Masterclass Infectious Diseases

1. Masterclass Infectious Diseases Dr Stephen Guy Semester 9 2010

2. Paper 1 A 28 year old plumber has a long history of intravenous drug use. He presents to casualty with a fever and pleuritic chest pain and shortness of breath. What could be going on: Pleurisy / viral infection Pneumonia Lung abscess Other suggestions What tests are going to help you here?

3.

4. Paper 1  A 28 year old plumber has a long history of intravenous drug use. He presents to casualty with a fever and pleuritic chest pain and shortness of breath. His blood cultures become positive 12 hours later. Gram positive Cocci are seen. Which of the following are appropriate: Wait and see what grows, then treat Ceftriaxone + Roxithromycin Benzylpenicillin + doxycycline Flucloxacillin + gentamicin Flucloxacillin + gentamicin + vancomycin

5. Paper 1  A 28 year old plumber has a long history of intravenous drug use. He presents to casualty with a fever and pleuritic chest pain and shortness of breath. An echo is performed that day and he is found to have Staphylococcus aureus endocarditis involving the tricuspid valve. He has anaphylaxis to the fluclox you gave him (similar to the reaction he now recalls happened 10 years earlier).       The preferred antibiotic is:   a) gentamicin b) ceftriaxone   b) cephalothin / cephazolin   c) vancomycin

6. Paper 2 A 75 year old polish lady from a hostel had a fractured neck of femur 2 months ago. The hostel where she resides has sent her back into casualty with a history of 5 days of cough productive of a small amount of sputum and fever. The hostel staff have noted that she is increasingly vague.      On examination she appears not acutely unwell. She is mildly confused. Her temperature is 38.1 degrees, pulse rate 100 and BP 120/70. Respiratory rate is 20.On examination of her chest there are coarse crepitations at the right lung base. A CXR shows:

8. Paper 2 a 75 year old polish lady from a hostel had a fractured neck of femur 2 months ago. The hostel where she resides has sent her back into casualty with a history of 5 days of cough productive of a small amount of sputum and fever. The hostel staff have noted that she is increasingly vague.       On examination she appears not acutely unwell. She is mildly confused. Her temperature is 38.1 degrees, pulse rate 100 and BP 120/70. Respiratory rate is 20.On examination of her chest there are coarse crepitations at the left lung base.       The most likely cause of her illness is:   a) bronchitis   b) urinary tract infection   c) meningitis   d) pneumonia   e) prosthetic joint infection

9. The best description of the infection is: Community acquired pneumonia Health care associated pneumonia Nosocomial pneumonia

10. Appropriate antibiotics could be Augmentin duo forte Benzylpenicillin + doxycycline Ceftriaxone + azithromycin Timentin + azithromycin Moxifloxacin

11. Paper 3 Mr Jones is 85 and lives independently. One Saturday afternoon he presents to casualty with 5 days of cough productive of a small amount of sputum and fever. O/E slightly confused, T°c 38°c, pulse rate 102, BP 85/60, respiratory rate – 21, Sats 93% room air. There are course creps at the right mid zone and CXR confirms patchy opacities at the right mid zone   The most likely causative organism is:   a) TB   b) pseudomonas aeruginosa   c) mycoplasma pneumoniae   d) Streptococcus pneumoniae   e) Staphylococcus aureus

12. Paper 3 Mr Jones is 85 and lives independently. One Saturday afternoon he presents to casualty with 5 days of cough productive of a small amount of sputum and fever. O/E slightly confused, T°c 38°c, pulse rate 102, BP 88/60, respiratory rate – 21, Sats 93% room air. There are course creps at the right mid zone and CXR confirms patchy opacities at the right mid zone Bloods: WBC 12,000, Na 132, Urea 8.7, Creat 105, CRP His CURB 65 score is: How is this useful

13. The risk of death increases as the score increases: 0—0.7% 1—3.2% 2—13.0% 3—17.0% 4—41.5% 5—57.0%

14. Paper 3 18 A 21 year old arts student presents to casualty with a 12 hour history of fevers with rigours, severe myalgias and headache. He reports returning from a snow boarding trip to New Zealand 5 days ago. His girlfriend has a runny nose and a mild sore throat.       On examination he is lying on a casualty trolley in distress. He is restless and complaining of a bad headache. His temperature is 39 degrees, pulse rate 100 , BP 100/70. There is a fine macular rash on his forearms and buttocks and he appears to resist movement at the extreme of neck flexion but he is somewhat un-cooperative during the examination.       The most appropriate immediate treatment is:   a) symptomatic treatment with paracetamol   b) oseltamivir   c) intravenous flucloxacillin and ceftriaxone   d) intravenous amoxycillin and gentamicin   e) doxycycline

15. Paper 3 19 A 28 year old lawyer presents with a fever and headache. She has been back from an overseas trip 2 days. She spent 2 weeks in northern Thailand but was unable to tolerate the doxycycline given as prophylaxis for malaria because of nausea.   She was vaccinated appropriately against Hepatitis A and typhoid   On examination she appears well , her temperature is 38.5 degrees. There is a suggestion of a faint erythema on the trunk and upper arms. You note numerous mosquito bites.     Possibilities to consider: Malaria Typhoid Dengue Influenza HIV Hepatitis A  

16. Initial Bloods reveal   FBE Hb – 124 g/dL (115–150g/DL)   WCC – 8.5 x 109/L (4–11 x 109/L)   Platelets – 90 x 109/L (140–400 x 109/L)   Liver Function Tests – ALT - 70 (<55 IU/L)   AST – 50 (0-40 IU/L)   GGT- 40 (<50 IU/L)    Thick and Thin Blood test for Malaria – negative Blood cultures; Negative The most likely diagnosis?  

17. Paper 4 20 10.1 You are called by Microbiology because the tip of a central venous catheter(CVC) you sent 2 days ago has grown gram positive cocci.   The patient concerned had developed a fever 6 days post total colectomy. You had not identified a focus for the fever but the CVC had been removed . Blood cultures have subsequently been negative.       The correct interpretation of this result is:   a) The patient has staphylococcus bacteraemia   b) The patients central line was colonized by staphylococci   c) Incorrect sterile technique was used when the tip was removed   d) The patient has septicaemia (e) None of the above)       10.2 The next step in management should be:   a) intravenous vancomycin   b) intravenous flucloxacillin   c) With-hold antibiotics and observe   d) Trans-thoracic oesophageal echocardiography (TOE)

18. Paper 4     An Intravenous drug user and alcoholic is found to have the following results       AST – 85 IU/L (0–40)   ALT – 120 – IU/L (<55)   Billirubin – 20 umol/L (<19)   GGT – 100 IU/L (<50)   Hepatitis Serology   HBsAg-positive   Hep BcIgG – positive   Hep BcIgM-negative   Hep A IgG-positive   Hep A IgM – negative       The most likely explanation for his abnormal LFT’s is   a) Acute hepatitis B   b) Acute Hepatitis A   c) Latent Hepatitis B Carriage   d) Acute flare of chronic Hepatitis B   e) Alcohol f) Is there anything else anyone would like to check??