26 year-old female presents to the ER with fever and rigors. Her symptoms are particularly troublesome every 2 days. While taking bloods, the resident asks her about a recent holiday or travel abroad. She mentions being in West Africa for some period of time for voluntary work.
O/E she has elevated temperature of 39 C.
What is the working diagnosis?
What signs would you look for?
( A bonus mark for explaining the pathophysiology !! )
First and foremost this is a really incomplete question. It reflects the ossified mentality of old-school clinicians who would rather play the game of "what am I thinking?" than "what do you think is wrong with the patient?"
ReplyDeleteModern medical questions are never written like that. USMLE, membership exams and board exams are written in a better way.
Volunteer work. Then that suggests contact with the population there. Are you looking for one of the African epidemics? Either Tuberculosis or HIV?
First of all, you'd do a proper physical examination. Head and neck (lymphadenopathy) , cardio-respiratory (signs of an effusion, consolidation...etc) and abdominal exam (splenomegaly?).
Draw up some bloods do FBC, ESR and Acid fast stain. Do a chest X-ray looking for cavitations in the upper zone of the lungs since this is most likely an infection and will colonize the area with the highest ventilation.
TB is caused by mycobacterium tuberculosis. The primary infection is often asymptomatic and is sealed off in cavitations. It can re-activate and will a CXR will show cavitations and hilar lymphadenopathy together they're called "Gohn Complex".
The idea is to go through a series of cases exercising a mental framework that would justify subsequent steps of trying to reach the answer, a process described as 'problem-solving'.Of course, arriving at the correct answer is the ultimate objective considering that what follows of patient management is dependent on it. However, the process of arriving at an answer is equally important because it shows a candidate can demonstrate clarity of the mental framework appropriate to reason and detect common and uncommon possibilities, and be able to differentiate between them!! In other words, a clear categorical and deductive method in diagnosis is essential to make sure that nothing is missed. However,I can understand your frustration and agree that this case carries little information which perhaps makes subsequent discussion in the blog slightly overwhelming !!
ReplyDeleteThe indirect question implied by this case addresses the most common imported infections causing fever in the returned tropical traveller. In other words, what is the most common infection imported to the UK?
O/E - she looks unwell. Pulse is 96 bpm. Bp 117/74. No heart murmurs. Respiratory exam unremarkable. However, there is some tenderness at left upper quadrant of abdomen. No palpable lymphadenopathy.
ESR is raised.
FBC:
Hb = 11.1 g/dl (11.7-15.7)
MCV= 97 fl (80.5-99.7)
WBC = 9.4X109/l (3.9-10.6 x109/l)
Platelets = 112 x 109/l (150-440 x 109/l).
CXR- clear.
Sputum sample is sent to the lab for acid-fast stain. Results come back next week.
What's next?
Do you want me to say Malaria?
ReplyDeleteThe question is why ?!!
ReplyDeleteMalaria is indeed the working diagnosis - It is the most common infection imported to the UK causing 30-50% of shaking chills and fever in travelers returning from the tropic.
Other commonly imported infections include hepatitis, dengue and typhoid
can you explain the abnormality in the FBC?
Further lab tests
ReplyDeleteNa = 134 mmol/l (135-145)
K = 4.8 (3.5-5)
Urea = 4.2 (2.5-6.7)
Creatinine = 74 (70-120 micro mol/l)
Alkaline phosphatase = 76 (30-300 UI)
Bilirubin = 28 miro mol/l (3-17)