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Question 1
Incorrect
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You encounter a 22-year-old man who visited you 4 weeks ago with symptoms of bloody diarrhoea and vomiting. He was diagnosed with Campylobacter jejuni after a stool sample test. He believes that he contracted the infection from consuming undercooked chicken at a barbecue 3 days before the onset of his symptoms.
Although he feels much better now, with the cessation of bloody diarrhoea, vomiting, and fever, he still experiences loose stools 3-4 times a day, along with abdominal pain and bloating after eating food. He maintains a regular diet.
What is the most probable diagnosis from the given options?Your Answer: Secondary inflammatory bowel disease
Correct Answer: Secondary lactose intolerance
Explanation:If a patient who previously had gastroenteritis and maintains a normal diet continues to experience changes in their bowel habits, the most probable diagnosis is acquired lactose intolerance.
The most likely explanation for this scenario is secondary lactose intolerance, which occurs when the lining of the gut is damaged and temporarily unable to produce sufficient lactase. This damage can be caused by any condition that irritates and harms the gut, such as gastroenteritis. This type of lactose intolerance is usually temporary, and avoiding dairy products for a few weeks or months allows the gut to heal. Over time, the gut’s ability to produce lactase will recover, and the patient will be able to consume dairy products again.
While other possibilities exist, inflammatory bowel disease and coeliac disease are less likely than lactose intolerance and are not typically associated with confirmed gastroenteritis.
Haemolytic uraemic syndrome is a rare complication of gastroenteritis, particularly with certain strains of E.coli, but it typically presents with haematuria and decreased urine output.
The final option is unlikely since it appears that the infection has improved.
Gastroenteritis can occur either at home or while traveling abroad, which is known as travelers’ diarrhea. This type of diarrhea is characterized by at least three loose to watery stools in 24 hours, along with abdominal cramps, fever, nausea, vomiting, or blood in the stool. The most common cause of traveler’s’ diarrhea is Escherichia coli. Another type of illness is acute food poisoning, which is caused by the ingestion of a toxin and results in sudden onset of nausea, vomiting, and diarrhea. Staphylococcus aureus, Bacillus cereus, and Clostridium perfringens are the typical causes of acute food poisoning.
Different infections have stereotypical histories and presentations. Escherichia coli is common among travelers and causes watery stools, abdominal cramps, and nausea. Giardiasis results in prolonged, non-bloody diarrhea. Cholera causes profuse, watery diarrhea and severe dehydration resulting in weight loss, but it is not common among travelers. Shigella causes bloody diarrhea, vomiting, and abdominal pain. Staphylococcus aureus causes severe vomiting with a short incubation period. Campylobacter usually starts with a flu-like prodrome and is followed by crampy abdominal pains, fever, and diarrhea, which may be bloody and may mimic appendicitis. Bacillus cereus has two types of illness: vomiting within six hours, typically due to rice, and diarrheal illness occurring after six hours. Amoebiasis has a gradual onset of bloody diarrhea, abdominal pain, and tenderness that may last for several weeks.
The incubation period for different infections varies. Staphylococcus aureus and Bacillus cereus have an incubation period of 1-6 hours, while Salmonella and Escherichia coli have an incubation period of 12-48 hours. Shigella and Campylobacter have an incubation period of 48-72 hours, while Giardiasis and Amoebiasis have an incubation period of more than seven days. The vomiting subtype of Bacillus cereus has an incubation period of 6-14 hours, while the diarrheal illness has an incubation period of more than six hours.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 2
Incorrect
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A 50-year-old business traveller noticed some moderate diarrhoea 3 days after he arrived in Korea. The diarrhoea lasted for 4 days.
What is the most probable reason for his diarrhoea?Your Answer: Giardia lamblia
Correct Answer: Enterotoxin-producing Escherichia coli
Explanation:Traveller’s Diarrhoea: Causes and Prevention
Traveller’s diarrhoea is a common problem that can disrupt holiday and business plans. The most common cause of this type of presentation is enterotoxin-producing Escherichia coli. Bacterial infections are responsible for 60-85% of cases, with E. coli being the most important bacterial pathogen. Symptoms are usually mild and last for about 3-5 days.
To reduce the risk of gastroenteritis, it is important to practice strict food and water hygiene. Water should be heated to 100°C to kill most pathogens, and chemical treatment with chlorine or iodine can also be effective (although iodine is not recommended for pregnant women or some patients with thyroid disease). Water filters can also be useful additions to prevent infection. By taking these precautions, travellers can reduce their risk of developing diarrhoea and enjoy their trips without interruption.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 3
Incorrect
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A 28-year-old intravenous drug user comes to the clinic after being released from prison. During his time there, he injected heroin and was forced to share needles. He reports experiencing flu-like symptoms for the past two weeks, including fever, joint and muscle pain, and a sore throat. He also had a rash, but it has since disappeared. Upon examination, he has lymph nodes in his neck and armpits, but his chest is clear. What is the most probable diagnosis?
Your Answer: Hepatitis C
Correct Answer: HIV seroconversion illness
Explanation:Early Detection of HIV: Recognizing Flu-Like Symptoms and Other Risk Factors
Flu-like symptoms in individuals with known risk factors for HIV should not be ignored. Early detection and treatment can significantly improve prognosis and reduce the risk of transmission. The initial seroconversion illness may be mild and last for about two weeks, after which patients may feel relatively well but continue to unknowingly transmit the virus. This illness typically occurs between one and six weeks after infection and presents with symptoms such as fever, malaise, myalgia, pharyngitis, headaches, diarrhea, neuralgia or neuropathy, lymphadenopathy, and a maculopapular rash. In rare cases, meningoencephalitis may occur. Acute infection may also be asymptomatic.
Other conditions such as tuberculosis, subacute bacterial endocarditis (SBE), hepatitis C, and glandular fever may present with similar symptoms. However, individuals with a high risk of HIV infection should consider it as the most likely diagnosis. SBE may be suspected in intravenous drug abusers who present with a murmur, particularly tricuspid regurgitation. Hepatitis C may be asymptomatic initially but should be considered if there is jaundice.
In conclusion, recognizing flu-like symptoms and other risk factors for HIV is crucial for early detection and treatment. It is important to seek medical attention and get tested if any of these symptoms are present, as early intervention can make a significant difference in both individual prognosis and the risk of transmission.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 4
Incorrect
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A 43-year-old man presents to the urgent treatment centre with a concern about a tick that he found attached to his calf after walking in the nearby woods. There are no signs of infection or erythema in the surrounding skin.
What is the best course of action for managing this patient?Your Answer: Irrigate the calf with a saline solution to 'soak' the tick off
Correct Answer: Remove the tick using fine-tipped tweezers, grasping the tick firmly by the head as close to the skin as possible and pulling firmly upwards
Explanation:To effectively remove a tick, it is recommended to use fine-tipped tweezers and grasp the tick as close to the skin as possible. Pulling upwards firmly is important to keep the head and body of the tick intact and prevent the body from detaching. If the body detaches, the mouthparts may be left in the skin and cause a local infection. After removal, the bite area should be cleaned with antiseptic or soap and water, and the patient should monitor for any changes for several weeks.
It is not recommended to remove the tick with a fine-toothed comb or attempt to soak it off with saline solution, as these methods may cause the head to detach.
Prophylactic antibiotics are not recommended by NICE for preventing Lyme disease in patients with tick bites.
Understanding Lyme Disease
Lyme disease is an illness caused by a type of bacteria called Borrelia burgdorferi, which is transmitted to humans through the bite of infected ticks. The disease can cause a range of symptoms, which can be divided into early and later features.
Early features of Lyme disease typically occur within 30 days of being bitten by an infected tick. These can include a distinctive rash known as erythema migrans, which often appears as a bulls-eye pattern around the site of the tick bite. Other early symptoms may include headache, lethargy, fever, and joint pain.
Later features of Lyme disease can occur after 30 days and may affect different parts of the body. These can include heart block or myocarditis, which affect the cardiovascular system, and facial nerve palsy or meningitis, which affect the nervous system.
To diagnose Lyme disease, doctors may look for the presence of erythema migrans or use blood tests to detect antibodies to Borrelia burgdorferi. Treatment typically involves antibiotics, such as doxycycline or amoxicillin, depending on the stage of the disease.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 5
Correct
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A 14-year-old male from France comes to the clinic complaining of feeling sick for the past 2 weeks. At first, he had a sore throat but now he is having occasional joint pains in his knees, hips, and ankles. During the examination, some pink, ring-shaped lesions are observed on his trunk, and he occasionally experiences jerking movements of his face and hands. What is the probable diagnosis?
Your Answer: Rheumatic fever
Explanation:Rheumatic fever is a condition that occurs as a result of an immune response to a recent Streptococcus pyogenes infection, typically occurring 2-4 weeks after the initial infection. The pathogenesis of rheumatic fever involves the activation of the innate immune system, leading to antigen presentation to T cells. B and T cells then produce IgG and IgM antibodies, and CD4+ T cells are activated. This immune response is thought to be cross-reactive, mediated by molecular mimicry, where antibodies against M protein cross-react with myosin and the smooth muscle of arteries. This response leads to the clinical features of rheumatic fever, including Aschoff bodies, which are granulomatous nodules found in rheumatic heart fever.
To diagnose rheumatic fever, evidence of recent streptococcal infection must be present, along with 2 major criteria or 1 major criterion and 2 minor criteria. Major criteria include erythema marginatum, Sydenham’s chorea, polyarthritis, carditis and valvulitis, and subcutaneous nodules. Minor criteria include raised ESR or CRP, pyrexia, arthralgia, and prolonged PR interval.
Management of rheumatic fever involves antibiotics, typically oral penicillin V, as well as anti-inflammatories such as NSAIDs as first-line treatment. Any complications that develop, such as heart failure, should also be treated. It is important to diagnose and treat rheumatic fever promptly to prevent long-term complications such as rheumatic heart disease.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 6
Correct
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A 30-year-old man presents with a 10-day history of mucopurulent anal discharge, anal bleeding, and pain during defecation.
What is the MOST PROBABLE diagnosis?Your Answer: Gonorrhoea
Explanation:Symptoms and Causes of Rectal Infections
Rectal infections can have various symptoms and causes. Gonorrhoea, for instance, is often asymptomatic but may cause anal discharge or perianal/anal pain, pruritus, or bleeding. Primary syphilis, on the other hand, is characterized by a painless ulcer or chancre. Candidiasis is associated with a perianal intertrigenous rash, while Crohn’s disease may lead to perianal pendulous skin tags, abscesses, and fistulas. Salmonella infection, meanwhile, causes acute diarrhea, vomiting, abdominal cramps, and fever. It is important to seek medical attention if you experience any of these symptoms to receive proper diagnosis and treatment.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 7
Incorrect
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A woman who is 16 weeks pregnant is planning to travel with her husband to the Middle East and South America for his job. She wants to know which vaccinations are safe to receive during pregnancy.
Which of the following vaccinations can be given without significant risk to the woman and her developing fetus?Your Answer: BCG
Correct Answer: Yellow fever
Explanation:Vaccinations for Travelers
Hepatitis A and B vaccinations are made from viral antigens and do not contain any living hepatitis virus component. For individuals traveling to countries with a high risk of hepatitis A, vaccination may be recommended. However, it is important to note that the other vaccines listed, such as polio, are live vaccinations. The polio vaccine can be administered orally or through an intramuscular injection, depending on the preparation used. It is crucial for travelers to consult with a healthcare professional to determine which vaccinations are necessary for their specific travel plans.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 8
Incorrect
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Sarah is a 28-year-old woman who is in the second trimester of her pregnancy. She presents to you with a red, hot swelling of her right big toe. She suspects that she may have been bitten by an insect in that area last week. She reports that the redness has started to spread onto the dorsum of her right foot over the past few days.
Sarah is stable hemodynamically and has no fever. Her right big toe has a cellulitic appearance. You observe that she has an allergy to penicillin.
What would be the most suitable course of action?Your Answer: Prescribe a 5 day course of oral clarithromycin
Correct Answer: Prescribe a 7 day course of oral erythromycin
Explanation:If a patient is allergic to penicillin, erythromycin is the preferred antibiotic for treating cellulitis during pregnancy. Clarithromycin, another macrolide antibiotic, is the alternative choice for penicillin-allergic patients, but it should be avoided during pregnancy.
Understanding Cellulitis: Symptoms, Diagnosis, and Treatment
Cellulitis is a common skin infection caused by Streptococcus pyogenes or Staphylococcus aureus. It is characterized by inflammation of the skin and subcutaneous tissues, usually on the shins, accompanied by erythema, pain, swelling, and sometimes fever. The diagnosis of cellulitis is based on clinical features, and no further investigations are required in primary care. However, bloods and blood cultures may be requested if the patient is admitted and septicaemia is suspected.
To guide the management of patients with cellulitis, NICE Clinical Knowledge Summaries recommend using the Eron classification. Patients with Eron Class III or Class IV cellulitis, severe or rapidly deteriorating cellulitis, very young or frail patients, immunocompromised patients, patients with significant lymphoedema, or facial or periorbital cellulitis (unless very mild) should be admitted for intravenous antibiotics. Patients with Eron Class II cellulitis may not require admission if the facilities and expertise are available in the community to give intravenous antibiotics and monitor the patient.
The first-line treatment for mild/moderate cellulitis is flucloxacillin, while clarithromycin, erythromycin (in pregnancy), or doxycycline is recommended for patients allergic to penicillin. Patients with severe cellulitis should be offered co-amoxiclav, cefuroxime, clindamycin, or ceftriaxone. Understanding the symptoms, diagnosis, and treatment of cellulitis is crucial for effective management and prevention of complications.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 9
Incorrect
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What is considered good practice for managing and storing vaccines?
Your Answer: Orders for vaccines are placed every 4-8 weeks according to need
Correct Answer: Named, trained, people are responsible for ordering, receipt and care of vaccines
Explanation:Best Practices for Vaccine Management in Healthcare Facilities
In healthcare facilities, it is crucial to have named, trained individuals responsible for the ordering, receipt, and care of vaccines. While one person from the nursing team and one from management are typically designated, all team members should understand the importance of proper vaccine management.
Orders for vaccines should be placed every 2-4 weeks based on need, rather than every 4-8 weeks. Vaccines must be stored in a vaccine fridge that is used solely for pharmaceutical products and kept between 2°C and 8°C. The fridge temperature should be monitored daily, recording the minimum, maximum, and actual temperatures when the practice is open.
Proper rotation of vaccines is essential, with the shortest expiry date used first. The term cold chain refers to the cold temperature conditions in which vaccine products must be kept during storage and distribution. Cool boxes from a recognized medical supplier should be used to transport vaccines. If the cold chain is compromised, vaccines should not be used or discarded until further advice is sought.
By following these best practices for vaccine management, healthcare facilities can ensure the safety and efficacy of vaccines for their patients.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 10
Correct
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As part of a medication review for a 75-year-old patient, who had a previous admission complicated by C. difficile infection, which of the following commonly prescribed medications should be potentially discontinued due to its association with an increased risk of C. difficile infection?
Your Answer: Omeprazole
Explanation:Proton pump inhibitors (PPIs) have been identified as a risk factor for C. difficile infection (CDI), with evidence suggesting that they increase the likelihood of infection more than H2 antagonists. As a result, patients with CDI or those at high risk of infection, such as those who have previously experienced CDI, should have their use of PPIs reviewed. Other factors that increase the risk of CDI include advancing age, the use of antibiotics (especially broad-spectrum antibiotics and multiple courses), inflammatory bowel disease, extended hospital stays, immunosuppression, and gastrointestinal surgery.
Clostridioides difficile is a type of bacteria that is commonly found in hospitals. It produces a toxin that can damage the intestines and cause a condition called pseudomembranous colitis. This bacteria usually develops when the normal gut flora is disrupted by broad-spectrum antibiotics, with second and third generation cephalosporins being the leading cause. Other risk factors include the use of proton pump inhibitors. Symptoms of C. difficile infection include diarrhea, abdominal pain, and a raised white blood cell count. The severity of the infection can be determined using the Public Health England severity scale.
To diagnose C. difficile infection, a stool sample is tested for the presence of the C. difficile toxin. Treatment involves reviewing current antibiotic therapy and stopping antibiotics if possible. For a first episode of infection, oral vancomycin is the first-line therapy for 10 days, followed by oral fidaxomicin as second-line therapy and oral vancomycin with or without IV metronidazole as third-line therapy. Recurrent infections may require different treatment options, such as oral fidaxomicin within 12 weeks of symptom resolution or oral vancomycin or fidaxomicin after 12 weeks of symptom resolution. In life-threatening cases, oral vancomycin and IV metronidazole may be used, and surgery may be considered with specialist advice. Other therapies, such as bezlotoxumab and fecal microbiota transplant, may also be considered for preventing recurrences in certain cases.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 11
Correct
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A 9-year-old boy is brought in to your clinic by his father. His father is worried because two days ago he had been playing in the same room as a child who was subsequently diagnosed with Chickenpox.
He is completely asymptomatic and has no other significant illnesses or allergies. His father declined the varicella vaccine when he was a baby having assumed that it could not be given because one of his grandparents had a history of shingles and a distant relative was undergoing investigation for possible autoimmune disease.
How would you handle this situation?Your Answer: Reassure that no further action necessary
Explanation:Measles and MMR Vaccination Guidelines
Significant contact with measles is defined as being in the same room as an infected individual for 15 minutes or more. If an individual has not been fully immunised or has not previously had laboratory confirmed measles, it is assumed that they lack immunity. This is important to note for children who have not received the MMR vaccination for no good reason, as family history of epilepsy or autism is not a contraindication.
Ideally, the MMR vaccine should be given within three days of contact with a possible case of measles. A repeat MMR vaccine should be given after at least a month. The first dose of MMR should be given between 12 and 13 months of age, within a month of the first birthday. Immunisation before one year of age provides earlier protection in localities where the risk of measles is higher, but residual maternal antibodies may reduce the response rate to the vaccine. The optimal age chosen for scheduling children is therefore a compromise between risk of disease and level of protection.
If a dose of MMR is given before the first birthday, either because of travel to an endemic country or because of a local outbreak, then this dose should be ignored, and two further doses given at the recommended times between 12 and 13 months of age and at three years four months to five years of age. During the 2012-13 outbreak in Wales, a recommendation was made about the possibility of withdrawal from educational establishments for unvaccinated close contacts.
It is important to follow these guidelines to prevent the spread of measles and protect individuals who may be at risk.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 12
Incorrect
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What is the most effective approach for preventing and treating hepatitis C?
Your Answer: No vaccine and no treatment is available
Correct Answer: No vaccine is available but treatment is successful in the majority of patients
Explanation:Hepatitis C is a virus that is expected to become a significant public health issue in the UK in the coming years, with around 200,000 people believed to be chronically infected. Those at risk include intravenous drug users and individuals who received a blood transfusion before 1991, such as haemophiliacs. The virus is an RNA flavivirus with an incubation period of 6-9 weeks. Transmission can occur through needle stick injuries, vertical transmission from mother to child, and sexual intercourse, although the risk is relatively low. There is currently no vaccine for hepatitis C.
After exposure to the virus, only around 30% of patients will develop symptoms such as a transient rise in serum aminotransferases, jaundice, fatigue, and arthralgia. HCV RNA is the preferred diagnostic test for acute infection, although patients who spontaneously clear the virus will continue to have anti-HCV antibodies. Chronic hepatitis C is defined as the persistence of HCV RNA in the blood for 6 months and can lead to complications such as rheumatological problems, cirrhosis, hepatocellular cancer, and cryoglobulinaemia.
The management of chronic hepatitis C depends on the viral genotype and aims to achieve sustained virological response (SVR), defined as undetectable serum HCV RNA six months after the end of therapy. Interferon-based treatments are no longer recommended, and a combination of protease inhibitors with or without ribavirin is currently used. However, these treatments can have side effects such as haemolytic anaemia, cough, flu-like symptoms, depression, fatigue, leukopenia, and thrombocytopenia. Women should not become pregnant within 6 months of stopping ribavirin as it is teratogenic.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 13
Incorrect
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Samantha is a 67-year-old woman who presents with skin changes on her left lower leg. During examination, Samantha has a low-grade fever and the left lower leg is erythematous, mildly swollen, and warm to touch. The diagnosis is cellulitis, and since Samantha is allergic to penicillin, you prescribe a course of oral clarithromycin.
One week later, Samantha returns with new palpitations. What potential side effect of this antibiotic can be observed on an ECG?Your Answer: Shortened PR interval
Correct Answer: Prolonged QT interval
Explanation:Macrolides have been known to cause QT interval prolongation, which can lead to palpitations as an uncommon side effect. On the other hand, a shortened PR interval may indicate pre-excitation or an AV nodal (junctional) rhythm, while a prolonged PR interval suggests delayed conduction of the sinoatrial nodal impulse to the ventricles, also known as first-degree AV block. Prominent P waves, on the other hand, are typically caused by right atrial enlargement due to various factors such as chronic lung disease, tricuspid stenosis, congenital heart disease, or primary pulmonary hypertension.
Macrolides are a class of antibiotics that include erythromycin, clarithromycin, and azithromycin. They work by blocking translocation during bacterial protein synthesis, ultimately inhibiting bacterial growth. While they are generally considered bacteriostatic, their effectiveness can vary depending on the dose and type of organism being treated. Resistance to macrolides can occur through post-transcriptional methylation of the 23S bacterial ribosomal RNA.
However, macrolides can also have adverse effects. They may cause prolongation of the QT interval and gastrointestinal side-effects, such as nausea. Cholestatic jaundice is a potential risk, but using erythromycin stearate may reduce this risk. Additionally, macrolides are known to inhibit the cytochrome P450 isoenzyme CYP3A4, which metabolizes statins. Therefore, it is important to stop taking statins while on a course of macrolides to avoid the risk of myopathy and rhabdomyolysis. Azithromycin is also associated with hearing loss and tinnitus.
Overall, while macrolides can be effective antibiotics, they do come with potential risks and side-effects. It is important to weigh the benefits and risks before starting a course of treatment with these antibiotics.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 14
Incorrect
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A 3-year-old girl has a temperature of 39.6ºC and a rash consisting of numerous dusky pink macules and papules. She became unwell 6 days ago, when her mother noticed that she had a dry cough, red eyes and a temperature. The rash started 2 days ago, appearing on her face initially, but then spreading to the trunk and limbs. She was in contact with a girl with a similar rash 2 weeks ago. There is no significant past medical history. She had not received all her childhood immunisations because of parental concerns regarding vaccine safety.
Select the single most likely cause of her rash.Your Answer: Rubella virus
Correct Answer: Measles virus
Explanation:Differentiating Measles from Other Childhood Illnesses
Measles is a highly contagious viral illness that typically presents with a prodrome of coryzal symptoms, dry cough, conjunctivitis, and fever before the appearance of a rash. Koplik’s spots may also be present on the buccal mucosa. However, other childhood illnesses can present with similar symptoms, making it important to differentiate between them. Rubella, for example, has a longer incubation period and is typically milder with no significant respiratory symptoms. Parvovirus B19 can mimic rubella with its slapped-cheek appearance. Infectious mononucleosis may present with a sore throat and lymphadenopathy, but any rash is fine and transient. Mumps may rarely cause a rash, but other symptoms are more prominent. It is crucial to accurately diagnose these illnesses to provide appropriate treatment and prevent further spread of infection.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 15
Incorrect
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One of your receptionists has tested positive for pertussis. Her GP has given her clarithromycin today.
She feels well enough to work, but with regard to her infectivity, when could she start back at work?Your Answer: In 7 days
Correct Answer: When her cough subsides
Explanation:Pertussis Guidance for Healthcare Workers
According to the latest guidance from Public Health England (PHE), healthcare workers (HCWs) suspected of having pertussis should be excluded from work until 48 hours of appropriate antibiotic treatment is completed or for 21 days from onset if not treated. This is a change from earlier advice to exclude for 5 days. Hospitalized patients with pertussis should be placed in respiratory isolation until 48 hours of treatment is completed or for 21 days from onset if not treated. HCWs looking after patients with pertussis should wear appropriate personal protective equipment (PPE).
It is important for GPs to understand and implement key national guidelines that influence healthcare provision for respiratory problems, as stated in the RCGP Curriculum Statement 3.19. Public Health England has published comprehensive guidelines on the symptoms, diagnosis, management, surveillance, and epidemiology of pertussis, including updated sub-documents. Staying up to date with the latest guidance is crucial for providing safe and effective care to patients and protecting the health of healthcare workers.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 16
Incorrect
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A 28-year-old woman who is 10-weeks pregnant presents with complaints of heightened vaginal discharge accompanied by itching. Upon conducting a sexual health screening, it is discovered that she has tested positive for gonorrhoea. What is the recommended treatment for her condition?
Your Answer: Oral metronidazole
Correct Answer: IM ceftriaxone
Explanation:Gonorrhoea is best treated with intramuscular ceftriaxone, which is also safe to administer during pregnancy.
Understanding Gonorrhoea: Causes, Symptoms, and Treatment
Gonorrhoea is a sexually transmitted infection caused by the Gram-negative diplococcus Neisseria gonorrhoeae. It can occur on any mucous membrane surface, including the genitourinary tract, rectum, and pharynx. Symptoms in males include urethral discharge and dysuria, while females may experience cervicitis leading to vaginal discharge. However, rectal and pharyngeal infections are usually asymptomatic. Unfortunately, immunisation is not possible, and reinfection is common due to antigen variation of type IV pili and Opa proteins.
If left untreated, gonorrhoea can lead to local complications such as urethral strictures, epididymitis, and salpingitis, which may result in infertility. Disseminated infection may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults. The pathophysiology of disseminated gonococcal infection is not fully understood but is thought to be due to haematogenous spread from mucosal infection.
Management of gonorrhoea involves the use of antibiotics. Ciprofloxacin used to be the treatment of choice, but there is now increased resistance to it. Cephalosporins are now more widely used, with a single dose of IM ceftriaxone 1g being the new first-line treatment. If sensitivities are known, a single dose of oral ciprofloxacin 500mg may be given. Disseminated gonococcal infection and gonococcal arthritis may also occur, with symptoms including tenosynovitis, migratory polyarthritis, and dermatitis.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 17
Incorrect
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A 42 year old patient is undergoing quadruple therapy (rifampicin, isoniazid, ethambutol and pyrizinamide) for pulmonary tuberculosis. The patient also takes sertraline for a history of depression. The patient reports a decline in vision, specifically a decrease in color vibrancy. Which medication is the most likely culprit?
Your Answer: Isoniazid
Correct Answer: Ethambutol
Explanation:The use of ethambutol has been linked to optic neuropathy and the onset of color blindness. If these symptoms occur, the medication should be stopped. To prevent these adverse effects, pyridoxine (vitamin B6) is often administered alongside ethambutol in medical settings.
Tuberculosis is a bacterial infection that can be treated with a combination of drugs. Each drug has a specific mechanism of action and can also cause side-effects. Rifampicin works by inhibiting bacterial DNA dependent RNA polymerase, which prevents the transcription of DNA into mRNA. However, it is a potent liver enzyme inducer and can cause hepatitis, orange secretions, and flu-like symptoms.
Isoniazid, on the other hand, inhibits mycolic acid synthesis. It can cause peripheral neuropathy, which can be prevented with pyridoxine (Vitamin B6). It can also cause hepatitis and agranulocytosis, but it is a liver enzyme inhibitor.
Pyrazinamide is converted by pyrazinamidase into pyrazinoic acid, which inhibits fatty acid synthase (FAS) I. However, it can cause hyperuricaemia, leading to gout, as well as arthralgia and myalgia. It can also cause hepatitis.
Finally, Ethambutol inhibits the enzyme arabinosyl transferase, which polymerizes arabinose into arabinan. However, it can cause optic neuritis, so it is important to check visual acuity before and during treatment. The dose also needs adjusting in patients with renal impairment.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 18
Incorrect
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A 28-year-old man comes to you complaining of fatigue and general discomfort. He recently went camping in the New Forest and recalls having multiple tick bites.
Upon examination, there are no visible rashes or swollen lymph nodes. The abdomen is soft and non-tender, with no signs of liver or spleen enlargement. The thyroid appears normal.
Lyme disease is suspected, but the ELISA test comes back negative. Based on the current NICE CKS guidelines, what is the next best course of action?Your Answer: Refer the patient for same day review by the infectious diseases team
Correct Answer: Repeat the ELISA test in 4-6 weeks after the start of symptoms
Explanation:If a patient is suspected to have Lyme disease and presents within 4 weeks of symptom onset, it is recommended to repeat the ELISA test after 4-6 weeks if the initial test is negative. This is because the initial test may not detect the disease in its early stages. It is important to avoid diagnosing Lyme disease at this stage without an erythema migrans rash, as it may lead to inappropriate treatment and the possibility of missing alternative diagnoses. An immunoblot test may be necessary if symptoms persist for 12 weeks or more, or if the ELISA test is positive or equivocal. Referring the patient for same-day review by the infectious diseases team is unnecessary as the patient is not acutely unwell. It is also incorrect to inform the patient that Lyme disease is excluded, especially if the ELISA test was done within 4 weeks of symptom onset, as it may result in a false-negative result. It is important to investigate other potential causes of the patient’s symptoms.
Understanding Lyme Disease
Lyme disease is an illness caused by a type of bacteria called Borrelia burgdorferi, which is transmitted to humans through the bite of infected ticks. The disease can cause a range of symptoms, which can be divided into early and later features.
Early features of Lyme disease typically occur within 30 days of being bitten by an infected tick. These can include a distinctive rash known as erythema migrans, which often appears as a bulls-eye pattern around the site of the tick bite. Other early symptoms may include headache, lethargy, fever, and joint pain.
Later features of Lyme disease can occur after 30 days and may affect different parts of the body. These can include heart block or myocarditis, which affect the cardiovascular system, and facial nerve palsy or meningitis, which affect the nervous system.
To diagnose Lyme disease, doctors may look for the presence of erythema migrans or use blood tests to detect antibodies to Borrelia burgdorferi. Treatment typically involves antibiotics, such as doxycycline or amoxicillin, depending on the stage of the disease.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 19
Incorrect
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You see a 28-year-old woman with painful lesions on her labia. On examination she has genital herpes.
Select the single correct statement about this condition.Your Answer: The first attack is usually mild, with severity increasing with recurrent attacks
Correct Answer: Regular antiviral medication can reduce transmission to sexual partners
Explanation:Understanding the Symptoms and Treatment of Herpes
Herpes is a viral infection that can cause lesions on the cervix, vulva, vagina, and prepuce. The first attack is usually the most severe, and healing can take up to 2-4 weeks in primary herpes and 10 days in recurrent attacks. Immunocompromised patients tend to experience longer and more severe attacks. However, a trial in the New England Journal of Medicine in 2004 found that daily use of valaciclovir can reduce transmission by 75% between discordant couples. It is important to understand the symptoms and treatment of herpes to manage the infection effectively.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 20
Incorrect
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Your practice manager is ordering influenza vaccinations for the forthcoming vaccination programme ahead of the winter. She asks you about storage of the intranasal influenza vaccination for adults.
Which of the following is the correct advice to give?Your Answer: It can be stored at room temperature (up to 25°C) providing it is protected from light
Correct Answer: It should be stored specifically between +2°C and +8°C in line with the storage of the intramuscular influenza vaccines
Explanation:Vaccine Storage and Sensitivity
To maintain the potency and effectiveness of vaccines, it is important to store them properly. Vaccines can be sensitive to changes in temperature and exposure to light, which can reduce their shelf life and potency. Excessive heat can cause a decline in potency, while freezing can increase reactogenicity and reduce vaccine potency. Freezing can also lead to cracks in vaccine containers, which can result in contamination.
The nasal influenza vaccine should be stored between +2°C and +8°C and protected from light, similar to the intramuscular influenza vaccine. Refrigeration with close temperature monitoring is necessary to achieve this. However, the nasal influenza vaccine can be left out of the refrigerator for up to 12 hours before use, as long as it is not exposed to temperatures above 25°C. If it has not been used within 12 hours, it should be disposed of rather than re-refrigerated for future use. Proper vaccine storage is crucial to ensure their effectiveness and safety.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 21
Incorrect
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A 28-year-old woman is being seen at the genitourinary medicine clinic for vaginal discharge and dysuria. Upon examination, an endocervical swab revealed a Gram-negative coccus identified as Neisseria gonorrhoea, marking her third episode of gonorrhoea in the last two years. What is the probable outcome of repeated infections?
Your Answer: Lymphogranuloma venereum
Correct Answer: Infertility
Explanation:Pelvic inflammatory disease (PID) resulting in infertility is frequently seen as a complication of gonorrhoea, with Chlamydia being the only cause of PID that is more common. Arthropathy is a rare occurrence in comparison. Chlamydia trachomatis is responsible for causing lymphogranuloma venereum.
Understanding Gonorrhoea: Causes, Symptoms, and Treatment
Gonorrhoea is a sexually transmitted infection caused by the Gram-negative diplococcus Neisseria gonorrhoeae. It can occur on any mucous membrane surface, including the genitourinary tract, rectum, and pharynx. Symptoms in males include urethral discharge and dysuria, while females may experience cervicitis leading to vaginal discharge. However, rectal and pharyngeal infections are usually asymptomatic. Unfortunately, immunisation is not possible, and reinfection is common due to antigen variation of type IV pili and Opa proteins.
If left untreated, gonorrhoea can lead to local complications such as urethral strictures, epididymitis, and salpingitis, which may result in infertility. Disseminated infection may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults. The pathophysiology of disseminated gonococcal infection is not fully understood but is thought to be due to haematogenous spread from mucosal infection.
Management of gonorrhoea involves the use of antibiotics. Ciprofloxacin used to be the treatment of choice, but there is now increased resistance to it. Cephalosporins are now more widely used, with a single dose of IM ceftriaxone 1g being the new first-line treatment. If sensitivities are known, a single dose of oral ciprofloxacin 500mg may be given. Disseminated gonococcal infection and gonococcal arthritis may also occur, with symptoms including tenosynovitis, migratory polyarthritis, and dermatitis.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 22
Correct
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A woman wants advice about air travel while pregnant. She wants to visit her mother who is unwell. The flight will be 6 hours in duration. She will be 28 weeks pregnant at the time of the flight. There have been no complications during this pregnancy. She wants to know how late into the pregnancy she is allowed to fly.
What would you advise her about air travel for an uncomplicated single pregnancy?Your Answer: Most airlines will not let a person fly after week 24 of pregnancy
Explanation:Airline Restrictions for Pregnant Passengers
Most airlines have restrictions on pregnant passengers flying beyond a certain gestation period. For single, uncomplicated pregnancies, the limit is usually week 37, while for those carrying twins or more, it is week 32. This is due to the increased risks of medical conditions and the possibility of going into labor while in the air.
In addition to these restrictions, pregnant passengers should also be advised on how to prevent deep vein thrombosis (DVT) during flights longer than four hours. This includes walking when possible, doing in-seat exercises, staying hydrated, and wearing compression stockings. The Royal College of Obstetricians and Gynaecologists (RCOG) provides a helpful patient leaflet on this topic.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 23
Incorrect
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A 19-year-old man is concerned about blood-borne viruses after getting a tattoo while backpacking abroad. He wants to get tested for HIV and hepatitis B and C, but you advise him that the tests may not show any infection yet. When should he return for an HIV blood test?
Your Answer: 12 months
Correct Answer: 4 weeks
Explanation:It is recommended to conduct HIV testing in asymptomatic patients 4 weeks after a potential exposure. This is the optimal time frame for detecting most infections through tests for antibodies and p24 antigen. Additionally, it may be beneficial to perform an HIV test upon presentation in case of a prior infection (although 1 week may be too soon for detection), and a follow-up test at 12 weeks should be offered to confirm the absence of infection.
HIV seroconversion is a process where the body develops antibodies against the virus. This process is symptomatic in 60-80% of patients and usually presents as a glandular fever type illness. The severity of symptoms is associated with a poorer long-term prognosis. The symptoms typically occur 3-12 weeks after infection and include a sore throat, lymphadenopathy, malaise, myalgia, arthralgia, diarrhea, maculopapular rash, mouth ulcers, and rarely meningoencephalitis.
Diagnosing HIV involves testing for HIV antibodies, which may not be present in early infection. However, most people develop antibodies to HIV at 4-6 weeks, and 99% do so by 3 months. The diagnosis usually involves both a screening ELISA test and a confirmatory Western Blot Assay. Additionally, a p24 antigen test can be used to detect a viral core protein that appears early in the blood as the viral RNA levels rise. Combination tests that test for both HIV p24 antigen and HIV antibody are now standard for the diagnosis and screening of HIV. If the combined test is positive, it should be repeated to confirm the diagnosis. Some centers may also test the viral load (HIV RNA levels) if HIV is suspected at the same time. Testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure, and after an initial negative result, a repeat test should be offered at 12 weeks.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 24
Correct
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You are working at a prestigious clinic in the south of England and your next patient is a 37-year-old male. He expresses his concern about having Lyme disease after reading an online article. He reports experiencing intermittent malaise, joint aches, muscle aches, and headaches for the past two years. He also mentions having swollen cervical lymph glands and feeling hot and sweaty at night. As an avid hiker and mountain-biker, he believes he may have been bitten by ticks in the past. However, he denies ever having a rash like erythema migrans. What would be your initial approach to managing his symptoms?
Your Answer: Perform ELISA
Explanation:When there is suspicion of Lyme disease in a patient without a history of erythema migrans, ELISA is the recommended initial investigation according to NICE Guidance. If the ELISA result is positive, immunoblot should be performed to confirm the diagnosis. However, if there is a high suspicion of Lyme disease despite the absence of erythema migrans, treatment should be initiated while waiting for the ELISA result. In patients with erythema migrans, treatment should be started immediately. The patient’s symptoms may not be specific to Lyme disease, but ELISA is still the first-line investigation.
Understanding Lyme Disease
Lyme disease is an illness caused by a type of bacteria called Borrelia burgdorferi, which is transmitted to humans through the bite of infected ticks. The disease can cause a range of symptoms, which can be divided into early and later features.
Early features of Lyme disease typically occur within 30 days of being bitten by an infected tick. These can include a distinctive rash known as erythema migrans, which often appears as a bulls-eye pattern around the site of the tick bite. Other early symptoms may include headache, lethargy, fever, and joint pain.
Later features of Lyme disease can occur after 30 days and may affect different parts of the body. These can include heart block or myocarditis, which affect the cardiovascular system, and facial nerve palsy or meningitis, which affect the nervous system.
To diagnose Lyme disease, doctors may look for the presence of erythema migrans or use blood tests to detect antibodies to Borrelia burgdorferi. Treatment typically involves antibiotics, such as doxycycline or amoxicillin, depending on the stage of the disease.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 25
Incorrect
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A 5-year-old boy is brought to the General Practitioner as he is febrile, restless and has excessive drooling from the mouth. Drinking and eating are painful and his breath smells foul. His gums are swollen and red and he has ulcers on the tongue, throat, palate and insides of the cheeks and a few vesicles and erosions on the lips.
Which of the following is the most likely infection?
Your Answer: Candida
Correct Answer: Herpes simplex virus
Explanation:Herpes Simplex Virus and Hand, Foot and Mouth Disease: A Comparison
Herpes simplex virus (HSV) is a common viral infection that can cause cold sores on the face (type 1) or genital infections (type 2). Primary type 1 infection is usually mild or subclinical, but can cause herpetic gingivostomatitis, which is the most common clinical manifestation of the infection. After the initial infection, the virus remains latent in nerve cell ganglia and can be reactivated by various stimuli, resulting in a recurrence of symptoms and shedding of the virus.
In contrast, hand, foot and mouth disease is caused by the Coxsackie A virus and is usually a minor illness with mouth ulcers and vesicles on the hands and feet. While the mouth may be sore, it is not typically as severe as a herpes simplex infection.
Overall, understanding the differences between these two viral infections can help with proper diagnosis and treatment.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 26
Incorrect
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A patient who has just returned from the Ivory Coast is experiencing cyclical fever and headache. During the examination, splenomegaly is observed. After a blood film, the patient is diagnosed with Plasmodium vivax malaria. The patient, who is in his 50s, is initially treated with chloroquine and later given primaquine. What is the advantage of administering primaquine?
Your Answer: Prevent immature trophozoites forming gamatocytes
Correct Answer: Destroy liver hypnozoites and prevent relapse
Explanation:To prevent relapse in non-falciparum malaria, primaquine is administered to eliminate liver hypnozoites.
Non-Falciparum Malaria: Causes, Features, and Treatment
Non-falciparum malaria is caused by Plasmodium vivax, Plasmodium ovale, Plasmodium malariae, and Plasmodium knowlesi. Plasmodium vivax is commonly found in Central America and the Indian Subcontinent, while Plasmodium ovale is typically found in Africa. Plasmodium malariae is associated with nephrotic syndrome. Plasmodium knowlesi is found predominantly in South East Asia.
The general features of non-falciparum malaria include fever, headache, and splenomegaly. Cyclical fever every 48 hours is associated with Plasmodium vivax and Plasmodium ovale, while Plasmodium malariae is associated with cyclical fever every 72 hours. Ovale and vivax malaria have a hypnozoite stage and may relapse following treatment.
In areas known to be chloroquine-sensitive, the World Health Organization recommends either an artemisinin-based combination therapy (ACT) or chloroquine for treatment. In areas known to be chloroquine-resistant, an ACT should be used. However, ACTs should be avoided in pregnant women. Patients with ovale or vivax malaria should be given primaquine following acute treatment with chloroquine to destroy liver hypnozoites and prevent relapse.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 27
Incorrect
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A sexually active 21-year-old Nigerian man presents with a 2-day history of small, painful ulcers on the glans penis and tender inguinal lymphadenopathy.
Select the single most likely diagnosis.Your Answer: Syphilis
Correct Answer: Herpes simplex
Explanation:Differentiating Primary Genital Herpes Simplex Virus Infection from Other Genital Lesions
Primary genital herpes simplex virus (HSV) infection caused by HSV type 2 is characterized by typical lesions. Unlike syphilis, which presents with a small, painless papule that quickly forms an ulcer, HSV lesions are usually painful and may be accompanied by flu-like symptoms. Enlarged lymph nodes are also common but are usually painful in HSV infection. In herpes zoster, vesiculation and ulceration occur in a dermatomal distribution, while scabies presents with a generalised itch and itchy nodules on the genitalia. Impetigo lesions are painless, superficial, and crusted or eroded, unlike the painful and often multiple lesions seen in primary genital HSV infection. Therefore, a careful examination and history-taking are essential to differentiate primary genital HSV infection from other genital lesions.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 28
Incorrect
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You are working in a rural GP surgery in Scotland and you have an urgent appointment with an eight-year-old boy and his mother. The child has a history of mild asthma and flexural eczema and his mother is concerned because they went out walking yesterday and this morning she found a tick attached to his upper arm. The child appears well and all observations are normal. The tick has been removed, leaving a puncture mark. The mother is worried about Lyme disease and asks for a prescription. What is the most appropriate management option?
Your Answer: Doxycycline 100 mg twice daily, 21 days total
Correct Answer: No antibiotics necessary - watchful waiting
Explanation:According to the 2018 NICE Guidance, it is not necessary to administer prophylactic antibiotics to individuals who have been bitten by a tick and show no symptoms of Lyme disease. Treatment should only be given if the patient develops erythema migrans or other symptoms associated with the disease. It is important to provide reassurance to the patient and advise them on what symptoms to watch out for.
Understanding Lyme Disease
Lyme disease is an illness caused by a type of bacteria called Borrelia burgdorferi, which is transmitted to humans through the bite of infected ticks. The disease can cause a range of symptoms, which can be divided into early and later features.
Early features of Lyme disease typically occur within 30 days of being bitten by an infected tick. These can include a distinctive rash known as erythema migrans, which often appears as a bulls-eye pattern around the site of the tick bite. Other early symptoms may include headache, lethargy, fever, and joint pain.
Later features of Lyme disease can occur after 30 days and may affect different parts of the body. These can include heart block or myocarditis, which affect the cardiovascular system, and facial nerve palsy or meningitis, which affect the nervous system.
To diagnose Lyme disease, doctors may look for the presence of erythema migrans or use blood tests to detect antibodies to Borrelia burgdorferi. Treatment typically involves antibiotics, such as doxycycline or amoxicillin, depending on the stage of the disease.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 29
Correct
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What is the correct statement about infection with Epstein-Barr virus (infectious mononucleosis)?
Your Answer: Deranged liver function is common in infectious mononucleosis
Explanation:Infectious Mononucleosis: Symptoms, Transmission, and Complications
Infectious mononucleosis, commonly known as mono, is a viral infection caused by the Epstein-Barr virus (EBV). While many patients may not show any symptoms, studies suggest that 90% of people over the age of 25 have antibodies to EBV. The virus is transmitted through droplet exchange and can continue to be excreted for several months.
Symptoms of mono include deranged liver function, mild hepatomegaly, and splenomegaly, which can cause tenderness over the spleen. Jaundice is rare in young adults but can occur in up to 30% of infected elderly patients. It is important for patients to avoid contact sports for at least a month after infection to prevent the risk of splenic rupture.
It is crucial to note that ampicillin and amoxicillin should not be given to any patient who may have infectious mononucleosis, as they can cause an itchy maculopapular rash. The illness is typically self-limiting and of short duration, but fatigue and myalgia may persist for several months after the acute infection has resolved.
In conclusion, infectious mononucleosis is a viral infection that can cause various symptoms and complications. It is important to take precautions to prevent transmission and seek medical attention if symptoms persist.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 30
Incorrect
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A 30-year-old office worker has come to the clinic with a painful swollen face that has developed over 24 hours. He is particularly swollen in the parotid area on the left. He has a fever of 38.2oC. He also has malaise, headache and has lost his appetite.
What is the most probable diagnosis?Your Answer: Parvovirus infection
Correct Answer: Mumps
Explanation:Mumps: Symptoms, Complications, and Differential Diagnosis
Mumps is a viral infection that is rare in vaccinated individuals but can affect those who have not been vaccinated or exposed to the virus. The onset of mumps can be sudden, and one-third of cases present with unilateral parotitis. Unlike parotid adenomas, which develop slowly, mumps is characterized by acute inflammation of the parotid gland. Glandular fever, on the other hand, typically affects the neck glands and is often accompanied by a sore throat. In children, parvovirus can cause slapped cheek syndrome, which is characterized by nonspecific viral symptoms followed by the appearance of firm red cheeks a few days later. Sialadenosis, a generalized swelling of the glands, is associated with hypertrophy of the acinar component of the gland and is commonly seen in individuals with systemic diseases such as Sjogren syndrome. Complications of mumps can include epididymo-orchitis, viral meningitis, pancreatitis, and, in rare cases, myocarditis. It is important to differentiate mumps from other conditions with similar symptoms to ensure proper diagnosis and treatment.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 31
Correct
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A 15-year-old boy has coryzal symptoms, conjunctivitis and a rash suggestive of measles.
Select the single correct statement regarding notification of this disease to the relevant public health authorities.Your Answer: Notification can be made on clinical suspicion
Explanation:The Importance of Speed and Accuracy in Notifying Infectious Diseases
Infectious disease control relies on the prompt identification and containment of outbreaks. To achieve this, doctors are required to provide identifying information to the Proper Office of the Local Authority for patients with notifiable infectious diseases. However, laboratory staff are not currently obligated to do so. The notifications system prioritizes speed in detecting outbreaks, with accuracy of diagnosis being secondary. Salivary surveillance schemes exist for measles, mumps, and rubella, but recent data shows low incidence compared to the number of notifications submitted. Prompt and accurate notification is crucial in preventing the spread of infectious diseases.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 32
Correct
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What is a true statement about Giardia lamblia?
Your Answer: May be excluded by stool microscopy
Explanation:Giardia Lamblia and Traveller’s Diarrhoea
Giardia lamblia is a common cause of traveller’s diarrhoea, often accompanied by E. coli. It can also lead to intestinal malabsorption. The preferred treatment for this condition is metronidazole.
Stool microscopy is a traditional method of detecting cysts and oocysts, but it is laborious and less sensitive than the current antigen detection test. A single stool examination can identify only 50% of cases, while three stool samples can detect up to 90%.
Unlike E. coli 0157 infection, giardiasis doesn’t cause blood loss. HUS, a severe complication, is not associated with giardiasis.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 33
Incorrect
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A 30-year-old woman has had frequency and dysuria for two days, but is otherwise well. Dipstick testing is positive for nitrites and blood.
What is the most appropriate management?
Your Answer: Amoxicillin for 7 days
Correct Answer: Trimethoprim for 3 days
Explanation:Antibiotic Treatment for Urinary Tract Infections
Antibiotic treatment is effective in treating uncomplicated cystitis in women. Trimethoprim is the preferred drug for empirical treatment, but resistance can occur in 10-20% of Escherichia coli infections. Nitrofurantoin and cefalexin can be used as alternatives for patients who cannot take trimethoprim. The recommended treatment period for women is three days, while men should be treated for seven days.
Amoxicillin is not routinely used due to its low effectiveness, with 50% of organisms being resistant. Cranberry juice and other cranberry products have no evidence to support their use in treating urinary tract infections.
In summary, antibiotic treatment is the most effective option for treating urinary tract infections, with trimethoprim being the preferred drug for women. Treatment should be for no longer than three days in women and seven days in men. Amoxicillin and cranberry products are not recommended for routine use.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 34
Incorrect
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A 55-year-old man is planning a trip and has been advised by his travel agent to take antimalarial medication. What is the correct statement about chemoprophylaxis for malaria?
Your Answer: Mefloquine is taken from 2 days before travel until 1 week after leaving a malaria area
Correct Answer: Mefloquine is contraindicated in patients with a history of psychiatric illness
Explanation:Antimalarials for Travellers: Importance and Considerations
Travellers should always seek up-to-date information on appropriate antimalarials for different regions before embarking on their journey. It is important to note that all travellers should be advised to use antimalarials where there is a risk, regardless of their previous exposure or the level of luxury of their accommodation.
While some may believe that immunity to malaria is strong and long-lasting, it is actually quite mild and wanes quickly when patients move away from the affected area. Therefore, it is crucial to take the necessary precautions to prevent contracting the disease.
Doxycycline is an effective antimalarial, but it can cause photosensitivity, making it less suitable for patients who plan to spend time sunbathing. Malarone, on the other hand, is ideal for short trips or where only part of a holiday is spent in malaria-prone areas, as it is taken for only 2 days before and 1 week after travel.
For all other antimalarials, they should be taken from 1 week before until 4 weeks after travel to the affected area. However, it is important to note that mefloquine is contraindicated for patients with a history of psychiatric illness or epilepsy, as it can cause a range of neuropsychiatric symptoms, including depression, panic attacks, agitation, hallucinations, psychosis, convulsions, and suicidal ideation. If such symptoms occur, the drug should be discontinued and replaced with an alternative antimalarial.
In conclusion, taking the necessary precautions and seeking professional advice on antimalarials is crucial for travellers to prevent contracting malaria.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 35
Incorrect
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A 5-year-old girl presents in the early evening with symptoms that have progressively worsened during the day. Her temperature is 39 oC and she has a cough, stridor, drooling of saliva and respiratory distress.
Select the single most likely diagnosis.Your Answer: Streptococcal throat infection
Correct Answer: Acute epiglottitis
Explanation:Acute Epiglottitis and Croup: Two Respiratory Conditions in Children
Acute epiglottitis is a rare but life-threatening condition that causes inflammation of the epiglottis and surrounding soft tissues. It is most common in children between the ages of 2 and 8 and is often caused by Haemophilus influenza type b. Throat examination with a tongue depressor should be avoided, and urgent referral for laryngoscopy is necessary. Intubation may be required in over 30% of patients, and prophylactic intubation may be carried out in those with dyspnoea or stridor.
Croup, on the other hand, is a relatively mild and self-limiting condition that causes a barking cough and stridor. It is typically associated with viral upper respiratory infections and affects children between 6 months and 3 years of age. Symptoms are often worse at night.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 36
Correct
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A 30-year-old man returned from a vacation visiting his parents in Pakistan on a long-haul flight 4 weeks ago. He is experiencing a persistent productive cough, haemoptysis and night sweats.
What is the most probable diagnosis?Your Answer: Tuberculosis
Explanation:Respiratory Symptoms and Differential Diagnosis
Persistent cough, haemoptysis, night sweats, and fever are classic symptoms of tuberculosis (TB), which accounts for 60% of respiratory cases in the UK. Acute bronchitis, on the other hand, is usually caused by a viral infection and resolves without treatment within three weeks. Lung cancer may present with productive cough and haemoptysis, but the patient’s age and immigrant status make TB more likely. Pulmonary embolism is a minor risk factor in this case, and whooping cough is a respiratory tract infection that affects both children and adults. Paroxysmal coughing followed by a whoop is a characteristic feature of whooping cough. It is important to consider the patient’s medical history and risk factors when making a differential diagnosis of respiratory symptoms.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 37
Incorrect
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A 35-year-old immigrant from India presents with fever, night sweats, backache, weight loss, chronic cough, and hemoptysis. What is the most probable diagnosis?
Your Answer: Pneumonia
Correct Answer: Tuberculosis
Explanation:Tuberculosis in the UK: Risk Factors and Diagnosis
Tuberculosis (TB) remains a significant public health concern in the UK, with 8587 cases reported in 2010. Pulmonary TB is the most common form, accounting for 60% of cases. Certain groups are at higher risk, including those who have had close contact with a TB patient, ethnic minorities, homeless individuals, alcoholics and drug abusers, HIV-positive and immunocompromised patients, elderly individuals, young children, and those with other underlying health conditions. TB can be difficult to diagnose, as primary infection is often asymptomatic and secondary infection can present with nonspecific symptoms. A high level of suspicion is necessary to identify TB in at-risk patients.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 38
Incorrect
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A 3-year-old dairy farmer's son has been experiencing diarrhoea for 7 days. A stool sample is sent and it comes back positive for Cryptosporidium.
What is the appropriate course of action for managing this child?Your Answer: The farmer should stop selling milk until the source of the outbreak has been identified
Correct Answer: He can expect the diarrhoea to last longer with possible relapses
Explanation:Cryptosporidiosis is a type of infection caused by Cryptosporidium species, which are parasites that live inside cells and can affect both humans and animals. This illness is a significant cause of diarrhea worldwide, especially in young children and people with weakened immune systems. In the UK, there are around 5000-6000 cases reported each year. The infection can be spread through direct contact with infected livestock or people, or through contaminated food or water. Symptoms can last for up to a month, with over a third of patients experiencing a relapse. However, healthy individuals typically recover without treatment, although rehydration is important. People with cryptosporidiosis should avoid swimming pools for two weeks, but can return to nursery after 48 hours of symptom resolution. Routine hygiene measures are sufficient to prevent further spread of the infection.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 39
Incorrect
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A 40-year-old man who works as a teacher and is generally healthy asks about getting the flu shot. Can you confirm if he is eligible for it on the NHS?
Your Answer: A 35-year-old woman who takes a salbutamol inhaler for asthma
Correct Answer: A 35-year-old woman on metformin for type 2 diabetes
Explanation:Familiarizing oneself with vaccine eligibility is crucial.
influenza vaccination is recommended in the UK between September and early November, as the influenza season typically starts in the middle of November. There are three types of influenza virus, with types A and B accounting for the majority of clinical disease. Prior to 2013, flu vaccination was only offered to the elderly and at-risk groups. However, a new NHS influenza vaccination programme for children was announced in 2013, with the children’s vaccine given intranasally and annually after the first dose at 2-3 years. It is important to note that the type of vaccine given to children and the one given to the elderly and at-risk groups is different, which explains the different contraindications.
For adults and at-risk groups, current vaccines are trivalent and consist of two subtypes of influenza A and one subtype of influenza B. The Department of Health recommends annual influenza vaccination for all people older than 65 years and those older than 6 months with chronic respiratory, heart, kidney, liver, neurological disease, diabetes mellitus, immunosuppression, asplenia or splenic dysfunction, or a body mass index >= 40 kg/m². Other at-risk individuals include health and social care staff, those living in long-stay residential care homes, and carers of the elderly or disabled person whose welfare may be at risk if the carer becomes ill.
The influenza vaccine is an inactivated vaccine that cannot cause influenza, but a minority of patients may develop fever and malaise that lasts 1-2 days. It should be stored between +2 and +8ºC and shielded from light, and contraindications include hypersensitivity to egg protein. In adults, the vaccination is around 75% effective, although this figure decreases in the elderly. It takes around 10-14 days after immunisation before antibody levels are at protective levels.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 40
Incorrect
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A 28-year-old individual visits the doctor complaining of vomiting and explosive diarrhoea that started 24 hours ago. Upon further inquiry, the patient denies any blood in their stool and has not traveled abroad recently. The patient mentions consuming rice that was kept warm in a rice cooker for multiple days. What is the probable causative agent responsible for the patient's symptoms?
Your Answer: Norwalk virus
Correct Answer: Bacillus cereus
Explanation:It is probable that this young man is suffering from toxigenic food poisoning caused by Bacillus cereus, which is known to occur after consuming reheated rice. The spores of Bacillus cereus germinate in cooked rice and produce toxins if the cooked product is not adequately chilled. While S. aureus can also cause toxigenic food poisoning, the specific history of this case makes it less likely to be the underlying organism. Norwalk virus, on the other hand, can cause severe diarrhea and vomiting, but it is not associated with any particular food items. Bacterial food poisoning caused by Campylobacter and Shigella typically involves a longer history of bloody diarrhea.
Gastroenteritis can occur either at home or while traveling abroad, which is known as travelers’ diarrhea. This type of diarrhea is characterized by at least three loose to watery stools in 24 hours, along with abdominal cramps, fever, nausea, vomiting, or blood in the stool. The most common cause of traveler’s’ diarrhea is Escherichia coli. Another type of illness is acute food poisoning, which is caused by the ingestion of a toxin and results in sudden onset of nausea, vomiting, and diarrhea. Staphylococcus aureus, Bacillus cereus, and Clostridium perfringens are the typical causes of acute food poisoning.
Different infections have stereotypical histories and presentations. Escherichia coli is common among travelers and causes watery stools, abdominal cramps, and nausea. Giardiasis results in prolonged, non-bloody diarrhea. Cholera causes profuse, watery diarrhea and severe dehydration resulting in weight loss, but it is not common among travelers. Shigella causes bloody diarrhea, vomiting, and abdominal pain. Staphylococcus aureus causes severe vomiting with a short incubation period. Campylobacter usually starts with a flu-like prodrome and is followed by crampy abdominal pains, fever, and diarrhea, which may be bloody and may mimic appendicitis. Bacillus cereus has two types of illness: vomiting within six hours, typically due to rice, and diarrheal illness occurring after six hours. Amoebiasis has a gradual onset of bloody diarrhea, abdominal pain, and tenderness that may last for several weeks.
The incubation period for different infections varies. Staphylococcus aureus and Bacillus cereus have an incubation period of 1-6 hours, while Salmonella and Escherichia coli have an incubation period of 12-48 hours. Shigella and Campylobacter have an incubation period of 48-72 hours, while Giardiasis and Amoebiasis have an incubation period of more than seven days. The vomiting subtype of Bacillus cereus has an incubation period of 6-14 hours, while the diarrheal illness has an incubation period of more than six hours.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 41
Incorrect
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A 50-year-old nun returns from a trip to Nigeria with fever and deranged LFTs. She has an ALT of 2500 U/l and bilirubin of 75 μ mol/l. She was fully vaccinated before travel. She also took mefloquine malaria prophylaxis.
Select the single most likely diagnosis.Your Answer: Dengue fever
Correct Answer: Hepatitis E
Explanation:Hepatitis E: A Likely Diagnosis for Abnormal Liver Function Tests
Abnormal liver function tests can be caused by various factors, but in this case, hepatitis E is the most likely diagnosis. While hepatitis A vaccine is effective in preventing hepatitis A, it is not the cause of the patient’s symptoms. Acute hepatitis B is less likely as it is transmitted through blood or sexual contact. Malaria and dengue fever may also cause abnormal liver function tests, but not to the extent seen in this patient.
Hepatitis E is a viral infection that is acquired through the faeco-oral route. Unlike hepatitis A, it has no chronic form but has a higher mortality rate of 1-2%. Pregnant women in their last trimester are at a higher risk of death from hepatitis E. Outbreaks of hepatitis E are more common in developing countries.
It is important to note that both hepatitis A and E can cause fulminant liver failure in patients with underlying liver disease. Therefore, prompt diagnosis and treatment are crucial in managing these conditions.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 42
Incorrect
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You have a telephone consultation with a 25-year-old man to discuss the results of a stool sample. He saw a colleague of yours 4 days ago with a 72-hour history of bloody diarrhoea and abdominal pain. The patient's symptoms have now resolved and he feels well.
Stool sample result:
Growth of Campylobacter jejuni
Shigella Not isolated
Salmonella Not isolated
Ova, cysts and parasites Not detected
What is the most suitable course of action to take?Your Answer: Prescribe ciprofloxacin
Correct Answer: No treatment is required
Explanation:In most cases, Campylobacter infection resolves on its own without the need for treatment. This is the case for the patient in this scenario, as their symptoms have completely disappeared. However, if the symptoms are severe or persist for more than a week, the first-line treatment is clarithromycin. Ciprofloxacin is an alternative treatment option but not the first choice. Vancomycin is not used to treat Campylobacter infection as it is used for C. difficile infections. There is no need to repeat the stool sample as the patient is clinically well and their diarrhea has resolved.
Campylobacter is a type of bacteria that is responsible for causing the majority of cases of infectious intestinal disease in the UK. It is a Gram-negative bacillus that is spread through the faecal-oral route and has an incubation period of 1-6 days. Symptoms of Campylobacter infection include a prodrome of headache and malaise, as well as diarrhoea that is often bloody and abdominal pain that may mimic appendicitis.
In most cases, Campylobacter infection is self-limiting and doesn’t require treatment. However, the British National Formulary (BNF) recommends treatment with antibiotics if the symptoms are severe or if the patient is immunocompromised. Clinical Knowledge summaries also suggest antibiotics if the symptoms are severe, such as high fever, bloody diarrhoea, or more than eight stools per day, or if the symptoms have lasted for more than one week. The first-line antibiotic for Campylobacter infection is clarithromycin, although ciprofloxacin is an alternative. However, the BNF notes that strains with decreased sensitivity to ciprofloxacin are frequently isolated.
Complications of Campylobacter infection can include Guillain-Barre syndrome, reactive arthritis, septicaemia, endocarditis, and arthritis.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 43
Incorrect
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A 67-year-old woman has chronic obstructive pulmonary disease, continues to smoke and is housebound due to her disability.
Which vaccination should she receive annually?Your Answer: Streptococcus pneumoniae
Correct Answer: influenza
Explanation:The Importance of Annual influenza Vaccination
influenza vaccines are designed to protect against the two subtypes of human influenza A (H3N2 and H1N1) and influenza B viruses. However, due to changes in the surface antigens of the virus, the composition of the vaccine must be modified annually. To ensure global recommendations on vaccine composition and surveillance for potential pandemic viruses, the World Health Organisation maintains a network of collaborating laboratories.
Annual re-immunisation is particularly recommended for those at the highest risk of morbidity, including patients in chronic care facilities (especially the elderly), those with chronic cardiopulmonary, lung or renal diseases, diabetes mellitus, haemoglobinopathies, and those who are immunocompromised. It is also offered annually to patients aged 65 and over.
While protection may be less effective in the elderly than in children, immunisation has been shown to reduce the incidence of bronchopneumonia, mortality, and hospital admission. In children aged 1-5, it has been shown to reduce influenza-associated respiratory illness in the 1- to 15-year age group by up to 90%, and may reduce influenza-associated otitis media by up to 30%.
In conclusion, annual influenza vaccination is crucial for protecting vulnerable populations and reducing the spread of the virus.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 44
Incorrect
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A 20-year-old woman has recently returned from a gap-year project in Tanzania. She has been feeling unwell since her return, experiencing shortness of breath and abdominal pain. Upon examination, she appears pale and a blood test reveals iron-deficiency anemia. A stool sample is positive for hookworm and she begins treatment. Her mother is worried that the rest of the family may have contracted the infection.
Select the only accurate statement regarding the transmission of hookworm.Your Answer: Hookworm infections can be acquired through swimming in contaminated water
Correct Answer: Walking barefoot is a risk factor for the disease
Explanation:Hookworm Infestation: Causes, Symptoms, and Treatment
Hookworm infestation is a parasitic infection caused by a nematode worm that lives in the small intestine of its host. It is acquired through eating contaminated food or walking barefoot on contaminated ground. The worms migrate through the body to the lungs, where they are coughed up and swallowed, completing their life cycle in the digestive tract and excreted in faeces.
Most hookworm infections are asymptomatic, but the most significant risk is anaemia due to loss of iron and protein in the gut. The worms suck blood and damage the mucosa, but the blood loss is occult. Larval invasion of the skin can cause intense, local itching, usually on the foot or lower leg, followed by lesions that look like insect bites. They can also cause the serpiginous lesions of cutaneous larva migrans.
Diagnosis is made by finding characteristic worm eggs on microscopic examination of the stools, and there may also be eosinophilia. Albendazole is the most effective medication for treatment. Relying on adequately cooked food will prevent faeco-oral but not percutaneous transmission.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 45
Incorrect
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A 49-year-old woman who breeds parrots presents with a dry cough, fever and myalgia. Upon examination, her temperature is 37.8°C and there are no other notable findings. You advise her to take fluids and paracetamol and to contact you if her symptoms do not improve. She returns after a week with a worsening cough that is now accompanied by blood and a severe headache. During the examination, you observe a faint macular rash on her face, and she has mild tachypnoea but minimal chest signs. What is the most likely diagnosis?
Your Answer: Viral upper respiratory tract infection
Correct Answer: Psittacosis
Explanation:Psittacosis: A Rare Illness Caused by Bird Exposure
Psittacosis is a rare illness caused by Chlamydophila psittaci, which is carried by birds, particularly parrots. The incubation period is 1-4 weeks, and symptoms include myalgia, cough, headache, and flu-like symptoms. It presents as a community-acquired pneumonia with marked signs of systemic illness, including fever and lassitude. Other symptoms include a non-productive cough, dyspnoea, sore throat, nosebleeds, and occasionally pleuritic chest pain. Severe headache and photophobia are common, and gastrointestinal symptoms may occur. Rose spots, called Horder’s spots, can appear on the face. The chest x-ray may look worse than the clinical signs suggest, and bradycardia and splenomegaly are common. Treatment is with tetracycline, and the prognosis is good if early antibiotic therapy is given.
Compared to influenza, which typically lasts for 3-5 days, psittacosis has a more gradual onset and lasts longer. L pneumophila is another possible cause of atypical pneumonia, but exposure to birds points to psittacosis. Typical community-acquired pneumonia, such as pneumococcal pneumonia, has a more acute onset and significant focal chest signs. Therefore, it is important to consider psittacosis in patients with bird exposure and atypical pneumonia symptoms.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 46
Incorrect
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A 72-year-old man seeks advice regarding his upcoming trip to Australia to visit his daughter who has emigrated. He is concerned about the risk of deep vein thrombosis as he was diagnosed with this condition approximately 40 years ago during his wife's second pregnancy. However, there are no other significant risk factors for venous thromboembolism. What is the best advice to provide?
Your Answer: Prescribe low-molecular weight heparin, starting one before the flight
Correct Answer: Wear compression stockings
Explanation:Considering her age, previous DVT, and long haul destination, this woman is at a higher risk of travel related thrombosis. Therefore, the most suitable recommendation for her would be to wear compression stockings.
Travel-Related Thrombosis and Guidelines for Prevention
Long-haul air travel has been associated with an increased risk of venous thromboembolism (VTE), commonly known as economy class syndrome. However, there is no universal agreement on how to advise patients regarding VTE prevention during travel. The British Committee for Standards in Haematology, SIGN, and Clinical Knowledge Summaries have all produced guidelines, but they differ in their recommendations.
The most recent CKS guidelines suggest a risk-based approach. Patients with no major risk factors for VTE do not require special measures. However, those with major risk factors should consider wearing anti-embolism stockings, which can be bought or prescribed. In cases of very high risk, such as a long-haul flight following recent major surgery, delaying the flight or seeking specialist advice regarding the use of low-molecular weight heparin may be necessary.
It is important to note that all guidelines agree that there is no role for aspirin in VTE prevention for low, medium, or high-risk patients. A 2001 study in the New England Journal of Medicine showed that the risk of pulmonary embolism increases with travel distance, with 4.8 cases per million for travel over 10,000 km. While the Civil Aviation Authority doesn’t provide specific guidance on VTE prevention, healthcare providers can use these guidelines to help patients make informed decisions about their travel plans.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 47
Incorrect
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For a patient undergoing an elective splenectomy, at what age is it best to administer the pneumococcal vaccine?
Your Answer: One week before surgery
Correct Answer: Two weeks before surgery
Explanation:According to the current British National Formulary, it is recommended to administer the vaccine at least 14 days prior to a planned splenectomy.
Splenectomy and its Management
Splenectomy is a surgical procedure that involves the removal of the spleen. After the operation, patients are at a higher risk of infections caused by pneumococcus, Haemophilus, meningococcus, and Capnocytophaga canimorsus. To prevent these infections, patients should receive vaccinations such as Hib, meningitis A & C, annual influenza, and pneumococcal vaccines. Antibiotic prophylaxis with penicillin V is also recommended for at least two years and until the patient is 16 years old, although some patients may require lifelong prophylaxis.
Splenectomy is indicated for various reasons such as trauma, spontaneous rupture, hypersplenism, malignancy, splenic cysts, hydatid cysts, and splenic abscesses. Elective splenectomy is different from emergency splenectomy, and it is usually performed laparoscopically. Complications of splenectomy include haemorrhage, pancreatic fistula, and thrombocytosis. Post-splenectomy changes include an increase in platelets, Howell-Jolly bodies, target cells, and Pappenheimer bodies. Patients are at an increased risk of post-splenectomy sepsis, which typically occurs with encapsulated organisms. Therefore, prophylactic antibiotics and pneumococcal vaccines are essential to prevent infections.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 48
Incorrect
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Which one of the following statements regarding hepatitis B is accurate?
Your Answer: The vaccine is of the live-attenuated type
Correct Answer: 10-15% of adults fail to respond or respond poorly to 3 doses of the vaccine
Explanation:An anti-HBs check is necessary only for healthcare workers and patients with chronic kidney disease who are at risk of occupational exposure.
Understanding Hepatitis B: Causes, Symptoms, Complications, Prevention, and Management
Hepatitis B is a virus that spreads through exposure to infected blood or body fluids, including from mother to child during birth. The incubation period is typically 6-20 weeks. Symptoms of hepatitis B include fever, jaundice, and elevated liver transaminases. Complications of the infection can include chronic hepatitis, fulminant liver failure, hepatocellular carcinoma, glomerulonephritis, polyarteritis nodosa, and cryoglobulinemia.
Immunization against hepatitis B is recommended for at-risk groups, including healthcare workers, intravenous drug users, sex workers, close family contacts of an individual with hepatitis B, individuals receiving regular blood transfusions, chronic kidney disease patients, prisoners, and chronic liver disease patients. The vaccine is given in three doses and is typically effective, although around 10-15% of adults may not respond well to the vaccine.
Management of hepatitis B typically involves antiviral medications such as tenofovir, entecavir, and telbivudine, which aim to suppress viral replication. Pegylated interferon-alpha was previously the only treatment available and can still be used as a first-line treatment, but other medications are increasingly being used. A better response to treatment is predicted by being female, under 50 years old, having low HBV DNA levels, being non-Asian, being HIV negative, and having a high degree of inflammation on liver biopsy.
Overall, understanding the causes, symptoms, complications, prevention, and management of hepatitis B is important for both healthcare professionals and the general public. Vaccination and early detection and treatment can help prevent the spread of the virus and reduce the risk of complications.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 49
Incorrect
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A local daycare center has reported a recent outbreak of norovirus. The director of the center has reached out to your pediatric clinic for information on the illness and guidance on minimizing the risk of transmission.
What is the best recommendation for preventing the spread of this virus?Your Answer: Avoid contact with any blood products of those infected with norovirus
Correct Answer: Handwashing with soaps and warm water before and after contact with those infected with norovirus
Explanation:Handwashing with soap and warm water before and after contact with those infected with norovirus is the most effective way to prevent its spread, while alcohol gels are less effective. Antivirals have no role in treating norovirus, which is not a blood-borne virus and is commonly spread through contaminated food or drinks, touching contaminated surfaces or objects, or direct contact with an infected person. Staff who have had norovirus must stay away from work for at least 48 hours after their symptoms have stopped.
Norovirus, also known as the winter vomiting bug, is a common cause of gastroenteritis in the UK. It is a type of RNA virus that can cause symptoms such as nausea, vomiting, and diarrhea, as well as headaches, low-grade fevers, and myalgia. The virus is highly contagious and can be transmitted through the fecal-oral route, as well as through aerosolized particles from vomit or contaminated bodily fluids. Good hand hygiene and isolation of infected individuals are important in limiting transmission. Diagnosis is typically made through clinical history and stool culture viral PCR. While the infection is self-limiting in most cases, dehydration and electrolyte imbalances can occur and require supportive management. Other differential diagnoses include rotavirus, E. coli, and Salmonella infections, each with their own distinguishing features.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 50
Incorrect
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A 20-year-old man who has not received measles, mumps and rubella (MMR) vaccine presents with temperature of 38.5oC, headache, orchitis and unilateral parotitis.
Select the single most appropriate initial response.Your Answer: Prescribe antibiotics
Correct Answer: Advise symptomatic treatment only
Explanation:Diagnosis and Management of Mumps
Mumps is a viral infection that is usually diagnosed clinically without the need for further investigations. However, in cases where meningitis is present without parotitis, mumps-specific antibodies in the serum can confirm the diagnosis. Salivary IgM against mumps can also be detected, but it may take several days for antibody levels to rise. If the initial test is negative, it is recommended to repeat the test.
There is no specific treatment for mumps, but symptomatic relief can be achieved with paracetamol and ibuprofen. Meningism, which occurs in about 10% of patients, is usually mild and self-limiting, even without parotitis. Orchitis, which occurs in approximately 25% of post-pubertal men, can be mistaken for testicular torsion in someone of this age. However, based on the given symptoms, hospital admission is not necessary.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 51
Incorrect
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What is a true statement about the intranasal flu vaccine for children?
Your Answer: Epistaxis occurs in around 1 in 10 children
Correct Answer: It is a live vaccine
Explanation:The live vaccine for influenza is administered intranasally.
influenza vaccination is recommended in the UK between September and early November, as the influenza season typically starts in the middle of November. There are three types of influenza virus, with types A and B accounting for the majority of clinical disease. Prior to 2013, flu vaccination was only offered to the elderly and at-risk groups. However, a new NHS influenza vaccination programme for children was announced in 2013, with the children’s vaccine given intranasally and annually after the first dose at 2-3 years. It is important to note that the type of vaccine given to children and the one given to the elderly and at-risk groups is different, which explains the different contraindications.
For adults and at-risk groups, current vaccines are trivalent and consist of two subtypes of influenza A and one subtype of influenza B. The Department of Health recommends annual influenza vaccination for all people older than 65 years and those older than 6 months with chronic respiratory, heart, kidney, liver, neurological disease, diabetes mellitus, immunosuppression, asplenia or splenic dysfunction, or a body mass index >= 40 kg/m². Other at-risk individuals include health and social care staff, those living in long-stay residential care homes, and carers of the elderly or disabled person whose welfare may be at risk if the carer becomes ill.
The influenza vaccine is an inactivated vaccine that cannot cause influenza, but a minority of patients may develop fever and malaise that lasts 1-2 days. It should be stored between +2 and +8ºC and shielded from light, and contraindications include hypersensitivity to egg protein. In adults, the vaccination is around 75% effective, although this figure decreases in the elderly. It takes around 10-14 days after immunisation before antibody levels are at protective levels.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 52
Incorrect
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A 16-year-old girl from the travelling community comes to you with a 4-day history of fever, myalgia, malaise, and headache. She reports that her face has been swelling for the past two days and the pain has increased while chewing food. Upon examination, you notice that her parotid glands are tender and bilaterally swollen. Her temperature is 38.5ºC, heart rate 120 beats/minute, and blood pressure 110/70 mmHg. What is the most appropriate course of action?
Your Answer: Arrange urgent vaccination
Correct Answer: Supportive treatment- advise rest, fluids and simple analgesia
Explanation:The individual in question is suffering from mumps, which may be more prevalent in travelling communities due to lower vaccination rates. Supportive care is the recommended treatment for mumps, as antibiotics are ineffective against viral infections and steroids are not advised. While immediate vaccination is not necessary for this patient, it may be beneficial to assess their immunisation status for other diseases such as rubella and measles and administer appropriate vaccinations. Additionally, those who have been in contact with the patient should be offered the measles, mumps, and rubella vaccine. Hospitalisation is not required. This information is sourced from NICE CKS Mumps.
Understanding Mumps: Causes, Symptoms, Prevention, and Management
Mumps is a viral infection caused by RNA paramyxovirus that typically occurs during the winter and spring seasons. The virus spreads through droplets and affects respiratory tract epithelial cells, parotid glands, and other tissues. The infection is contagious, and a person can be infectious seven days before and nine days after the onset of parotid swelling. The incubation period for mumps is usually 14-21 days.
The clinical features of mumps include fever, malaise, and muscular pain. The most common symptom is parotitis, which causes earache and pain while eating. Initially, the swelling is unilateral, but it becomes bilateral in around 70% of cases.
Prevention of mumps is possible through the MMR vaccine, which has an efficacy rate of around 80%. Management of mumps involves rest and the use of paracetamol to alleviate high fever and discomfort. Mumps is a notifiable disease, and healthcare professionals must report cases to the relevant authorities.
Complications of mumps include orchitis, which is uncommon in pre-pubertal males but occurs in around 25-35% of post-pubertal males. It typically occurs four or five days after the onset of parotitis. Other complications include hearing loss, meningoencephalitis, and pancreatitis.
In conclusion, understanding the causes, symptoms, prevention, and management of mumps is crucial in preventing the spread of the infection and minimizing its complications. Vaccination and early diagnosis are essential in controlling the disease.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 53
Correct
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A 16-year-old girl has been diagnosed with glandular fever. What advice should be given regarding participation in sports?
Your Answer: Avoid contact sports for 4 weeks after having glandular fever
Explanation:Screening for splenomegaly cannot be effectively done through clinical examination alone. Additionally, individuals with glandular fever should refrain from participating in contact sports for a period of 4 weeks.
Understanding Infectious Mononucleosis
Infectious mononucleosis, also known as glandular fever, is a viral infection caused by the Epstein-Barr virus (EBV) in 90% of cases. It is most commonly seen in adolescents and young adults. The classic symptoms of sore throat, pyrexia, and lymphadenopathy are present in around 98% of patients. Other symptoms include malaise, anorexia, headache, palatal petechiae, splenomegaly, hepatitis, lymphocytosis, haemolytic anaemia, and a rash. The symptoms typically resolve after 2-4 weeks.
The diagnosis of infectious mononucleosis is confirmed through a heterophil antibody test (Monospot test) in the second week of the illness. Management is supportive and includes rest, drinking plenty of fluids, avoiding alcohol, and taking simple analgesia for any aches or pains. It is recommended to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture.
Interestingly, there is a correlation between EBV and socioeconomic groups. Lower socioeconomic groups have high rates of EBV seropositivity, having frequently acquired EBV in early childhood when the primary infection is often subclinical. However, higher socioeconomic groups show a higher incidence of infectious mononucleosis, as acquiring EBV in adolescence or early adulthood results in symptomatic disease.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 54
Incorrect
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A 10-year-old girl has been brought to see you by her father who is concerned that she has another episode of tonsillitis. A locum sent a throat swab 3 days earlier, which is reported as showing a Group A streptococcus.
Select the single most appropriate management.Your Answer: 5 days penicillin V
Correct Answer: 10 days penicillin V
Explanation:Throat Swabs and Antibiotic Treatment for Sore Throat
Throat swabs are not always reliable in differentiating between infection and carriage, and their results take up to 48 hours to be reported. However, they may be useful in high-risk groups to guide treatment choices in case of treatment failure. Symptomatic treatment and a delayed prescription may be reasonable options for sore throat, but after three days, a prescription for antibiotics may be necessary. Penicillin V is the recommended antibiotic for a 10-day course, while erythromycin or clarithromycin should be given for 5 days if the patient is allergic to penicillin. Overall, careful consideration of the patient’s condition and risk factors is necessary in determining the appropriate treatment for sore throat.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 55
Incorrect
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A 25-year-old student has a 5-day history of fever and sore throat that has not responded to penicillin. On examination his temperature is 38.8 °C, he has grey plaques on his tonsils, cervical lymphadenopathy and splenomegaly. You ask for a Monospot® test (test for heterophile antibody).
Select from the list the single correct statement regarding the heterophile antibody test.Your Answer: Antibody titres correlate with the severity of the disease
Correct Answer: It may be negative early in the course of the disease
Explanation:Understanding the Monospot® Test for Infectious Mononucleosis
The Monospot® test is a rapid diagnostic tool used to detect infectious mononucleosis caused by the Epstein-Barr virus. This test is based on the detection of heterophile antibodies produced by the human immune system in response to the virus. While the test is highly specific, it may not be sensitive during the incubation period or early stages of the illness. Additionally, the test doesn’t correlate with the severity of the disease and may not be positive after active infection has subsided.
The Monospot® test relies on the agglutination of horse red blood cells by heterophile antibodies in the patient’s serum. An alternative test, the Paul-Bunnell test, uses sheep red blood cells. However, heterophile antibody tests may be less sensitive in children under 12 years of age and may produce false-negative results in young children and elderly patients. False-positive results may also occur due to other infections, malignancies, or connective tissue diseases.
In summary, the Monospot® test is a useful tool for diagnosing infectious mononucleosis, but it should be interpreted in conjunction with other clinical and laboratory findings.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 56
Incorrect
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Which of the following individuals doesn't need the pneumococcal vaccine?
Your Answer: 30-year-old man with chronic kidney disease
Correct Answer: 40-year-old asthmatic using salbutamol and beclomethasone
Explanation:According to the Green Book guidelines, only asthmatic patients who use oral steroids at a level that significantly weakens their immune system require the pneumococcal vaccine. However, since the angina patient is on beta-blockers, they should be given the vaccination. For more information, please refer to the provided link.
The pneumococcal vaccine comes in two types: the pneumococcal conjugate vaccine (PCV) and the pneumococcal polysaccharide vaccine (PPV). The PCV is given to children as part of their routine immunizations at 3 and 12-13 months. On the other hand, the PPV is offered to adults over 65 years old, patients with chronic conditions such as COPD, and those who have had a splenectomy.
The vaccine is recommended for individuals with asplenia or splenic dysfunction, chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic liver disease, diabetes mellitus, immunosuppression, cochlear implants, and patients with cerebrospinal fluid leaks. However, controlled hypertension is not an indication for vaccination. Patients with any stage of HIV infection are also included in the list of those who should be vaccinated.
Adults usually require only one dose of the vaccine, but those with asplenia, splenic dysfunction, or chronic kidney disease need a booster every five years. It is important to note that asthma is only included if it requires the use of oral steroids at a dose sufficient to act as a significant immunosuppressant.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 57
Incorrect
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A woman who is 12 weeks pregnant is planning to travel to South America with her husband, who works for the diplomatic service. She is concerned about the risk of contracting a serious infection and wants to know which vaccine is safest to receive during pregnancy.
Which of the following vaccinations is considered the safest for administration during pregnancy?Your Answer: BCG
Correct Answer: Hepatitis A
Explanation:Live vs Antigen vs Toxoid Vaccines in Pregnancy
Live vaccines, such as BCG, oral polio, oral typhoid, and yellow fever vaccinations, are not recommended during pregnancy due to their potential risks. However, if travel to an endemic area is unavoidable and there is an increased risk of exposure, yellow fever vaccination may be administered to a pregnant woman. On the other hand, hepatitis A and B vaccinations are antigen-based and can be given safely during pregnancy if there is a high risk of exposure. Tetanus and diphtheria vaccinations are toxoid-based and can also be given with low risk of complications during pregnancy. It is important to understand the differences between these types of vaccines to ensure the safety of both the mother and the developing fetus.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 58
Correct
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A 23-year-old woman with stable sickle cell anaemia presents with an erythematous rash all over her body, which is associated with painful swollen joints. On examination she has clinical signs of anaemia. The full blood count shows absent reticulocytes in the peripheral blood.
Which pathogen is most likely to have caused her symptoms?Your Answer: Parvovirus B19
Explanation:Parvovirus B19 Infection: Symptoms, Transmission, and Complications
Parvovirus B19 infection is a common viral illness that is primarily spread through respiratory droplets, but can also be transmitted through contaminated surfaces. Children between the ages of 6 and 10 are most commonly affected, with up to 70% of the population having been infected by the age of 20. Susceptible adults can also become infected, often through exposure to the virus from their own children. Epidemics tend to occur every 4-5 years, with peak infection rates in the winter and spring.
The most common symptom of parvovirus B19 infection is erythema infectiosum, a rash illness characterized by a red rash on the face and extremities. The rash typically appears 17-22 days after exposure to the virus and is preceded by mild fever and fatigue. In addition to the rash, more than 80% of adults with parvovirus B19 infection experience joint pain and swelling, particularly in the small joints of the hands and feet. A positive test for parvovirus B19-specific IgM indicates current or recent infection.
While parvovirus B19 infection typically doesn’t cause significant anemia in individuals with normal red-cell lifespan and function, it can lead to a more severe form of anemia called aplastic crisis in individuals with shortened red-cell lifespan, such as those with sickle-cell anemia. During the acute phase of aplastic crisis, there is a lack of reticulocytes in the blood and erythroid aplasia in the bone marrow. However, recovery is typically marked by the presence of reticulocytosis and giant pronormoblasts in the bone marrow.
In summary, parvovirus B19 infection is a common viral illness that can cause a range of symptoms, including rash and joint pain. While typically not severe, it can lead to complications in individuals with certain medical conditions.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 59
Correct
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What is the correct approach to managing head lice (Pediculosis capitis) in schools and other childcare settings?
Your Answer: Regular detection by combing should be carried out by parents
Explanation:Head Lice Treatment and Prevention
Head lice are a common problem, especially among children. However, it is important to note that children should not be excluded from school if they have head lice. Treatment is only necessary if live lice have been seen. Hatched eggs or nits are not a sign of infestation.
Plastic combs are designed to be used with conditioner and have been shown to have a 38-57% cure rate after 14 days of treatment. Close contacts should also be checked, but only treated if live lice are present.
If chemical or physical insecticides are being used, such as malathion 0.5% or dimethicone 4%, at least two applications are needed, seven days apart, to effectively kill the lice that emerge from eggs after the first treatment.
Overall, it is important to take preventative measures, such as avoiding head-to-head contact and sharing personal items, to reduce the risk of head lice infestation.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 60
Incorrect
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A 35-year-old man has multiple, painful, vesicles and erosions on an erythematous base in an area on the left side of the abdomen corresponding to the T10 dermatome. Lesions have been present for a week. He had similar lesions on the opposite flank 18 months before. He also has a solitary verrucous papule on the shaft of the penis. He has had multiple unprotected sexual exposures with commercial sex workers.
Select from the list the single most important investigation in this patient.Your Answer: Swab the vesicular lesions for bacterial culture and sensitivity
Correct Answer: HIV test
Explanation:Unusual Symptoms and Recommended Tests for a Man with Recurrent Shingles and Penile Wart
The man in question is experiencing a recurrent attack of herpes zoster, commonly known as shingles, which is an unusual occurrence. This symptom is often associated with HIV infection, where opportunistic infections become prevalent as the disease progresses. Other symptoms that may occur include oral candida, oral hairy leukoplakia, recurrent ulcerating herpes simplex, seborrhoeic dermatitis, tinea infections, warts, and molluscum contagiosum.
To screen for syphilis, a treponemal enzyme immunoassay for immunoglobulin M (EIA IgM) test is recommended. Additionally, a full sexual health screen should be offered to the patient, along with an HIV test. It is important to note that the patient will already have varicella zoster IgG from their original Chickenpox infection.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 61
Incorrect
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A 32-year-old care worker presents with 3 days of fever, abdominal cramps and profuse diarrhoea. You send a stool sample for culture and the result confirms campylobacter infection.
What is a true statement about this infection?Your Answer: It is a normal commensal in the human bowel
Correct Answer: It is usually acquired through eating chicken
Explanation:Campylobacter: The Leading Cause of Diarrhoea in the UK
Campylobacter sp. is the primary cause of diarrhoea in the UK, with a high incidence rate. Although it usually resolves on its own within five days, it can persist for up to four weeks. In rare cases, it can lead to reactive arthritis. Treatment options include ciprofloxacin, clarithromycin, erythromycin, or azithromycin.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 62
Incorrect
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A 6-year-old girl is brought in to the surgery having become progressively more ill over a few hours. She is febrile, looks unwell, is pale with cold extremities, tachypnoeic and complains of leg pain. She keeps asking for water but drinks very little. She has had some diarrhoea and vomited once.
Select from the list the single most likely diagnosis.Your Answer: Urinary infection
Correct Answer: Meningococcal disease
Explanation:Early Diagnosis of Meningococcal Disease: Importance of nonspecific Features
Meningococcal disease is a severe bacterial infection caused by Neisseria meningitidis. Although it is a common commensal of the nasopharynx, it is also the leading infectious cause of death in early childhood. The disease can present as bacterial meningitis, septicaemia, or a combination of both.
A recent study of children with meningococcal disease found that classical signs such as haemorrhagic rash, meningism, and impaired consciousness did not appear until 13-22 hours after onset. However, nonspecific features such as leg pain, cold hands and feet, abnormal skin colour, breathing difficulty, and thirst appeared much earlier, with a median onset of 7-12 hours.
These nonspecific features are crucial for early diagnosis and may allow for earlier initiation of life-saving treatment. Therefore, healthcare professionals should be aware of these early symptoms and consider meningococcal disease as a potential diagnosis in children presenting with these features. Early recognition and treatment can significantly improve outcomes for children with meningococcal disease.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 63
Incorrect
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A 5-year-old girl is brought to the clinic with a cough, conjunctivitis and coryza. She developed a confluent maculopapular rash starting in the head and neck area and spreading elsewhere on the body within a few days. Subsequent testing has confirmed measles. Her mother has reached out to you because she seems to be more unwell and you schedule an appointment for her evaluation.
What is the most frequent complication that occurs after a measles infection?Your Answer: Subacute sclerosing panencephalitis
Correct Answer: Acute demyelinating encephalitis
Explanation:Complications of Measles
It is crucial to understand that measles can lead to various complications. While it is essential to be aware of the rare and severe complications, it is also important to keep in mind the common ones. Pneumonia occurs in 1-6% of cases, while otitis media affects 7-9% of cases. Diarrhoea is another common complication, occurring in approximately 8% of cases, and convulsions may occur in 1 in every 200 cases. Although rare, encephalitis (1 per 1000 cases) and subacute sclerosing panencephalitis are also possible complications. It is worth noting that pancreatitis is more commonly associated with mumps infection.
After advising parents to treat their children symptomatically with fluids, rest, and paracetamol, it is crucial to remain vigilant for any symptoms and signs of complications. While death in the UK occurs in around 1 in every 5000 cases, it is still important to take necessary precautions and seek medical attention if any complications arise.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 64
Incorrect
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You are asked to visit a nursing home where a 90-year-old man has diarrhoea and vomiting. When you see the patient, he has symptoms suggestive of norovirus infection.
Select the single most appropriate management option in this situation.Your Answer: Admit to the local cottage hospital
Correct Answer: Barrier-nurse in isolation within the residential home
Explanation:Understanding Norovirus: Symptoms, Transmission, and Control Measures
Norovirus is a highly contagious virus that causes diarrhoea and vomiting. It spreads rapidly through person-to-person contact, aerosol, and contact with infected vomit or stool. The symptoms typically include diarrhoea and vomiting with fever and abdominal cramps, and the illness usually lasts for 12-60 hours.
Outbreaks of norovirus are common in restricted environments such as hospitals, nursing homes, schools, military establishments, and cruise ships. To prevent the spread of the virus, patients should be barrier-nursed and treated with fluid replacement and symptomatic treatment. It is important to note that these patients should not be admitted to hospitals unless absolutely necessary due to the highly infectious nature of the disease.
Key control measures for norovirus include frequent cleaning, environmental disinfection, and prompt clearance of soiling caused by vomit or faeces. Hygiene and hand-washing are also crucial in preventing the spread of the virus. Anyone who is infected should not prepare food for others until at least 3 days after symptoms have gone.
In conclusion, understanding the symptoms, transmission, and control measures of norovirus is crucial in preventing outbreaks and protecting public health.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 65
Correct
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The practice nurse is seeking advice on malaria prophylaxis for a 26-year-old female patient who is currently taking the combined oral contraceptive pill for contraception and has a history of anxiety treated with sertraline two years ago. What would be the most suitable recommendation?
Your Answer: Mefloquine may not be prescribed due to the history of anxiety
Explanation:Strengthened Warnings on the Neuropsychiatric Side-Effects of Mefloquine
Mefloquine, also known as Lariam, is a medication used for the prevention and treatment of certain types of malaria. However, there has been a long-standing concern about its potential neuropsychiatric side-effects. Recently, a review has led to the strengthening of warnings regarding these risks.
Patients taking mefloquine may experience side-effects such as nightmares or anxiety, which could be a sign of a more serious neuropsychiatric event. There have also been reports of suicide and deliberate self-harm in patients taking this medication. Adverse reactions may persist for several months due to the long half-life of mefloquine.
It is important to note that mefloquine should not be used in patients with a history of anxiety, depression, schizophrenia, or other psychiatric disorders. If patients experience any neuropsychiatric side-effects while taking mefloquine, they should stop the medication and seek medical advice. These warnings aim to ensure the safe use of mefloquine in the prevention and treatment of malaria.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 66
Incorrect
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What percentage of individuals with Chlamydia infection in their genital area do not experience any symptoms?
Your Answer: Around 50% of women and 25% of men
Correct Answer: Around 70% of women and 50% of men
Explanation:Chlamydia is the most common sexually transmitted infection in the UK caused by Chlamydia trachomatis. It is often asymptomatic but can cause cervicitis and dysuria in women and urethral discharge and dysuria in men. Complications include epididymitis, pelvic inflammatory disease, and infertility. Testing is done through nuclear acid amplification tests (NAATs) on urine or swab samples. Screening is recommended for sexually active individuals aged 15-24 years. Doxycycline is the first-line treatment, but azithromycin may be used if contraindicated. Partners should be notified and treated.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 67
Incorrect
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A mother brings her 3-year old daughter, Lily into your clinic with concerns about vaccinations. Lily has recently undergone a liver transplant and is on immunosuppressants. The mother is worried that some vaccinations may not be safe for her daughter. Which of the following vaccinations can be administered in this situation?
Your Answer: Measles vaccine
Correct Answer: Pertussis vaccine
Explanation:Live attenuated vaccines, such as those for seasonal nasal flu, oral polio, mumps, and measles, are commonly used. The pertussis vaccine, on the other hand, is an inactivated whole-cell vaccine that is safe for immunocompromised individuals. Immunization schedules for both children and adults are undergoing rapid changes, and some candidates may not be aware of these changes or recommendations for special groups. Although the administration of vaccinations is often delegated to clinical staff, it is important for GPs to be aware of contraindications and schedules in order to advise patients and parents. Auditing specific target groups may reveal a need for catch-up immunization in cases where recommendations have changed.
Vaccinations: Types and Precautions
Vaccinations are an important aspect of preventive healthcare. However, it is crucial to be aware of the different types of vaccines and their potential risks, especially for immunocompromised individuals. Live-attenuated vaccines, such as BCG, MMR, and oral polio, may pose a risk to these patients. In contrast, inactivated preparations, such as rabies and hepatitis A, and toxoid vaccines, such as tetanus and diphtheria, are safer options. Subunit and conjugate vaccines, which use only part of the pathogen or link bacterial polysaccharide outer coats to proteins, respectively, are also available for diseases like pneumococcus, haemophilus, meningococcus, hepatitis B, and human papillomavirus.
It is important to note that different types of influenza vaccines are available, including whole inactivated virus, split virion, and sub-unit. Additionally, the cholera vaccine contains inactivated strains of Vibrio cholerae and the recombinant B-subunit of the cholera toxin. The hepatitis B vaccine is prepared from yeast cells using recombinant DNA technology and contains HBsAg adsorbed onto an aluminum hydroxide adjuvant.
In summary, vaccinations are an essential tool in preventing the spread of infectious diseases. However, it is crucial to understand the different types of vaccines and their potential risks to make informed decisions about vaccination.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 68
Correct
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A 30-year-old man who is typically healthy comes in with a cough that produces clear sputum and feeling generally unwell for the past three days. The physician provides him with a prescription for antibiotics to be filled at a later time. What is the estimated percentage of patients who will ultimately take antibiotics using this approach?
Your Answer: 33%
Explanation:The Debate on Delayed Prescribing for Antibiotics
Delayed prescribing has been a topic of debate for many years, particularly in relation to reducing antibiotic prescriptions for respiratory tract infections. The National Institute for Health and Care Excellence (NICE) currently advocates for this strategy, but its effectiveness and acceptability among patients remain in question.
In 2013, Cochrane conducted a review of 10 studies on the delayed prescription of antibiotics for acute respiratory tract infections. The review found that delayed prescribing reduced antibiotic use from 93% to 32%, regardless of the method used (e.g. post-dated script, same-day script with advice to use after 48 hours). However, patient satisfaction levels were not significantly affected by delayed prescribing.
Critics of delayed prescribing argue that patient satisfaction levels were just as high for patients who were refused antibiotics. Despite the ongoing debate, delayed prescribing remains a potential strategy for reducing unnecessary antibiotic use.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 69
Incorrect
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Which group of patients should receive a pneumococcal booster vaccination every 6 years and be vaccinated against pneumococcus if they have any of the following conditions?
Your Answer: Alcoholics who have liver cirrhosis
Correct Answer: Those with chronic kidney disease
Explanation:The pneumococcal vaccine is typically administered as a single dose, but individuals who have undergone a splenectomy or have chronic kidney disease should receive a booster shot every five years.
The pneumococcal vaccine comes in two types: the pneumococcal conjugate vaccine (PCV) and the pneumococcal polysaccharide vaccine (PPV). The PCV is given to children as part of their routine immunizations at 3 and 12-13 months. On the other hand, the PPV is offered to adults over 65 years old, patients with chronic conditions such as COPD, and those who have had a splenectomy.
The vaccine is recommended for individuals with asplenia or splenic dysfunction, chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic liver disease, diabetes mellitus, immunosuppression, cochlear implants, and patients with cerebrospinal fluid leaks. However, controlled hypertension is not an indication for vaccination. Patients with any stage of HIV infection are also included in the list of those who should be vaccinated.
Adults usually require only one dose of the vaccine, but those with asplenia, splenic dysfunction, or chronic kidney disease need a booster every five years. It is important to note that asthma is only included if it requires the use of oral steroids at a dose sufficient to act as a significant immunosuppressant.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 70
Incorrect
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A 25-year-old man has been feeling sick for 48 hours with a fever and headache. He is a frequent smoker. He woke up that morning to discover an itchy vesicular rash mostly on his face and trunk.
What is the most suitable course of action for his management?Your Answer: Erythromycin
Correct Answer: Aciclovir
Explanation:Treatment for Chickenpox
Chickenpox is a common viral illness that can be treated with aciclovir if caught early. Most doctors would prescribe this medication to patients over the age of 12 within the first 24 hours of the rash appearing. Aciclovir can help reduce the severity of the illness, but it is ineffective if started later. The recommended dose is 800 mg taken five times daily for seven days.
Children usually have milder symptoms and only require symptomatic treatment. However, non-immune pregnant women who come into contact with Chickenpox may be given varicella zoster immunoglobulin to reduce the severity of the illness. If a rash develops after 20 weeks of pregnancy, aciclovir may be given. It is important to seek medical attention if you suspect you or someone you know has Chickenpox.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 71
Incorrect
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A young patient of yours has returned from a school trip abroad with a diarrhoeal illness. They were one of twenty-four students on a study abroad program who developed bloody diarrhoea on the third day.
Which of the following organisms is the likely cause?Your Answer: Entamoeba histolytica
Correct Answer: Schistosoma mansoni
Explanation:Understanding Dysentery and Amoebiasis
Dysentery is a gastrointestinal infection that is characterized by frequent stools that may contain blood, mucous, or pus. It is caused by Shigella dysenteriae, which is often associated with unsanitary conditions. The disease is transmitted through faecal contamination of water or food, and symptoms usually appear within one to four days of infection. The bacteria penetrate the mucosal epithelial cells of the intestine, causing intense irritation and producing cramps and watery, bloody diarrhoea.
Amoebiasis, on the other hand, is often asymptomatic initially, with cysts present in the faeces. However, symptoms such as lower abdominal pain and diarrhoea can develop later in the disease course. If left untreated, dysentery can also develop. It is important to note that stool examination has low sensitivity in detecting amoebiasis.
Other gastrointestinal infections that you should also be familiar with include C. difficile and E. coli toxins, bacterial causes such as salmonella and campylobacter, viral causes such as rotavirus and norovirus, and parasitic causes such as Giardia lamblia. Understanding these conditions is crucial in providing appropriate management and preventing further spread of the disease.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 72
Incorrect
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A 42-year-old man presents with a painful, red right eye, blurred vision, and photophobia. Vesicles are observed at the lid margins and fluorescein staining reveals a dendritic ulcer. What is the most probable causative organism?
Your Answer: Adenovirus
Correct Answer: Herpes simplex
Explanation:Eye Infections: Differentiating Herpes Simplex from Other Causes
When it comes to eye infections, it’s important to differentiate between different causes in order to provide appropriate treatment. In the case of a man with features of herpes simplex eye infection, including keratitis and ulceration, it’s important to rule out other possibilities. Herpes zoster ophthalmicus is more common in older patients and presents with more widespread vesicles. Adenovirus, Staphylococcus aureus, and Streptococcus pneumoniae can all cause conjunctivitis, but do not typically present with the same symptoms as herpes simplex. It’s important to note that the absence of a dendritic ulcer doesn’t necessarily rule out a diagnosis of corneal herpes simplex, and referral should be considered if the presentation is otherwise suspicious.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 73
Incorrect
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A 68-year-old man has been diagnosed with COPD and currently receives the yearly flu shot. What should be done regarding the pneumococcal vaccine?
Your Answer: He requires the vaccine once every 5 years
Correct Answer: He should be given it as a one-off
Explanation:Individuals who have asplenia, splenic dysfunction, or chronic kidney disease require a booster every 5 years, while most adults only need one dose.
The pneumococcal vaccine comes in two types: the pneumococcal conjugate vaccine (PCV) and the pneumococcal polysaccharide vaccine (PPV). The PCV is given to children as part of their routine immunizations at 3 and 12-13 months. On the other hand, the PPV is offered to adults over 65 years old, patients with chronic conditions such as COPD, and those who have had a splenectomy.
The vaccine is recommended for individuals with asplenia or splenic dysfunction, chronic respiratory disease, chronic heart disease, chronic kidney disease, chronic liver disease, diabetes mellitus, immunosuppression, cochlear implants, and patients with cerebrospinal fluid leaks. However, controlled hypertension is not an indication for vaccination. Patients with any stage of HIV infection are also included in the list of those who should be vaccinated.
Adults usually require only one dose of the vaccine, but those with asplenia, splenic dysfunction, or chronic kidney disease need a booster every five years. It is important to note that asthma is only included if it requires the use of oral steroids at a dose sufficient to act as a significant immunosuppressant.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 74
Incorrect
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A woman who is pregnant with twins wants advice about air travel while pregnant. It will be a ten-hour flight. There have been no complications during this pregnancy. She wants to know how late into the pregnancy she is allowed to fly.
What would you advise her about air travel for an uncomplicated twin pregnancy?Your Answer: Most airlines will not let a person fly after week 37 of pregnancy
Correct Answer: Most airlines will not let a person fly after week 28 of pregnancy
Explanation:Flying while pregnant with twins
When it comes to flying while pregnant with twins, there are certain restrictions that airlines impose. Unlike a single, uncomplicated pregnancy where the limit is week 37, most airlines will not allow pregnant women carrying twins or more to fly after week 32. This is due to the increased risks of certain medical conditions while travelling in the air that are compounded by pregnancy, as well as the higher risk of going into labor.
Aside from these restrictions, pregnant women should also be advised on DVT prophylaxis, especially for flights longer than four hours. This includes walking when possible, in-seat exercises, keeping hydrated, and wearing compression stockings. The Royal College of Obstetricians and Gynaecologists (RCOG) provides a helpful patient leaflet on this topic.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 75
Incorrect
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A 25-year-old man is starting a nursing program. He requires hepatitis B vaccination.
Which serological marker indicates successful hepatitis B immunisation?Your Answer: HBs antigen
Correct Answer: Anti-HBs antibodies
Explanation:Monitoring and Prevention of Hepatitis B through Vaccination
Hepatitis B is a viral infection that can lead to chronic liver disease and cancer. Vaccination against hepatitis B is an effective way to prevent the spread of the virus. The development of protective antibodies, known as anti-HBs, is used to monitor the response to vaccination. The antibody profile, along with the results of HBsAg and HBeAg tests, can help determine the phase of HBV infection.
Initially, vaccines were derived from viral proteins in infected blood, but now recombinant HBsAg proteins are used. Vaccination strategies range from universal vaccination in infancy to targeted vaccination of high-risk individuals. In areas with high rates of infection, universal vaccine programs have already reduced the incidence of infection, carriage, and hepatocellular cancer.
Conventional three-dose immunization in adults leads to protective immunity in 90% of individuals. Passive immunization with anti-HBsAg hyperimmune globulin can provide rapid protection after exposure, such as after a needlestick injury. For children born to infected mothers, a combination of passive and active immunization is recommended. However, in some infants, chronic infection with a mutant escape virus has occurred despite vaccination.
In conclusion, monitoring and prevention of hepatitis B through vaccination is crucial in reducing the spread of the virus and preventing chronic liver disease and cancer.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 76
Incorrect
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A 30-year-old homeless alcoholic man has had a chronic productive cough for 6 weeks with purulent sputum, anorexia and weight loss. He sleeps rough and in hostels. You suspect he may have tuberculosis.
Select the single correct statement concerning diagnostic procedures for tuberculosis.Your Answer: Sputum samples should be obtained by bronchoscopy and lavage
Correct Answer: Three spontaneous sputum samples should be sent for culture and microscopy
Explanation:To definitively diagnose tuberculosis, a sample of the patient’s sputum must be cultured to detect the presence of Mycobacterium tuberculosis. At least three spontaneous sputum samples should be collected and stained with Ziehl-Neelsen (ZN) stain for rapid direct microscopy. Culture on a Löwenstein-Jensen slope takes several weeks, and antibiotic sensitivity testing takes even longer. If sputum samples cannot be obtained, bronchoscopy and lavage or gastric washings can be considered. Treatment can be started without culture results if there are signs and symptoms of tuberculosis.
Mantoux skin testing is used to screen for latent tuberculosis in close contacts of patients with active TB. However, as the test may be positive in patients who have had BCG vaccine, interferon-γ is recommended as a second-line test. A chest X-ray may also be ordered to rule out pulmonary tuberculosis in a person with a positive skin test and no symptoms. Abnormalities on the X-ray may not always be diagnostic of tuberculosis.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 77
Incorrect
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A 30-year-old man presents with a 9-day history of mucopurulent anal discharge, anal bleeding, and pain during defecation. What is the MOST APPROPRIATE next step in the diagnosis?
Your Answer: Erythrocyte sedimentation rate
Correct Answer: Stained specimen microscopy
Explanation:Diagnosis and Testing for Gonorrhoea
Gonorrhoea is the most probable diagnosis in this case. To confirm the diagnosis, rapid testing can be done by examining Gram-stained anal specimens for Gram-negative diplococci. Culture testing is also necessary to confirm the diagnosis and determine the appropriate antimicrobial treatment. It is important to send the specimens to the laboratory as soon as possible. If there is a significant delay in getting the swabs to the laboratory, it may be advisable to refer the patient to a genito-urinary medicine clinic.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 78
Incorrect
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A 24-year old health care assistant, Sarah, arrives at the emergency department with a needle-stick injury that occurred on Saturday evening. She has just been informed that the patient who caused the injury has tested positive for HIV and is seeking guidance.
What advice would you offer?Your Answer: Do a HIV test on Helena today to see if she has contracted HIV
Correct Answer: Immediately start post-exposure prophylaxis
Explanation:Fortunately, Helena falls within the 72-hour window period for commencing post-exposure prophylaxis (PEP) for HIV, and as such, she should start PEP without delay.
Post-Exposure Prophylaxis for Viral Infections
Post-exposure prophylaxis (PEP) is a preventive treatment given to individuals who have been exposed to a viral infection. The type of PEP given depends on the virus and the clinical situation. For hepatitis A, either human normal immunoglobulin or the hepatitis A vaccine may be used. For hepatitis B, the PEP given depends on whether the source is known to be positive for HBsAg or not. If the person exposed is a known responder to the HBV vaccine, then a booster dose should be given. If they are a non-responder, they need to have hepatitis B immune globulin and a booster vaccine. For hepatitis C, monthly PCR is recommended, and if seroconversion occurs, interferon +/- ribavirin may be given. For HIV, a combination of oral antiretrovirals should be given as soon as possible for four weeks. The risk of HIV transmission depends on the incident and the current viral load of the patient. For varicella zoster, VZIG is recommended for IgG negative pregnant women or immunosuppressed individuals. The risk of transmission for single needlestick injuries varies depending on the virus, with hepatitis B having a higher risk than hepatitis C and HIV.
Overall, PEP is an important preventive measure for individuals who have been exposed to viral infections. It is crucial to determine the appropriate PEP based on the virus and the clinical situation to ensure the best possible outcome.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 79
Incorrect
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A 32-year-old woman returns from a 3-week holiday to Thailand with a 5-day history of feeling generally unwell, feverish, nauseous with a loss of appetite and right upper quadrant pain.
Upon examination, she appears unwell with a temperature of 38.2ºC and a heart rate of 102 beats per minute. Abdominal examination reveals tender hepatomegaly.
Blood tests are conducted, and the results are as follows:
Hb 148 g/L Male: (135-180)
Female: (115 - 160)
Platelets 456 * 109/L (150 - 400)
WBC 12.2 * 109/L (4.0 - 11.0)
Na+ 142 mmol/L (135 - 145)
K+ 4.3 mmol/L (3.5 - 5.0)
Urea 5.2 mmol/L (2.0 - 7.0)
Creatinine 76 µmol/L (55 - 120)
CRP 32 mg/L (< 5)
Bilirubin 42 µmol/L (3 - 17)
ALP 164 u/L (30 - 100)
ALT 512 u/L (3 - 40)
γGT 86 u/L (8 - 60)
Albumin 38 g/L (35 - 50)
What is the most probable diagnosis from the options below?Your Answer: Amoebic abscess
Correct Answer: Hepatitis A
Explanation:Hepatitis A is a viral infection that affects the liver and typically presents with flu-like symptoms, nausea, fatigue, and pain in the upper right quadrant of the abdomen. The liver may also become enlarged and tender, and liver function tests may be abnormal. As the infection progresses, it can lead to significant liver inflammation and a cholestatic picture.
While an amoebic abscess is a possibility given the patient’s history of travel and symptoms of fever and right upper quadrant pain, the blood tests do not fully support this diagnosis, as the white blood cell count and C-reactive protein are only mildly elevated, and the alanine transaminase (ALT) is significantly raised.
Ascending cholangitis, which is characterized by fever, right upper quadrant pain, and jaundice, is less likely in this scenario, as the liver function tests show marked hepatic inflammation with the raised ALT in proportion to the slightly raised bilirubin.
Cholecystitis, which is inflammation of the gallbladder, would not typically cause such a significant rise in ALT or the development of jaundice.
Understanding Hepatitis A: Symptoms, Transmission, and Prevention
Hepatitis A is a viral infection that affects the liver. It is usually a mild illness that resolves on its own, with serious complications being rare. The virus is transmitted through the faecal-oral route, often in institutions. The incubation period is typically 2-4 weeks, and symptoms include a flu-like prodrome, abdominal pain (usually in the right upper quadrant), tender hepatomegaly, jaundice, and deranged liver function tests.
While complications are rare, there is no increased risk of hepatocellular cancer. An effective vaccine is available, and it is recommended for people travelling to or residing in areas of high or intermediate prevalence, those with chronic liver disease, patients with haemophilia, men who have sex with men, injecting drug users, and individuals at occupational risk (such as laboratory workers, staff of large residential institutions, sewage workers, and people who work with primates).
It is important to note that the vaccine requires a booster dose 6-12 months after the initial dose. By understanding the symptoms, transmission, and prevention of hepatitis A, individuals can take steps to protect themselves and others from this viral infection.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 80
Incorrect
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A previously healthy 27-year-old man presents with abdominal discomfort and shortness of breath. He has been experiencing a dry cough for the past two weeks. He works as a financial analyst and drinks about 15 units of alcohol per week. He recently went on a trip to Amsterdam with his friends. He has also developed a skin rash consisting of pink rings with pale centers.
Upon admission, his blood work shows:
- Sodium: 129 mmol/L
- Potassium: 3.8 mmol/L
- Urea: 8.5 mmol/L
- Creatinine: 155 µmol/L
A chest x-ray reveals diffuse reticular infiltrates and a small left-sided pleural effusion. What is the most likely organism responsible for his symptoms?Your Answer: Streptococcus pneumoniae
Correct Answer: Mycoplasma pneumoniae
Explanation:Typical presentation of mycoplasma pneumonia includes flu-like symptoms that progressively worsen and a dry cough. During examination, the patient may exhibit erythema multiforme, indicating the presence of the infection. This type of pneumonia is commonly acquired within the community. Although Streptococcus pneumoniae is also a possible cause, it is not the focus of this particular case.
Comparison of Legionella and Mycoplasma pneumonia
Legionella and Mycoplasma pneumonia are both causes of atypical pneumonia, but they have some differences. Legionella is associated with outbreaks in buildings with contaminated water systems, while Mycoplasma pneumonia is more common in younger patients and is associated with epidemics every 4 years. Both diseases have flu-like symptoms, but Mycoplasma pneumonia has a more gradual onset and a dry cough. On x-ray, both diseases show bilateral consolidation. However, it is important to recognize Mycoplasma pneumonia as it may not respond to penicillins or cephalosporins due to it lacking a peptidoglycan cell wall.
Complications of Mycoplasma pneumonia include cold autoimmune haemolytic anaemia, erythema multiforme, meningoencephalitis, and other immune-mediated neurological diseases. In contrast, Legionella can cause Legionnaires’ disease, which is a severe form of pneumonia that can lead to respiratory failure and death.
Diagnosis of Legionella is generally by urinary antigen testing, while diagnosis of Mycoplasma pneumonia is generally by serology. Treatment for Legionella includes fluoroquinolones or macrolides, while treatment for Mycoplasma pneumonia includes doxycycline or a macrolide. Overall, while both diseases are causes of atypical pneumonia, they have some distinct differences in their epidemiology, symptoms, and complications.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 81
Incorrect
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Samantha is 29 weeks pregnant and travels to Brazil to attend her sister's wedding. She is aware of the risk of Zika virus and uses an insect repellent containing DEET on all exposed areas. What additional precautions should she take upon returning to the UK?
Your Answer: Chorionic villous sampling
Correct Answer: Ultrasound of foetus
Explanation:There is compelling evidence that Zika virus can cause congenital microcephaly and other neurological developmental disorders in fetuses. The National Travel Health Network and Centre (NaTHNaC) has issued guidelines for pregnant women traveling to areas affected by Zika virus, advising them to postpone non-essential travel until after pregnancy and to avoid becoming pregnant while in these areas and for eight weeks after returning home, regardless of whether they experienced symptoms of Zika infection or not. Pregnant women who have traveled to a Zika virus area should seek immediate medical attention, and regular ultrasound scans throughout pregnancy are recommended to detect microcephaly. Asymptomatic women do not need routine testing for Zika virus PCR via blood, urine, or amniotic fluid. However, women who develop Zika virus symptoms during or within two weeks of traveling to a Zika virus area should be tested for Zika virus PCR, and their fetuses should be monitored through serial ultrasounds. If microcephaly is detected on ultrasound, amniocentesis may be considered to check for Zika PCR, but only after weighing the risks and benefits. Chorionic villous sampling, fundal height measurements, and cardiac monitoring are not useful for testing for Zika virus.
Understanding Zika Virus
Zika virus is a type of infection that is transmitted through mosquito bites. It belongs to the flavivirus genus and Flaviviridae family, and was first discovered in 1947 in Uganda. While most people who contract the virus do not experience any symptoms, those who do may experience a mild fever, rash, joint pain, red eyes, muscle pain, headache, and itching. In rare cases, Zika virus has been linked to Guillain-Barre syndrome in adults. However, the most concerning aspect of Zika virus is its potential to cause birth defects in babies born to infected mothers. The virus can be transmitted from mother to fetus through the placenta, and has been linked to microcephaly and other congenital abnormalities. Due to this risk, the World Health Organization has declared a Public Health Emergency of International Concern. It is important to take precautions to avoid mosquito bites in areas where Zika virus is present, and for pregnant women to take extra care to protect themselves from infection.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 82
Incorrect
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A 19-year-old male student presents with a purulent urethral discharge and tests positive for Chlamydia. He has had a number of partners over the past 12 months. Who should be contacted as part of routine contact tracing?
Your Answer: All partners from the last 3 months or the most recent sexual partner
Correct Answer: All partners from the 4 weeks prior to the onset of symptoms
Explanation:For symptomatic men, it is recommended to notify all sexual partners from the 4 weeks before the onset of symptoms. For women and asymptomatic men, it is recommended to notify all sexual partners from the last 6 months or the most recent sexual partner.
Chlamydia is the most common sexually transmitted infection in the UK caused by Chlamydia trachomatis. It is often asymptomatic but can cause cervicitis and dysuria in women and urethral discharge and dysuria in men. Complications include epididymitis, pelvic inflammatory disease, and infertility. Testing is done through nuclear acid amplification tests (NAATs) on urine or swab samples. Screening is recommended for sexually active individuals aged 15-24 years. Doxycycline is the first-line treatment, but azithromycin may be used if contraindicated. Partners should be notified and treated.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 83
Incorrect
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A 28-year-old man, born and raised in the UK, has been diagnosed with HIV. He has no prior medical history and is currently in good health. When is the appropriate time to initiate antiretroviral therapy?
Your Answer: CD4 < 250 * 106/l
Correct Answer: At the time of diagnosis
Explanation:Antiretroviral therapy (ART) is a treatment for HIV that involves a combination of at least three drugs. This combination typically includes two nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI). ART reduces viral replication and the risk of viral resistance emerging. The 2015 BHIVA guidelines recommend that patients start ART as soon as they are diagnosed with HIV, rather than waiting until a particular CD4 count.
Entry inhibitors, such as maraviroc and enfuvirtide, prevent HIV-1 from entering and infecting immune cells. Nucleoside analogue reverse transcriptase inhibitors (NRTI), such as zidovudine, abacavir, and tenofovir, can cause peripheral neuropathy and other side effects. Non-nucleoside reverse transcriptase inhibitors (NNRTI), such as nevirapine and efavirenz, can cause P450 enzyme interaction and rashes. Protease inhibitors (PI), such as indinavir and ritonavir, can cause diabetes, hyperlipidaemia, and other side effects. Integrase inhibitors, such as raltegravir and dolutegravir, block the action of integrase, a viral enzyme that inserts the viral genome into the DNA of the host cell.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 84
Correct
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A 35-year-old woman presents to her GP with a complaint of feeling constantly fatigued for the past 3 months. She has a history of intravenous drug use and routine testing reveals abnormal liver enzyme tests, including a significant increase in alanine aminotransferase (ALT). Although she is not jaundiced, the GP suspects that she may be suffering from acute hepatitis. Which of the following tests is most likely to be positive in this patient if this suspicion is correct?
Your Answer: Hepatitis C antibody
Explanation:Diagnosing Hepatitis C: Understanding the Clinical Features and Testing Methods
Hepatitis C (HCV) is a viral infection that often goes undetected due to the lack of specific symptoms. Fatigue, a common symptom, is not enough to suspect hepatitis C unless other risk factors are present. Abnormal liver function tests may indicate HCV, but a positive serology test is needed to confirm the diagnosis. This test is usually positive three months after exposure, but may take up to nine months. HCV RNA testing is used to confirm ongoing infection, and negative results should be repeated after six months. Chronic infection is common in HCV, affecting about 80% of those infected.
Other viral infections, such as hepatitis B and Epstein-Barr virus (EBV), may also cause liver abnormalities. Jaundice is more common in hepatitis B, while EBV typically causes mild elevation of serum transaminases. Testing for IgM and IgG antibodies can help diagnose acute or past infections. Enzyme levels, such as alkaline phosphatase and gamma-glutamyl transpeptidase, may also be used to differentiate between viral infections.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 85
Incorrect
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Sophie is a 25-year-old woman who presented to your clinic last week complaining of fatigue, muscle aches, and swollen glands. She had gone on a camping trip to a wooded area recently but did not recall any insect bites. Upon examination, there was no visible rash. You ordered an enzyme-linked immunosorbent assay (ELISA) test for Lyme disease, and the result came back as equivocal today.
What would be the most suitable course of action now?Your Answer: Refer to a specialist for further advice
Correct Answer: Perform an immunoblot test for Lyme disease
Explanation:According to NICE guidelines, if a patient is suspected to have Lyme disease and doesn’t have erythema migrans, an ELISA test should be offered. If the ELISA test result is positive or equivocal, an immunoblot test should be performed. In the case of Jess, her ELISA test result was equivocal, so she requires an immunoblot test.
NICE guidelines suggest that if there is a high clinical suspicion of Lyme disease, antibiotics should be started while waiting for the results of the immunoblot test. However, Jess’s symptoms are nonspecific, and her clinical suspicion of Lyme disease is not high. Additionally, NICE recommends a 21-day course of doxycycline as the first-line treatment for Lyme disease, not a 14-day course. Amoxicillin is only recommended if doxycycline is not suitable.
There is no need to repeat the ELISA test at this time. NICE advises repeating the ELISA test 4-6 weeks after the initial test if the first test is negative and Lyme disease is still suspected within 4 weeks from symptom onset.
Referral to a specialist is not currently necessary for Jess. NICE recommends referring patients with focal symptoms to the appropriate specialist or considering a discussion with a specialist. If the immunoblot test is negative but symptoms persist, a discussion with or referral to a specialist should be considered (regardless of the ELISA result) to review whether further tests are required or to consider alternative diagnoses.
Understanding Lyme Disease
Lyme disease is an illness caused by a type of bacteria called Borrelia burgdorferi, which is transmitted to humans through the bite of infected ticks. The disease can cause a range of symptoms, which can be divided into early and later features.
Early features of Lyme disease typically occur within 30 days of being bitten by an infected tick. These can include a distinctive rash known as erythema migrans, which often appears as a bulls-eye pattern around the site of the tick bite. Other early symptoms may include headache, lethargy, fever, and joint pain.
Later features of Lyme disease can occur after 30 days and may affect different parts of the body. These can include heart block or myocarditis, which affect the cardiovascular system, and facial nerve palsy or meningitis, which affect the nervous system.
To diagnose Lyme disease, doctors may look for the presence of erythema migrans or use blood tests to detect antibodies to Borrelia burgdorferi. Treatment typically involves antibiotics, such as doxycycline or amoxicillin, depending on the stage of the disease.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 86
Incorrect
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What is the accurate statement about the heightened risk of venous thromboembolism (VTE) after air travel for individuals?
Your Answer: All patients >= 65-years-old should be advised to wear compression stockings for flights >= 5 hours
Correct Answer: Compression stockings have a role in reducing the risk of VTE in moderate or high risk patients
Explanation:For patients at moderate or high risk, compression stockings are the most suitable preventative measure, with low molecular weight heparin potentially necessary for those at very high risk. Aspirin is not recommended by any current UK guidelines. Although it is sensible to maintain good hydration, there is no evidence to suggest that it effectively prevents VTE, as noted by SIGN in their guideline.
Travel-Related Thrombosis and Guidelines for Prevention
Long-haul air travel has been associated with an increased risk of venous thromboembolism (VTE), commonly known as economy class syndrome. However, there is no universal agreement on how to advise patients regarding VTE prevention during travel. The British Committee for Standards in Haematology, SIGN, and Clinical Knowledge Summaries have all produced guidelines, but they differ in their recommendations.
The most recent CKS guidelines suggest a risk-based approach. Patients with no major risk factors for VTE do not require special measures. However, those with major risk factors should consider wearing anti-embolism stockings, which can be bought or prescribed. In cases of very high risk, such as a long-haul flight following recent major surgery, delaying the flight or seeking specialist advice regarding the use of low-molecular weight heparin may be necessary.
It is important to note that all guidelines agree that there is no role for aspirin in VTE prevention for low, medium, or high-risk patients. A 2001 study in the New England Journal of Medicine showed that the risk of pulmonary embolism increases with travel distance, with 4.8 cases per million for travel over 10,000 km. While the Civil Aviation Authority doesn’t provide specific guidance on VTE prevention, healthcare providers can use these guidelines to help patients make informed decisions about their travel plans.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 87
Incorrect
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A 68-year-old woman with type II diabetes mellitus has a tender erythematous rash on her right leg. She has no drug allergies and no other predisposing risk factors. She has been taking flucloxacillin for seven days. The rash has been slow to respond but has not worsened. She is afebrile and feeling otherwise well.
What is the most appropriate drug option now?
Your Answer: Amoxicillin
Correct Answer: Flucloxacillin
Explanation:Antibiotics for Cellulitis: A Comparison of Treatment Options
Cellulitis is a bacterial skin infection that can be caused by either Staphylococcus aureus or Streptococcus pyogenes. The choice of antibiotic treatment depends on the severity of the infection and the patient’s medical history. Here is a comparison of the most commonly used antibiotics for treating cellulitis:
Flucloxacillin: This antibiotic is recommended as the first-line treatment for uncomplicated cellulitis because it covers both Staphylococcus aureus and Streptococcus pyogenes. A 7-day course is recommended, with a review after 2-3 days to ensure there is no worsening of the condition. If symptoms persist after 7 days, another 7-day course should be continued. If there is no improvement after 14 days, specialist advice or hospital admission should be considered.
Amoxicillin: This antibiotic is recommended for patients with lymphoedema who develop cellulitis. It is not the first-line treatment for uncomplicated cellulitis.
Clarithromycin: This antibiotic is an alternative to flucloxacillin for patients with penicillin allergy. However, if the patient has no drug allergies, flucloxacillin is the preferred treatment.
Co-amoxiclav: This broad-spectrum antibiotic should be reserved for more severe infections to reduce the risk of antibiotic resistance. It is recommended for facial cellulitis close to the eyes or nose if intravenous treatment is not required.
Penicillin V: This antibiotic has a narrow spectrum and mainly covers streptococcal infections. It is not resistant to penicillinase, which most staphylococci produce, leading to resistance against penicillin V. Flucloxacillin is the preferred first-line treatment for cellulitis.
In conclusion, the choice of antibiotic treatment for cellulitis depends on the severity of the infection and the patient’s medical history. Flucloxacillin is the preferred first-line treatment for uncomplicated cellulitis, while other antibiotics may be used for specific patient populations or in more severe cases.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 88
Incorrect
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A 4-year-old boy presents to the clinic with a fever that developed at home this morning. According to his mother, he has vomited twice and is now feeling very tired. During the examination, the child is cooperative and doesn't resist. His temperature is 38.1 degrees Celsius, and a non-blanching rash is visible on both thighs. What is the most appropriate initial step in managing this child?
Your Answer:
Correct Answer: Give IM benzylpenicillin sodium 600mg
Explanation:For a child aged 1-9 years, the recommended single dose of benzylpenicillin sodium prior to hospitalisation is 600mg, provided that it doesn’t cause any delay in transferring the child to the hospital. Any other dosage would be inappropriate for children in this age group.
When suspected bacterial meningitis is being investigated and managed, it is important to prioritize timely antibiotic treatment to avoid negative consequences. Patients should be urgently transferred to the hospital, and if meningococcal disease is suspected in a prehospital setting, intramuscular benzylpenicillin may be given. An ABC approach should be taken initially, and senior review is necessary if any warning signs are present. A key decision is when to attempt a lumbar puncture, which should be delayed in certain circumstances. Management of patients without indication for delayed LP includes IV antibiotics, with cefotaxime or ceftriaxone recommended for patients aged 3 months to 50 years. Additional tests that may be helpful include blood gases and throat swab for meningococcal culture. Prophylaxis needs to be offered to households and close contacts of patients affected with meningococcal meningitis, and meningococcal vaccination should be offered to close contacts when serotype results are available.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 89
Incorrect
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A 30-year-old woman has pyrexia of unknown origin. She has recently been in Africa. The laboratory reports that she has Plasmodium falciparum infection.
Select from the list the single correct statement regarding Plasmodium falciparum infection.Your Answer:
Correct Answer: Chemoprophylaxis is not a guarantee against infection
Explanation:Understanding Malaria: Symptoms, Severity, and Prevention
Malaria is a parasitic infection that can be transmitted through the bite of infected mosquitoes. The symptoms and severity of malaria can vary depending on the type of parasite causing the infection.
Plasmodium falciparum is the most severe form of malaria and can cause impaired consciousness, fits, renal failure, hypoglycemia, bleeding, and even death. Other types of malaria, such as P. vivax and P. ovale, may not present symptoms until months or even years after exposure.
The classic symptom of malaria is a cyclical occurrence of sudden coldness, followed by rigor, fever, and sweating lasting about 2 hours or more. The frequency of these cycles can vary depending on the type of parasite causing the infection. P. vivax and P. ovale infections typically occur every 2 days, while P. malariae infections occur every 3 days. P. falciparum infections can cause recurrent fever every 36-48 hours or a less pronounced and almost continuous fever.
Severe cases of malaria can lead to renal failure, jaundice, and even death. However, the use of effective chemoprophylaxis and insecticide-treated nets can prevent up to 90% of malaria cases. Travelers should be encouraged to use appropriate prophylaxis for their travel itinerary, but it’s important to note that this is not a guarantee against infection.
In summary, understanding the symptoms, severity, and prevention of malaria is crucial in protecting oneself from this potentially deadly infection.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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Question 90
Incorrect
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At what stage of pregnancy is the ideal timing for administering the pertussis vaccine to protect infants prior to their initial primary immunisation?
Your Answer:
Correct Answer: As soon as the pregnancy is confirmed
Explanation:Pertussis Vaccination for Pregnant Women
Pregnant women are now recommended to receive a pertussis vaccination during late pregnancy, between 16-32 weeks, to protect their unborn infants against pertussis. Antibody levels in adults reach their peak two weeks after the booster but then significantly decline. Therefore, immunizations given early in pregnancy would likely be less effective and could be falsely associated with any adverse effects identified at the anomaly scan. Additionally, transplacental antibody transfer is minimal after 34 weeks of pregnancy. Immunization after 16 weeks would also provide protection to infants born prematurely who may be particularly vulnerable. The vaccine can be offered up until labor, but just prior to labor is not the optimal time as antibody levels peak at two weeks after the booster. It is important for pregnant women to consider receiving the pertussis vaccine to protect their unborn infants.
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This question is part of the following fields:
- Infectious Disease And Travel Health
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