Case 01 5 Abdomen : no hepatosplenomegaly, no

tenderness, decreased bowel sounds, pinched skin

A 3 years old boy with fever and rash test retracts >2 seconds
5 Groin: desquamation of skin
What do I see 5 Extremities : swelling of hands and feet, small
Patient is alert, irritable, not in respiratory distress joint swelling, no clubbing
5 Skin: maculopapular polymorphous flat reddish
Primary Survey
irregular that blanches on pressure on the hands
5 A : Airway Clear
5 B : Breathing spontaneously and feet with desquamation,
5 C : Good strong pulse
5 Vital signs BP 100/60 , HR 130, RR 24, T 40, O2 Differential Diagnosis
96% -Kawasaki disease/Mucocutaneous Lymph Node Syndrome
5 BW: 18kg -Hand-foot and mouth disease (punctuate)
-Drug allergy
Action -Scarlet Fever
5 -Juvenile Rheumatoid Arthritis
-Meningococcemia
History
5 HPI : started to have fever 6 days ago then rash Diagnostic
turn out yesterday 5 FBE (normocytic, normochromic anemia),
5 Continuous, no chills ESR/CRP, ECG, LFTs, UEC, Echo, MSU
5 Runny nose and dry cough
5 Poor appetite, drinking less Parents ask what is the diagnosis
5 Took paracetamol but it didn’t help 5 Explain to parents adequately about presumptive
5 Desquamation on groin with rash started there diagnosis
5 No itch, no pain
5 No nausea/no vomiting/no diarrhea Preliminary Result
5 Decreased nappies, yellow urine 5

Past Medical History Working Diagnosis

5 Birth: per vaginam
5 Immunization: complete basic
5 Nutrition: normal as recommended
5 Development & Growth: normal as common
5 Growth chart: normal weight for age
5 Has allergy to amoxicillin and cow’s milk,
reaction: eczema
Family History
5 Father has asthma
Social History
5 goes to childcare, some kids were normally sick
too
5 Stay with parents at home most of the time
Physical Examination
5 Eyes: bilateral nonpurulent conjunctivitis, no
jaundice, sunken eyes
5 ENT : dry parched lips and strawberry tongue,
tonsils erythematous. Ear normal.
5 Neck: lymphadenopathy 1.5cm, mobile, non
tender, no stiffness
5 Heart : adynamic precordium, normal rate regular
rhythm, murmur, no gallop
5 Lungs : normal breath sounds, no rhales, no
wheeze
5 Kawasaki disease
5 Moderate dehydration
Plan
5 Inpatient
5 IVFD NS 20ml/kg
5 Refer to paediatrician
5 Aspirin (3-5mg/kg/day) reduces thrombocytosis.
Reye’s syndrome: nausea, vomiting, headache,
excitability, delirium, and combativeness with
frequent progression to coma
5 IV Ig (2g/kg/Single slow infusion)
Treatment in the first 10 days reduces 5x the
prevalence of coronary artery aneurysms
5 Echo within 2 weeks of development of
symptoms, repeat in 6-8 weeks and once every 5
years. 30% develops dilatation of coronary
vessels (aneurysms).
5 High-dose steroids and plasmapheresis reserved
for non-responders
Specialist on duty has not reply his after 30 minutes.
5 Call another pediatrician
Inform the parents about the care
Complications:
 coronary artery aneurysms,
 depressed myocardial contractility and heart failure,
 myocardial infarction,
 arrhythmias,
 peripheral arterial occlusion.

DIAGNOSIS — by Tomisaku Kawasaki (1967)

fever lasting ≥5 days, combined with at least four of the
five
●Bilateral bulbar conjunctival injection
●Oral mucous membrane changes (injected or fissured lips,
injected pharynx, or strawberry tongue)
●Peripheral extremity changes (erythema of palms or soles,
edema of hands or feet in acute phase and periungual
desquamation in convalescent phase)
●Polymorphous rash
●Cervical lymphadenopathy (at least one lymph node >1.5
cm in diameter)

Redness or crust formation at the site of Bacille

Calmette-Guerin (BCG) inoculation is also suggested as a
useful sign in several diagnostic guidelines

Case 02
 5 Groin: no abnormalities
A 4 years old boy with fever and rash 5 Extremities : no edema, no clubbing, CRT
normal
What do I see 5 Skin: lesions in different stages of development
Patient is alert, irritable, not in respiratory distress on the face, trunk and extremities, macule,
papule, vesicles.
Primary Survey
5 A : Airway Clear
Diagnostic
5 B : Breathing spontaneously
5 C : Good strong pulse 5 None
5 Vital signs BP 100/60 , HR 100, RR 24, T 39, O2
98% Parents ask what is the diagnosis
5 BW: 18kg 5 Explain to parents adequately about presumptive
diagnosis
Action 5 Is it affecting my pregnancy
5
Working Diagnosis
History 5 Chicken pox
5 HPI : started to have fever 2 days ago then rash
turn out yesterday Plan
5 Continuous fever, no chills 5 Isolation
5 Runny nose and dry cough 5 Paracetamol
5 Poor appetite, drinking less 5 Antiseptic body wash
5 Took paracetamol but it didn’t help 5 Calamine lotion
5 Vesicle rash with itch, no pain 5 Antihistamine
5 No nausea/no vomiting/no diarrhea 5 Mom: Check IgG + IgM
5 decreased nappies, yellow urine
Complications
Past Medical History  Secondary bacterial infections
5 Birth: per vaginam  meningitis,
5 Immunization: complete basic  encephalitis,
5 Nutrition: normal as recommended  cerebellar ataxia,
5 Development & Growth: normal as common  pneumonia,
5 Growth chart: normal weight for age  glomerulonephritis,
5 Has allergy to amoxicillin and cow’s milk,  myocarditis,
reaction: eczema  ocular disease,
 adrenal insufficiency,
Family History  death
5 Father has asthma
5 Mother is 32 weeks pregnant, not sure whether Pregnancy Risk: first trimester 0.4% , later on goes up to
she had history of chicken pox 2%.
Congenital varicella syndrome: mothers were infected
Social History between 8 and 20 weeks gestation.
5 Live with parents ●Cutaneous scars in a dermatomal pattern
●Neurological abnormalities (eg, mental retardation,
5 Goes to childcare
microcephaly, hydrocephalus, seizures, Horner’s
5 Last week his classmate had chicken pox
syndrome)
●Ocular abnormalities (eg, optic nerve atrophy, cataracts,
Physical Examination chorioretinitis, microphthalmos, nystagmus)
5 Eyes: bilateral nonpurulent conjunctivitis, no ●Limb abnormalities (hypoplasia, atrophy, paresis)
jaundice, no sunken eyes ●Gastrointestinal abnormalities (gastroesophageal reflux,
5 ENT : Ear normal, inflamed palate and pharynx atretic or stenotic bowel)
5 Neck: no lymphadenopathy, no stiffness ●Low birth weight
5 Heart : adynamic precordium, normal rate regular
rhythm, no murmur, no gallop Neonatal varicella: within two weeks of delivery.
5 Lungs : normal breath sounds, no rhales, no Complications: encephalitis, pneumonia and hepatitis.
wheeze
5 Abdomen : no hepatosplenomegaly, no Mother:
tenderness, decreased bowel sounds, pinched skin If IgM+ give Immunoglobulins IM (within 4 days of
exposure)
test retracts <2 seconds
If develop symptoms, give acyclovir 5 A : Airway Clear
Review by an obstetrician 5 B : Breathing spontaneously
5 C : Good strong pulse.
Postexposure prophylaxis: 5 Vital signs BP 120/60 , HR 100, RR 20, T 38.5,
●Immunoprophylaxis (eg, VariZIG within 10 days of O2 96%
exposure), or either IVIG 400 mg/kg single does or closely
monitor for signs and symptoms of varicella and institute Action
treatment with acyclovir if illness occurs. 5

History
5 HPI : started to have fever 2 days ago then rash
turn out yesterday
5 Continuous, no chills
5 Runny nose and dry cough
5 Poor appetite
5 Took paracetamol but it didn’t help
5 No itch, no blisters, no pain
5 No nausea/no vomiting/no diarrhea
5 Joint pain
5 lost some weight recently

Past Medical History

5 Major blunt abdomen trauma surgery year 2000

Family History
5 Father has diabetes

Social History
5 had unprotected sex 3 weeks ago when he was
Rubella exposure in pregnancy
traveling overseas
-Complete damage of baby (>45%) if mother exposed
5 Confidentiality. May I ask, are you sexually
during the 1st trimester
active? What is your preference? Male or female?
-Offer termination of pregnancy How many partners have you had in the past?
-NO vaccination in pregnancy Did you practice safe sex with the use of
-Can cause abortion, miscarriage, stillbirth, IUGR, fetal condoms? Have you or any of your partners ever
infection, cataract, deafness, developmental delay, been diagnosed with STIs? Which infection? Was
irritability, mental retardation, microcephaly, neurologic it treated? Are you still in touch with that
(meningoencephalitis), patent ductus arteriosus, tricuspid partner?
stenosis 5 work as nurse
5 Smokes 1 pack/day
Management 5 Allergy to amoxicillin
Rubella Varicella 5 Recreational drugs and alcohol socially
Vaccination No No
Immunoglobulin No Yes Physical Examination
5 Eyes: PERRL no anemic, no jaundice
Termination Yes if IgM (+) Never
5 ENT : Ear normal, inflamed palate and pharynx
5 Neck: no lymphadenopathy
5 Heart : adynamic precordium, normal rate regular
rhythm, no murmur, no gallop
5 Lungs : normal breath sounds, no rhales, no
Case 03 wheeze
5 Abdomen : no hepatosplenomegaly, no
A 30 years male with fever and rash tenderness, normal bowel sounds,
5 Extremities : no edema, no clubbing, CRT
What do I see normal
Patient is alert, irritable, not in respiratory distress 5 Back: tattoo
5 Skin: generalized erythematous maculopapular
Primary Survey rash
Diagnostic
5 FBE: Hb115, WCC 7000, platelets 400,000
5 UEC: normal range
5 LFT: normal
5 BSL: 4.8 mmol/L
5 Blood Group A-, antibody screening negative
5 HIV serology positive
5 HBV and HCV serology negative
5 Syphilis serology negative
5 ESR/CRP
5 Urine MCS,
5 monospot test for EBV,
5 TORCH serology.
5 CD4 count as a baseline, If CD4 <200: start on
antiretroviral therapy
5 ELISA antibody testing.
5 urethral and anal swab for culture
5 Blood culture
5 PPD Mantoux for TB

DD/ Who are at risk:

mononucleosis due to Epstein-Barr virus (EBV) or -MSM
cytomegalovirus (CMV), toxoplasmosis, rubella, syphilis, -IV drug abusers (needle-sharing)
viral hepatitis, disseminated gonococcal infection, and -Partners of HIV patients
other viral infections, autoimmune diseases. -Tattooing or piercing
-Vertical transmission (20-45%)
Working Diagnosis -Occupational transmission Healthcare professional (0.3%)
5 HIV

Plan
5 Consult medicine
5 Symptomatic
5 practice a healthy lifestyle including quitting
smoking, safe drinking habits, proper nutrition,
regular exercises
5 adopt behaviors that guard against HIV
transmission, including consistent and correct
condom use and avoidance of sharing injection
drug use equipment
Management
-Symptomatic treatment for acute febrile illness. Resolves What do I see
in 2-3 weeks. Patient is alert, irritable, not in respiratory distress
-Drug resistance testing
Primary Survey
-Regular follow up CD4 blood counts and viral load tests 5 A : Airway Clear
-Antiretroviral therapy (ART) to reduce transmission risk 5 B : Breathing spontaneously
from HIV-seropositive to HIV-seronegative sexual partner. 5 C : Good strong pulse.
-Pregnancy: ART is recommended regardless of CD4 cell 5 Vital signs BP 90/60 , HR 150, RR 48, T 40, O2
count to decrease rates of perinatal HIV transmission 96% GCS 12
-Patient preference and/or "readiness" should play a role in
the timing of therapy initiation, as long as the CD4 cell Action
count is in the normal range and the patient has no 5 None
HIV-related symptoms.
History
-Infection is generally low among patients with a CD4 cell
5 HPI : started to have sudden fever 4 hours ago,
count >500 cells/microL becomes lethargic and irritable
5 had mild URTI for the last 3 days
Pretest Counseling 5 now he is uninterested in food
-Explain what tests are being done and why 5 has a very cold skin
-Talk about full STI screening 5 no chills
-Talk about confidentiality, privacy, and informed consent 5 Vomited once
-Explain to the patient the natural history of HIV (graph) 5 Took paracetamol but it didn’t help
-Explain the behavioral changes required for prevention 5 No nausea/no diarrhea
-Explain the implication of positive and negative tests 5 Poor appetite
-Explain window period to the patient 5 Reduced diapers and yellow urine
-Mention support and followup 5 No travel history
-Dispel myths about transmission of infection
-Give preventive advice on safer practices Past Medical History
5 None
-Assess possible coping mechanisms
-Patient’s social support networks & interpersonal bonds
Family History
-Reassure confidentiality
5 Father has asthma

Post-test Counseling Social History

-Rapport building 5 Go to child care
-Give the results 5 Allergy to amoxicillin
-Avoid overloading information
-Listen to the patient Physical Examination
-Explain immediate implications 5 Eyes: bilateral nonpurulent conjunctivitis, no
-Explain repeating the test jaundice
-Talk about contact tracing 5 ENT : Ear normal, inflamed palate and pharynx
-Arrange support and followup 5 Neck: no lymphadenopathy, no neck stiffness
-Talk about safe behavioral habits 5 Heart : adynamic precordium, normal rate regular
-Discuss vaccination for HPV and HBV rhythm, no murmur, no gallop
5 Lungs : normal breath sounds, no rhales, no
-Screen for other STIs if indicated
wheeze
-Explain about possible treatment options
5 Abdomen : no hepatosplenomegaly, no
-Talk about disclosure
tenderness, decreased bowel sounds
-Talk about relationship counseling 5 Extremities : no edema, no clubbing, CRT
-Work place implications normal
-Life insurance 5 Skin: fine non-specific macular petechial rash on
-Lifestyle modification the trunk and legs
-Referral to HIV specialist Differential Diagnosis
-Notify Department of health ●Child abuse (eg, abusive head trauma)
Case 04 ●Hypoglycemia
●Environmental hyperthermia
A 2 year old boy fever and lethargy ●Gastroenteritis with dehydration
●Toxic exposures (eg, methemoglobinemia or carbon
monoxide poisoning)

Diagnostic
5 Blood Culture
5 FBE, ESR/CRP, UEC, BSL
5 SPA or straight catheterization for CS
5 CXR
5 Lumbar puncture

Parents ask what is the diagnosis

5 Explain to parents adequately about presumptive
diagnosis

Working Diagnosis
5 Meningococcal Septicemia

Plan
5 IVFD NS
5 Consult pediatric
5 Antipyretic
5 Cephalosporins cefotaxime q6 (50mg/kg up to
2g) or ceftriaxone (100mg/kg up to 4g) OD IV or
IM or Benzylpenicillin (60 mg/kg) IV or IM.
5 Prophylaxis for close contacts : Rifampicin
600mg BD x 2 days; ceftriaxone 250mg IM SD
(pregnancy), Ciprofloxacin 500 mg SD (woman
on OCP)

Most common cause: N. meningitides or H. influenza.

The typical initial presentation: sudden onset of fever,
nausea, vomiting, headache, decreased ability to
concentrate, and myalgia.

The classic clinical features of meningococcal disease:

 hemorrhagic rash, (evolved from nonspecific to
petechial to hemorrhagic over several hours)
 meningismus, and
 impaired consciousness

Signs and symptoms of early sepsis:

●Leg pain Sepsis: severe infection + systemic inflammatory response
●Cold hands and feet syndrome (SIRS), immune dysregulation, microcirculatory
●Abnormal skin color (eg, pallor or mottling) derangements, and end-organ dysfunction.

SIRS: two or more of the following criteria (one of which

must be abnormal temperature or leukocyte count)
●Core temperature of >38.5°C or <36°C (measured by
rectal, bladder, oral, or central probe)
●Tachycardia (mean HR > 2 standard deviations above
normal for age), or for children younger than one year of
age, bradycardia (mean heart rate <10th percentile for age)
●Mean respiratory rate > 2 standard deviations above
normal for age or mechanical ventilation for an acute
pulmonary process
●Leukocyte count elevated or depressed for age, or >10
percent immature neutrophils

CLINICAL MANIFESTATIONS:
Infection
Systemic inflammatory response syndrome
Shock: Distributive ("warm") shock or Cold shock
Other physical findings:
●Toxic or ill appearance
●Signs of
●Rigors
●Altered mental status (eg, irritability, anxiety, confusion,
lethargy, somnolence)
●Decreased tone in neonates and infants
●Seizures
Laboratory studies
●Meningismus
●Rapid blood glucose
●Respiratory depression or failure
●Arterial blood gas or venous blood gas and pulse
●Pulmonary rales or decreased breath sounds caused by
oximetry
bronchopneumonia
●Complete blood count with differential: neutrophilia,
●Distended, tender abdomen (eg, perforated viscus or
neutropenia, or thrombocytopenia
intraabdominal abscess)
●Blood lactate
●Costovertebral angle tenderness (eg, pyelonephritis)
●Serum electrolytes (hyponatremia, hyperkalemia,
●Macular erythema (toxic shock syndrome)
hypokalemia, and hypophosphatemia)
●Skin cellulitis or abscess
●Blood urea nitrogen and serum creatinine
●Peripheral edema caused by capillary leak
●Serum calcium – Hypocalcemia
●Petechiae or purpura suggesting either a specific
●Serum total bilirubin and alanine aminotransferase
infectious source (eg, meningococcemia, rickettsial
●Prothrombin time (PT), partial thromboplastin time
infection) or disseminated intravascular coagulopathy
(aPTT), international normalized ratio (INR)
●Multiple nodules which can be seen with disseminated
●Fibrinogen and D-dimer
S.aureus or fungal infections
●Blood culture
●Urinalysis
●Urine culture
●Other cultures (eg, cerebrospinal fluid [CSF], wound
culture, aspirated fluid from an abscess collection)
●Diagnostic serologic testing (eg, herpes simplex virus,
enterovirus, influenza), other diagnostic testing (eg, viral
culture, polymerase chain reaction, rapid immunoassay
antigen test, or direct and immunofluorescent antibody
staining)

Procalcitonin versus C-reactive protein

CRP is the most common laboratory marker used to
evaluate systemic inflammatory response to an infectious
agent.
Procalcitonin is a more useful diagnostic inflammation
parameter in the diagnosis of bacterial sepsis than CRP in
patients with pediatric neutropenic fever, both in estimating
the severity of infection and the duration and origin of the
fever.
Procalcitonin levels may also be elevated in medullary
thyroid carcinoma and small-cell lung carcinoma,
paralytic/vascular ileus exhibiting paraneoplastic
production, and renal failure.
 received immunization against hep A/B? any past medical,
EXTRA CASE surgical or any other another condition?

Viral Hepatitis A (Travel Jaundice) Physical examination:

Case 1: 25-year-old man comes to you complaining of
fever, malaise and nausea for the past 10 days. Since
yesterday, he noticed his urine getting darker and stools
getting paler.
- General appearance: pallor, jaundice and
dehydration
- Vitals: Temperature (38.8); LN
- Abdomen: skin (pruritus marks); tenderness and
hepatosplenomegaly;

Task: Investigations
a. Relevant history – travel to Thailand a month - FBE, LFTs, INR and complete serology for
back for 2 weeks; ate street food hepatitis A/B/C, EBV and CMV
b. Physical examination – ; pale and slightly - Hepatitis IgM (+) – current infection;
dehydrated; T: 38.8; liver slightly enlarged, 2cm palpable
with slight RUQ tenderness Management
c. Investigation - Most likely you have a condition called hepatitis
d. Management A. it is a viral illness that causes inflammation of the liver. It
usually spreads from person to person through close
Differential diagnosis contact via hands, towel, shaving as well eating
- Hepatocellular: hepatitis contaminated foods and drinks. Symptoms are fever,
- Obstructive: gallstones; malaise, yellowing of the skin, dark urine and pale stools.
Patients can transmit infection to others 2 weeks before
Urine Stool and 1 week after appearance of jaundice.
Color Bilirubin Urobilinogen Color - This condition is completely curable. I will give a
Unconjugated Normal - ++++ Normal leave certificate. You will need to stay home for at least a
Hepatocelluar Dark ++ ++ Normal week, have complete bed rest, drink lots of fluids, no
Obstructive Dark ++++ - Pale alcohol, decreased fat diet, no paracetamol.
- Prognosis is good. Complete recovery is
Hepatitis Chart expected. To decrease transmission, please maintain good
- Mnemonic: ABP FIT No SEX personal hygiene, wash your hands frequently, don’t share
o A – antibiotics towels and food. If your girlfriend and close contacts don’t
o B – blood transfusion have symptoms, we can give them immunoglobulins. I will
o P – piercing (tattoo/body piercing) see you with the result of the test in 3 days.
o F – food (street) - No admission is necessary unless you are really
o I – IV drugs/immunization against hep unwell. If you don’t improve within a week, we may need to
o T – travel admit you.
o NO – needlestick injury - Immunizations are available against hepatitis A
o SEX – full sexual history before traveling. After infection, some immunity will be
- Ask about bladder (dark urine) and bowel (pale acquired.
stools) - Give reading materials.
- Detailed alcohol use and medications
(augmentin/PCM) Case 2: You are a GP and a 25-year-old male is
complaining of fever, nausea, and malaise for the last 10
History: days and progressing to dark urine since yesterday. The
- Since when did you have a fever? Did you check patient visited Thailand 4 weeks ago with his girlfriend
how high it is? Do you have any chills? Have you taken any where they stayed about 2 weeks. They did not get any
tablets? Have you lost any weight? Appetite? Urine? vaccines before traveling. There is no history of drug
Bowels? Sore throat? Anyone with similar complaints? abuse, tattooing, medications, and unprotected sex, but the
Recent travel? When and where? Did you go to your GP couple was not careful with food and drink while traveling.
before traveling? Have you taken any vaccinations? Were On examination, the patient’s temperature is 38.8, obvious
you careful about eating out? Did you use bottled water? jaundice, and his liver is palpable 2cm below the costal
Did anyone accompany you on the trip? Is she fine? Do margin. The rest of examination is normal.
you practice safe sex? Are you using any medications?
SADMA? IV drugs and tattooing? Have you ever donated Task
or received blood? What’s your occupation? Have you ever a. History
b. Physical examination
c. Investigation (WBC increased with leftshift; HAV
IgM)
d. Management
Case 3: (Pre-icteric Phase): Marsh aged 35 years presents
to your GP clinic with history of feeling unwell for 2-3
weeks. He tells you he had lost his appetite and feels sick
most of the time. He had also malaise and mild headache.
He thinks he might have mild fever also but had not
checked temperature. Marsh works as an accountant in a
tax office and had missed office for the last few days due to
this problem. He lives with his girlfriend in an apartment in
the CBD area.
Task
a. Further history (traveled 4 weeks ago to Thailand
and ate street foods; smokes 10-15 cigarettes per day;
drinks alcohol )
b. Physical examination (tired, no pallor or jaundice,
+ mild dehydration, VS normal; chest and hear t normal;
thyroid normal; liver palpable 1.5cm below subcostal
margin, spleen not palpable; PR normal; urine dipstick
normal and BSL 4.6mmol/L)
c. Probable diagnosis and management advise
History
- Any chills or rigors? Do you have a sore throat?
Have you noticed any lumps or enlarged glands in the body
especially around the neck? When you traveled to
Thailand, did you come in contact with a sick person? Did
you receive hepatitis B vaccination or hepatitis A? What is
your occupation? At the moment, do you smoke, drink
alcohol, any allergies to medications. May I ask, how is
your girlfriend, is she sick at the moment? Any weight loss?
Any change in color of stool? Any chance of contact with
pets (cats and dogs)?
- How’s your general health? Any past medical or
surgical history?
Physical examination
- General appearance: pallor, dehydration,
jaundice;
- Vital signs
- Chest and heart
- Abdomen: tenderness or organomegaly
- PR
Investigation
- FBE, urea and electrolytes, LFTs, INR, hepatitis
serology as well as CMV, EBV, HIV (if indicated)
Management
- Most likely what you have is a viral illness called
hepatitis A. This virus is usually spread from person to
person, either through closed contact or through
contaminated food and water. It causes inflammation of the
liver giving symptoms like fever, malaise, lack of appetite,
yellowish skin, pale stools, and dark urine. This is a very
common infection especially after returning from endemic
areas. I am going to do some tests for you in order to
exclude any serious causes of fever and jaundice. If
possible, please ask your girlfriend to come and see me or
her GP because it is a highly infectious disease where the
patient is infective 2 weeks before and 1 week after the
appearance of jaundice.
- Regarding management, the best treatment is to
take rest and eat a healthy nutritious diet. I will give you a
leave certificate for at least one week. You are advised to
take bed rest, have a fat free diet, have plenty of fluids but
avoid alcohol. Please avoid paracetamol as well as any
other medications without consulting the doctor first. You
can have aspirin for fever. The prognosis is excellent. A
complete recovery is expected. However, sometimes, the
symptoms might worsen for a few days where there is a
risk of dehydration and malnutrition. In that case, we will
admit you in the hospital for a few days. What is important
is to practice hygiene by regularly washing hands, avoid
sharing food, drinks, as well as items of personal use. For
all close contacts, we can give Immunoglobulins to protect
them from this disease. For you, after recovery, lifelong
immunity develops. However, it is advisable for all others to
be vaccinated against hepatitis A before traveling.
- I need to notify the Department of health because
they are the ones who will do tracing for those who came
into contact with you two weeks before jaundice appeared.
- Complications: none
- I would like to see you after two weeks. If your
symptoms become worse, please go to the hospital.
Hepatitis B
Case: You are a GP and a 25-year-old female comes to
you. She was referred to you by Red Cross and she was
found to be hepatitis B positive.
Task
a. History (+ IV Drug abuser when she was young,
no tattoo, safe sex with partner, unsafe sex when teenager)
b. Relevant investigations (LFTs elevated, ALT/AST
increased, HBsAG(+), HBeAg(-), viral load (-), anti-HBV Ab
(+)
c. Management
Cases of Hepatitis B
- Immunotolerant: HBsAg (+), HBeAg (+), ALT
normal, HBV DNA>20,000 IU/L (normal <2,000 IU/L), Liver
biopsy normal, Core Ag/Ab (monitored for effectiveness of
therapy)
- Phase II (Immune clearance): HBsAg (+), HBeAg
(+), Anti-HBe (+), ALT (increased), HBV DNA (increased),
moderate to severe hepatitis
- Phase III (Immune Controlled): HBsAg (+),
HBeAg (-), Anti-HBe (+), ALT (normal), viral load (<2,000
IU/L- undetectable)
- Phase IV (Immune Escape): HBsAg (+), HBeAg
(-), Anti-HBe Ab (+), ALT (increased), viral load increased,
liver biopsy: chronic inflammation/cirrhosis
History
- How are you feeling at the moment? Do you
have any symptoms at the moment like nausea, vomiting,
tummy pains, lack of appetite, yellowish discoloration of the
skin, fever, or change in color of urine or stool? Any pain
anywhere in the body especially joint pain? How is your
general health? Any past medical or surgical condition?
Have you ever had blood transfusion? Any history of
contact with a person who had hepatitis B? Did you travel
overseas in the past? Any history of tattooing, body
piercing? Do you smoke or drink? Have you ever tried any
recreational drugs especially IV drugs? Did you ever share
needles with someone? When was the last time you
shared a needle? Are you in a stable relationship? How
many partners have you had previously? What method of
contraception do you use? Any history of STIs in yourself
or your partner? What is your occupation? Have you ever
been pregnant before and do you intend to become
pregnant in the near future?
Investigation
- FBE, INR, inflammatory markers, LFTs, complete
hepatitis serology, STD screening (if indicated), HBV
genotyping
Counseling
- Unfortunately, the results confirm that you have
been infected with a virus called Hepatitis B. All hepatitis
viruses usually present with the same symptoms, but the
mode of transmission is different for each one of them.
Most likely you got this infection by sharing needles for IV
drug usage many years ago.
- At the moment, it seems like your liver is
functioning well, so there is a very high chance that you
might clear this infection spontaneously. However, around
6-8% of hepatitis B carriers develop chronic hepatitis where
the liver becomes inflamed and gives symptoms like fever,
jaundice, and lack of appetite. Later on, the liver might start
to fail ending up with cirrhosis of liver. Therefore, the most
important management aspect would be to prevent chronic
hepatitis from developing. What you need to do is STOP
smoking and alcohol. It damages the liver everyday if you
keep on drinking. Please take a healthy and nutritious diet.
You need to practice safe sex from now onwards with the
use of condoms as there is a risk of transmission to sexual
contacts. If you like you can call in your partner for further
discussions. We will do monthly hepatitis B testing for you.
If at anytime the LFTs are found to be abnormal, I will refer
you to the specialist and they will do further testing such as
liver biopsy and start you on antiretroviral therapy
(lamivudine [nucleoside analog] PO up to 4 years and
interferon [cytokine] SQ x 48 weeks). If the LFTs remain
normal, most likely you will be able to clear this infection on
your own. However, I want you to be aware of the risk of
developing hepatic cancer seen in around 20% of patients
with hepatitis B especially if they are alcoholic, liver
cirrhosis, older age, males, and coexisting hepatitis C/D
infection. We will do frequent testing of AFP and CEA to
detect development of this type of cancer.
- I will notify the department of health. Please be
assured that it will be done in a confidential manner where
you do not need to trace any contacts. It will be handled by
them but it is important to stop the spread of this infection. I
will give you some reading material to read about it.
- Diagnosis of Chronic Hepatitis B: HBsAg (+)
>6mos, no clinical or laboratory evidence of acute Hepatitis
B.
Infectious mononucleosis
Case: You are a GP and a 32-year-old male comes to you
complaining of fever, sore throat, rash and some enlarged
glands over his neck. On examination he is found to be
febrile. He has a maculopapular rash on the trunk, more on
the back. The throat is showing inflamed tonsils but no pus
exudates. He has cervical LAD bilaterally along with mild
hepatosplenomegaly.
Task
a. Discuss differentials based on history and
examination with examiner
b. Explain investigations and management to
patient
Differential Diagnosis
- EBV
- HIV
- Streptococcus pharyngitis (tonsillitis)
- Lymphoma/leukemia
- CMV/toxoplasmosis
- Hepatitis
- Rickettsia/leptospirosis
- Rubella
- Disseminated gonococcal disease (DIC)
- Kawasaki (kids)
About EBV:
- Can mimic diseases such as HIV, strep tonsillitis,
viral hepatitis, ALL
- 3 forms:
o Febrile
o Anginose (sore throat) (2months max). Most of these symptoms subside within 3
o Glandular (LAD) weeks. At the moment, you need to take bed rest, ample
- Occurs in 10-35 but usually 15-25 years fluids, control fever (ASA), avoid alcohol, smoking and fatty
- Low infectivity; transmitted by close contact foods as well. Choose a healthy, nutritious diet.
(kissing and sharing drinking vessels) - Complication:
- Rash is almost always related to taking penicillins o Antibiotic-induced rash
(for strep) o Hepatitis
- Investigation o Depression
o Blood film (atypical lymphocytes) o Chronic fatigue syndrome
o Monospot test/Paul Bunnel test (antibodies and o Rare: myocarditis, hemolytic anemia, splenic
specific EBV nuclear antigen) rupture, cranial nerve paralysis, GBS
 False positives: hepatitis, HL, acute leukemia - IF you develop any symptoms like jaundice,
o EBV antibodies excessive fatigue, right-sided tummy pain, bleeding, or
- Prognosis: uncomplicated 6-8 weeks; subside excessive bruising please come to the hospital ASAP. At
within 2-3 weeks the moment, your spleen is a bit enlarged, so you need to
- Treatment: avoid any type of contact sports for at least 4 weeks. I have
o Supportive arranged some tests to confirm the diagnosis. Please avoid
o Rest any antibiotics as they are not helpful. Practice personal
o ASA/PCM hygiene.
o Advise against alcohol, fatty foods, avoid contact - Reading material and review.
sports
o Hydration
o Steroids: neurologic involvement,
thrombocytopenia Sexually Transmitted Infection (Chlamydia trachomatis)

History: Case: Andrew aged 21 years visits your surgery first time
- When fever started? How high? Continuous or and looks anxious. He is university student living in shared
intermittent? Shaking/chills? accommodation. He complains of a 3-week history of pain
- What about sore throat? Do you have difficulty on micturition and dull throbbing low abdominal pain. His
swallowing? Joint pain? Body aches? girlfriend thinks he has urinary infection. Andrew developed
- What about the rash? When did it come? Is it nocturia 3-4 times per night. There is no blood in his urine
itchy? Do you know if you’re allergic to anything? Did you but there has been staining in his underwear. He reports
take any medications? Any antibiotics? Have you noticed feeling lousy with no appetite or energy, but has not been
yellowish discoloration of your skin? N/V, headache, visual feverish.
problems, tummy pain? Change in BM? Change in
waterworks? Case 2: David is 21 years old. He presented as a new
- Did you come in contact with a person with patient in your clinic. He seems to be a little bit anxious. He
similar symptoms? What is your occupation? Did you travel complains of 3 weeks history of pain on micturition and dull
recently? PMHx? May I know, are you sexually active at lower abdominal pain.
the moment? Are you in a stable relationship? What is your
preference? How many partners have you had previously? Task
Any history of STIs? Do you use condoms? SADMA? Any a. History
history of needle sharing, blood transfusion or tattoing/body b. Examination findings
piercing? How is your mood, sleep, appetite? Any c. Investigations
problems/stress at the moment? d. Differential diagnosis
e. Management
Investigations:
- Blood film Differential Diagnosis
- Monospot test - STI
- STI screen if indicated - UTI
- DM
Management
- You most likely have a condition called glandural Do Abdomen, genital (ulcers, discharge, scrotal exam) and
fever. It is a viral infection that is usually acquired by close PR exams
personal contact. Please don’t worry. It is not a dangerous
condition. It can make you feel sick for a few weeks Diagnosis and treatment advice:
- Based on your history and physical examination,
you have a condition called Chlamydia. It is caused by a
bacteria called Chlamydia trachomatis and is the most
common sexually transmitted infection.
- Do STI screen
- Informed consent
- 1st pass urine for PCR of Chlamydia and
gonorrhea
- Blood test for syphilis, HIV, hepatitis, urine MSU
for urine and culture
- Chlamydia:
o Asymptomatic – azithromycin 1g SD
o Symptomatic – doxycycline 100mg BD x 1 week
- IF with gonorrhea: ceftriaxone 500mg IM SD
- Notify DHS. Trace up to 6 months. Inform
partners for the last 6 months by patient himself or by DHS.
- GIVE SAFE SEX ADVICE. Abstain from sex for 7
days while on treatment.
- Repeat PCR 6 weeks after treatment.
Gonorrhoea
Case: You are working in GP practice and your next patient
is George a 20-year-old truck driver who has a sore throat
and discomfort on swallowing for the past 2 days.
Task
a. Take history
b. Physical examination findings from the examiner
c. Ask further investigations
d. Management
Features:
- Gonorrhoea is caused by infection with Neisseria
gonorrhea which may involve columnar epithelium in the
lower genital tract(Urethritis), rectum, pharynx(Pharyngitis),
and eyes(Conjuctivitis).
- Gonococcal conjunctivitis is common in new born
especially from infected mother. It can also cause by Auto-
spread (within your body and spread by yourself eg.
Contaminated fingers.)
- Gonococcal Urethritis: Patient presents with
Mucopurulent urethral discharge. Very thick yellow
discharge. D/D Chlamydia: Whitish discharge.
- Gonorrhoea can also cause infection of
Bartholin’s gland. It is a Gram negative diplococci.
- Sexual partner must be examined and treated.
Sexual intercourse must be avoided until the infection is
clear. Follow up culture is advisable after 4 weeks
especially in the female patients.
History
- Sore throat and discomfort: When did it start (2
days ago)? Is it getting worse (Yes it’s getting worse -
Discomfort and some itchiness/burning sensation)? Do you
have any runny nose, sneezing, cough, with sputum? Any
chest pain? Any SOB? Any headache? Any rash? Do you
think you are feverish? How about your water work?
Change in colour? Dysuria? Frequency? How about the
bowel habit? Are you sexually active? Do you have a
stable partner? Do you remember you practice unsafe sex
recently (a week ago)? Did you practice safe sex (yes I
wear condoms)? Did you practice any alternative sex? Oral
sex (yes)? Do you have any idea if the women had any
STD infection? Have you ever been diagnosed with STD
before? SAD (He doesn’t smoke, he is a casual drinker, not
recreational drug)? No allergies?
- Health in General: Tired and joint pain.
Physical Examination
- General appearance: Healthy looking
- V/S: Temp 37.6
- ENT: Ear and nose looks ok!
- Pharynx is red, tonsils seem inflamed. There’s no
pus.
- No LN enlargement
- Genital examination: all good.
- Rest of the systems ok
- Urine dip stick and BSL normal
Investigation
- I’d like to run some investigations: Throat swab
for Gram staining, FBE and blood culture, Urine
microscopy and culture (1st pass urine), STD screening
HIV Syphilis and Clamydia
Diagnosis and Management
- From the history, examination and investigation
you got a condition called Gonococcal Pharyngitis. It is the
inflammation of your throat caused by a bug call Neisseria
gonorrhea. Its known to be a STD infection. Most likely you
got it from unprotected sex. But it’s a good idea you have
come.
- We will give you Ceftriaxone 250mg stat IM plus
Azithromycin 1g orally 1 dose/Doxy100mg twice a day for
10 days. If sensitivity is confirmed Ciprofloxacine 500mg
orally stat.
- Rest. Pain killer
- Advice for the safe sex. Use condoms and wash
after sex intercourse.
- “Can it get complicated?” Less likely, the
complications disseminated gonococcal infection,
conjunctivitis, epididymo-orchitis and prostitis. But these
are the conditions if you don’t have treatment.