dukes criteria is used to diagnose endocarditis. Which of the following statement is NOT
TRUE regarding dukes criteria:
A. Diagnosis can be made by having 2 major criteria B.
Diagnosis can be made by having 1 major and 3 minor criteria
C. Diagnosis can be made by having 5 minor criteria
D. Diagnosis must always have at least 1 major
criteria
18. Refer to the ECG below; what is the most likely diagnosis?
A. Mobitz type Il block
B. Mobitz type I block
C. Complete heart block
D. Ventricular tachycardia
 19. A patient presents to emergency department with complaints of chest tightness and difficulty breathing.
You notice his HR irregularly irregular rhythm. You order an ECG and the ECG findings are as
follows; atrial rate is approximately 380/min with no iso-electric baseline. You cannot see any P waves.
The QRS complex are of
80ms in duration. The ventricular rate is approximately 40/min. "f" waves are seen. What is the most
likely ECG diagnosis:
A. Ventricular fibrillation
B. Atrial fibrillation
C. Paroxysmal supraventricular tachycardia
D. Sick sinus syndrome
20. A patient is diagnosed with heart failure. He is 67 years of age. He has a depressed left ventricular
ejection fraction (30%) and he has a history of coronary heart disease. His systolic BP is low. Classify
his heart failure:
A. Bi-ventricular failure
B. Systolic heart failure
C. Diastolic heart failure
D. Failure due to stiff heart wall musculature
21. Which of the following below is not a major criteria (Framingham) for diagnosing heart failure?
A. Paroxysmal nocturnal dyspnoea
B. S gallop
C. Bipedal ankle oedema

D. Weight loss of 4.5 kilograms in 5 days in response to treatment

22. Blue bloaters is a term coined for those patients with COPD who have chronic productive cough and
sputum for
A. 3 months over 2 consecutive years
B. 2 months over 3 consecutive years
C. 3 months over 1 consecutive year
D. 2 months over 1 consecutive year
23. A chronic smoker presents to respiratory department of the hospital. He complains of chronic
cough. You investigate and find that he is suffering from emphysema. You also note that entire
alveolus distal to the terminal bronchiole is involved. His alpha — 1 antitrypsin results shows
65mg/dL. Chest x-ray shows that most of his lower lobes are affected. Which morphological pattern
of emphysema does this patient have:
A. Centriacinar
B. Panacinar
C. Paraseptal or distal Acinar
D. Lobular acina

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 24. A 65 year old male with a history of smoking 20 Packs/year presents with a history of shortness of
breath with strenuous exercise or while hurrying on the level ground or walking slight uphill. His
FEVI is 65% predicted and his FEVI/FVC ration is 0.6. Which stage of COPD is this patient?
A. At risk (not yet COPD)

B MILD

C. Moderate
D. Severe
25. A 42 year old female presents with yellowish productive cough, shortness of breath for 1 day. She
also complains of chest tightness but no pain. She also states that recently she has lost appetite and
feels tired. On auscultation you can hear bi-basal wheezes. Chest CT reveals that there is thickening
of the bronchial walls and bronchi are filled with mucous. Her oxygen saturation is 85% at room air.
Chest X-ray reveals cardiomegaly. This patient is ;likely to be suffering from:
A. Acute bronchitis
 B. Chronic bronchitis
C. Asthma
D. Empyema
26. Cystic fibrosis is an inherited disorder of ion transport that affects fluid secretions in exocrine glands
and in the epithelial lining of the respiratory, gastrointestinal and reproductive tracts which leads to
thick sticky mucous, which clogs the lungs, causes repeated infections and difficulty in breathing.
Which genetic defect causes cystic fibrosis?
A. Autosomal dominant disorder of the CFTR gene on chromosome 8
B. Autosomal recessive disorder of the CFTR gene on chromosome 7
C. Mutation of chromosome 7 p arm
D. Translocation of CFTR gene on chromosome 7 to q arm on chromosome 8
27. There are six (6) classes of defects resulting from CFTR mutations that have been described and these
are labelled as Class I to Class VI. In which class would you classify a patient who is having defective
protein synthesis leading to cystic fibrosis?
A. Class IV
B. Class VI
C. C. Class
D. Class Ill
28. A 45 year old male presents to your health centre in rural Fiji. You do not have access to radiological
services nor have readily accessible laboratory services. The patient complains to chest pain,
productive cough, fever and malaise. He has reduced appetite and is in mild respiratory distress. On
auscultation, bilateral crepitations are heard in both lung fields and the right lung has reduced air entry.
Oxygen saturation is 94% in room air. Temperature of 37.9 deg. C, HR of 102, BP 135/85 mmHg and
a RR of 20/min. He also mentions that his sputum is rusty coloured. Based on the above information
you would suspect the most likely cause to be:
A. H. influenza
B. K. pneumoniae
C. Mycoptasma pneumoniae
D. S. pneumoniae
29. A 38 year old Asian male who has been in Fiji for tourism falls ill. He presents to your health centre
with fever accompanied by headache, malaise, chills and rigors. He also complains of non productive
cough, dyspnoea, shortness of breath, and diarrhoea. His oxygen saturation is 91% in room air. His
vitals are as follows: T = 38.7 deg Cel. ; Chest x-ray is consistent with pneumonia like findings with
infiltrates. He does not have any other co-morbidities. The most likely diagnosis would be?
A. Severe acute respiratory syndrome
B. Very severe pneumonia
C. Acute exacerbation of COPD
D. Very severe bacterial infection of the lungs
30. Which of the following is not lung cancer?
A. Small cell lung cancer
B. Lung adenocarcinoma
C. Large cell lung carcinoma
D. D. Teratoma
31. Oat cell carcinoma of lungs is also known as:
A. Large cell carcinoma of the lung
B. Small cell carcinoma of the lung
C. Squamous cell carcinoma of lungs

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D. Adenocarcinoma of the lung
32. Given below is a chest radiograph. Look at it and answer the question. The arrow on the x-ray shows:

A. Atelectesis
B. Consolidation
C. C. Pleural effusion
D. Cardiomegaly
33. For clinical pneumoconiosis to develop, 3 essential factors are required. Two are given as (1)
exposure to specific substances; (2) particles of appropriate size to be retained in the lungs (1 — 5
micrometres). What is the 3 rd essential factor?
A. Be in contact with person who has the disease
B. Have a blood transfusion using blood from person having the disease
C. Have a genetic pre-disposition
D. Exposure for a sufficient time ( usually around 10 years)
34. Dengue is spread by Aedes aegypti mosquito. The virus is a positive sense single stranded RNA virus.
Which family does this virus belong to?
A. Picomavirus
B. Retrovirus
C. Flaviviridae
D. Coronaviridae
35. The incubation period in mosquito for dengue virus is;
4— 10 days
B. Less than 4 days
C. More than 10 days D. At most 10 to 12 days
36. There are 3 phases of dengue haemorrhagic fever. These are:
A. Initial febrile, state of recovery and relapse
B. Febrile, coma and death
C. Confusion, febrile and recovery
D. D. Initial febrile, shock, recovery

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 37. The causative agent for leptospirosis is?

A. Tinea saginata
B. Ecchinococcus granulosus
C. Ascaris lumbricoides
D. D. Leptospira interrogans
38. Weil's disease is a severe form of leptospirosis. This disease is characterized by:
A. Jaundice and involvement of other organs
B. Anaemia
C. Hepatomegaly and anemia D. Splenomegaly and rashes
39. Salmonella typhi causes typhoid fever. Which species is the reservoir of infection for this disease?
A. Human beings
B. Apes
C. Rodents D. Insects
40. What is the infective stage of malaria life cycle known as?
A. Pupa
B. Gametocytes
C. Sporozoite
D. D. Larva
41. Which of the following statements is FALSE regarding the diagnosis of mycobacterium
tuberculosis? A. The IGRA test is the preferred test in diagnosing latent TB infection (LTBI) in
patients who are immunosuppressed without HIV or in patients who have been vaccinated with
BCG
B. The IGRA test is better than the Mantoux test in diagnosing active TB
C. The Mantoux test is cheaper than the IGRA test
D. The proteins injected into the subcutis in the Mantoux test have reactivity with other non-tuberculous
mycobacterium
42. What is the CORRECT regime to be used in patients with latent TB infection?
A. Isoniazid for 4 months
B. Yearly CXR, and if progresses, treat with RIPE regime for 6 months
C. Isoniazid for 6 — 9 months, or Rifampicin for 4 months
D. Rifampicin, Isoniazid for 6 months, Rifampicin, Isoniazid, Vitamin B6, Pyrazinamide, Ethambutol for
2 months
43. A 78yo male patient presents from India with 4 months of fevers, night sweats and haemoptysis. He
tells you that he has been visiting his aunt who has resistant TB. Which of the following defines a case
of multi-drug resistant TB compared to XDR-TB?
A. MDR TB has resistance to both rifampicin and isoniazid, XDR TB has resistance to Rifampicin +
isoniazid + quinolone + injectable
B. MDR TB has resistance to rifampicin, XDR TB has resistance to rifampicin and isoniazid
C. MDR TB has resistance to rifampicin and isoniazid, XDR TB has resistance to rifampicin, isoniazid,
pyrazinamide and ethambutol
D. MDR TB has resistance to rifampicin and isoniazid, XDR TB has resistance to rifampicin, isoniazid,
pyrazinamide and ethambutol plus a quinolone
44. A 26 year old female nurse presents to the TB clinic following a positive exposure to TB. She has
never been previously exposed. An initial mantoux test shows an induration of 3mm. She is also
quantaferon negative. What is the most appropriate step?
A. offer her post-exposure prophylaxis

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 B. discharge her with reassurance

C. Offer her a CXR and repeat quantaferon/ mantoux test in one months' time, and follow her up, looking
for conversion
D. Offer her treatment as per LTBI
45. A 72 year old female with no significant past medical history passes out while exercising. He has
intermittent exertional chest pains and dyspnea on exertion as well. Her physical examination reveals a
Ill/Vl late-peaking creshendo-decreshendo murmur at the right upper sternal border and a Ill/Vl
holosystolic murmur at the apex. Her S2 heart sound is very soft and her carotid upstroke is weak and
delayed. Which of the following is most likely causing her symptoms?
A. Aortic valve
regurgitation
B. Aortic valve stenosis
C. Mitral valve
regurgitation
D. Mitral valve stenosis
46. A 56-year-old man presents to your clinic with symptoms of exertional chest tightness which is
relieved by rest. You request an ECG which reveals that the patient has first degree heart block.
Which of the following ECG abnormalities is typically seen in first degree heart block?
A. PR interval >120 ms
B. PR interval >300 ms
C. PR interval <200 ms
D. PR interval >200 ms
47. A patient is diagnosed as having anteroseptal myocardial infarction. Which leads on a 12 lead ECG
would you be looking at to confirm the diagnosis?
A. VI, V2, V3,
V4
B. l, aVL, \./5
c.
D. l, Il, Ill
48. CK — MB is a cardiac marker for myocardial infarction. It is specific for myocardial injury. Plasma
CK-MB begins to rise between 4 — 6 hours after the onset of chest pain. When does it reaches its
peak?
A. 24 — 36 hours
B. 36 to 48 hours
C. 12 — 24 hours
D. 1 — 2 weeks
49. The chest X- ray below was taken for a man who has been having symptoms of cough, palpitations and
sweating. His BP is elevated and has mild chest discomfort. What is seen in the chest x-ray?

A. cardiomegaly
B. miliary TB
C. Pneumonia
D.pleural effusion

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50. Which is the first line of treatment of acute myocardial infarction?
A. Oxygen, Morphine, nitrates, Aspirin
B. Beta blockers, aspirin, diuretic and brufen
C. Paracetamol, amoxicillin and vitamin B12
D. None of the above

SECTION B. SHORT ANSWER QUESTION (5 MARKS EACH) - ANSWER ALL

QUESTIONS (Write short notes on the following)
51. Clinical features and treatment of leptospirosis
52. List 5 classes of anti-hypertensive drugs with at least 1 example (do not use brand names)
53. Tabulate the differences between primary and secondary hypertension
54. Diagnostic criteria (modified Jones) for rheumatic heart disease
55. Draw the algorithm (flow chart) for the management of stable angina
56. Briefly write on the auscultatory signs of aortic stenosis
57. List the signs and symptoms specific to meningococcemia
58. What is malaria fever paroxysm (write short notes on all 3 stages?)
59. Draw a NORMAL electrocardiogram (ECG) and label the waves, time durations and voltages
60. Write briefly on the cardiac markers for Myocardial infarction.

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SECTION C: LONG ANSWER QUESTIONS (10 marks each)
61. Define and classify Heart Failure. Discuss the clinical assessment of heart failure with investigations
and management of congestive cardiac failure
62. Discuss aetiology, clinical features, investigations and management of infective endocarditis.
63. Describe in detail the causes, clinical features and management of Pneumonia
64. Discuss the clinical features and management of dengue fever.
65. Define and discuss the pathogenesis, clinical features and treatment of bronchial asthma.

SECTION D: CASES (50 MARKS EACH)

Question 66. Case 1. (20 marks)
A 65 year old male from Sabeto, Nadi presented to the emergency department of nadi hospital. He is a
known

case of type 2 Diabetes for the last 12 years and coronary artery disease for the last 2 years. His presenting

complaints are chest pain and breathlessness for the last 6 hours. He has vomited once along his way to the

hospital. He is conscious and well oriented. Overall health state is weak and meagre.

HPI: He is a known case of DM type 2 (12 years) and Il-ID (2 years). According to him the chest pain
started 6

hours ago. The onset was sudden and crushing pain in nature. He describes the pain as being retrosternal,

radiating to his left arm, back and neck and is aggravated on exertion. He developed SOB suddenly about 6
hours

ago and still having difficulty breathing. SOB is present at rest. He has vomited twice 5 hours ago and the
colour

was yellowish. He also has palpitations and moderate fever.

O/E: looks in mild distress, sweating but oriented to time, place and person. Pale and anxious

Social History; chronic smoker, non alcoholic and lives a sedentary lifestyle.

Vitals: BP 160/90mmHg,• HR 115/min; T 37.9 deg cel. ; RR 30/min

General Physical Exam: no clubbing, no raised JVP

CVS: apex beat lateralized to mid clavicular line at 6 th intercostal space and well sustained heave at apex

Bloods: Troponin and CK-MB are raised

CXR: nil pulmonary edema. Cardiomegaly present.

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 ECG: refer to page 12

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エ
ー
 1. What is your diagnosis?
2. How would you manage this patient? Give the name and dosage of the medications used to treat this
condition.
3. What is the pathophysiology of disease?
4. How would you discharge this patient?
5. Will this patient benefit from thrombolytic therapy and discuss how and why it would or would not
make a difference.

Question 67. Case 2 (20 marks)

Mr. S is a 63-year old gentle man who has been under your care for a variety of medical problems during
the past 5 years. He has been treated for two myocardial infarctions, hypertension, non-insulin dependent
diabetes and stasis dermatitis of the left leg. He had an aorto-coronary bypass one year ago.

Today he presents in the office with shortness of breath which has been progressive over the past five days.
He has, however, experienced episodes of shortness of breath during the past four months, especially when
exerting himself. He fatigues easily and has lost 'tall my energy to do anything. " He also complains of
anorexia. Last night he awoke suddenly from sleep because Il l couldn't catch my breath" and developed a
dry cough. The breathing problem improved when he sat on the edge of his bed for an hour. He generally
sleeps with two, sometimes three pillows. He has not experienced chest pain, leg pain or fainting spells.
Examination in the office reveals an undernourished man who appears depressed and older than his stated
age.
He is unkept and unshaven. His shoes are untied. His breathing is labored and his lips have a blue tinge.

Vital Signs: Blood Pressure 98/82mmHg in the right arm; Heart Rate 110/min; Respiratory Rate 26/min;
Temperature 37deg.Cel. Examination of the lungs reveals dullness to percussion in both bases with
decreased excursion of the diaphragms. Course rhonchi and moist, inspiratory crackles are heard
bilaterally in the lower lung fields.
Examination of the cardiovascular system: Neck veins are prominent and distended to the mandible
when the patient is sitting upright. The apical pulse is palpated in the 51CS, left of the MCI-. S3 is
palpable at the apex. Sl and S2 are diminished. S3 is heard at the apex. A grade 3/6 holosytolic murmur
is heard best at the apex; it radiated to the left axilla.

Examination of the abdomen: The anterior wall is round and soft. The liver edge is palpable and
tender. The spleen is not palpable. Examination of the extremities revealed diminished peripheral
pulses. There is an irregular pulse. There is pitting edema of both lower extremities.
The patient is hospitalized.

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ADMISSION LABORATORY TEST

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 CBC:

Leukocyte count = 84000/mm3 with normal differential count

Haemoglobin 14.6g/dL, Haematocrit 40%

Platelet count 290,000/mm3

Chemistries:

Glucose 112mg/dL (non-fasting); BUN 33mg/dL; Creatinine 1.6mg/dL; Total Bilirubin 1.9gm/dL, Direct
Bilirubin
0.3mg/dL; Total Protein 5.8g/dL, Albumin 3.1g/dL; Electrolytes: Sodium 132mEq/L, Chloride 93mEq/L,
Potassium
4.0mEq/L, Bicarbonate 23mEq/L; Urine: Specific Gravity 1.032, 1 plus protein, hyaline casts.

Chest X-ray:

"Marked prominence of the pulmonary vascular shadows (bilateral), bilateral pleural effusions, increased
haziness and decreased radiolucency of the lung parachyma (bilateral), increased transverse diameter of
the heart."

1. What is the primary clinical problem 9not the diagnosis)?

2. Develop a differential diagnosis list based on the history
3. What is your diagnosis? Describe the data from the history that supports your diagnosis.
4. In terms of pathophysiology, explain the mechanisms for the following physical finding: (Diaphoresis,
blue lips, labored breathing, cold hands)

Question 68. Case 3 (10 marks)

A 44-year-old man is seen at a physician's office in the Suva, during a week-end, for suspected malaria.

The patient was born in Pakistan but has lived in the Fiji for the past 12 years. He travels frequently back to
Pakistan to visit friends and relatives. His last visit there was for two months, returning 11 months before
the current episode. He did not take malaria prophylaxis then.

Five weeks ago, he was diagnosed with malaria and treated at a local hospital. The blood smear at that time
was reported by the hospital as positive for malaria, species undetermined. He was then treated with 2 days
of IV fluids (nature unknown) and tablets (nature unknown), and recovered.

The patient now presents with a history of low grade fever for the past few days, with no other symptoms.
A blood smear is taken and examined at a hospital laboratory by the technician (no pathologist is available
on this week-end). Through a telephone discussion, the technician states that she sees 4 parasites per 1000
red blood cells, with rings, "other forms with up to four nuclei," and that some of the infected red blood
cells are enlarged and deformed.

1. What is your most probable reason for relapse/

2. Which pathogen is capable of causing this disease?
3. What treatment approach would you recommend based on history and on the fact that the microscopy
findings will not be confirmed by a pathologist for at least 24 hours?
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