Murtagh Flashcards
The Returned Traveler
a) Dengue Fever b) Cholera c) Malaria d) Typhoid Fever e) Yellow Fever f) Melioidosis g) Leishmaniasis h) Amoebiasis i) Giardiasis j) Strongyloides k) Cutaneous Larva migrans
Q. High Fever, Anorexia, Fatigue, Profuse bloody diarrhoea.
h) Amoebiasis
The Returned Traveler
a) Dengue Fever b) Cholera c) Malaria d) Typhoid Fever e) Yellow Fever f) Melioidosis g) Leishmaniasis h) Amoebiasis i) Giardiasis j) Strongyloides k) Cutaneous Larva migrans
Q. Fever subsiding then returning, Headache, Sore muscles, Macular papular rash on limbs including petechiae.
a) Dengue Fever
The Returned Traveler
a) Dengue Fever b) Cholera c) Malaria d) Typhoid Fever e) Yellow Fever f) Melioidosis g) Leishmaniasis h) Amoebiasis i) Giardiasis j) Strongyloides k) Cutaneous Larva migrans
Q. Fever, Vomiting and Rice water stools
b) Cholera
The Returned Traveler
a) Dengue Fever b) Cholera c) Malaria d) Typhoid Fever e) Yellow Fever f) Melioidosis g) Leishmaniasis h) Amoebiasis i) Giardiasis j) Strongyloides k) Cutaneous Larva migrans
Q. Fever, Headache, Cough + Pleuritic pain, myalgia. Returned from SE Asia.
f) Melioidosis
The Returned Traveler
a) Dengue Fever b) Cholera c) Malaria d) Typhoid Fever e) Yellow Fever f) Melioidosis g) Leishmaniasis h) Amoebiasis i) Giardiasis j) Strongyloides k) Cutaneous Larva migrans
Q. Fever, wasting, Splenomegaly, hyper pigmentation of the skin
g. Leishmaniasis (Visceral) Transmitted by sandflies Also known as Kala azar (black fever)
The Returned Traveler
a) Dengue Fever b) Cholera c) Malaria d) Typhoid Fever e) Yellow Fever f) Melioidosis g) Leishmaniasis h) Amoebiasis i) Giardiasis j) Strongyloides k) Cutaneous Larva migrans
Q. High Fever, Rigors, Headache, Myalgias, Diarrhoea. Returned from Holiday 8 weeks prior
c) Malaria
Fever in returned traveller will be malaria 27% of the time. (Higher than URTI and LRTI) Diagnosis by exclusion - 3 negative daily thick films Requires immediate treatment on suspicion - referral to Infectious Diseases unit. Tx inc: Malarone (atovaquone + proguanil) 4 tabs daily for 3 days. or doxycycline 100mg BD for 7 days.
The Returned Traveler
a) Dengue Fever b) Cholera c) Malaria d) Typhoid Fever e) Yellow Fever f) Melioidosis g) Leishmaniasis h) Amoebiasis i) Giardiasis j) Strongyloides k) Cutaneous Larva migrans
Q. Fever, Headache, Abdominal pain, Jaundice, Bleeding gums, Bradycardia.
e) Yellow Fever
Initial prodrome - mild symptoms that quickly resolve ~ 48-72 hrs post exposure. 50% will progress to a second stage of severe illness. Involving Liver failure and coagulopathy (prolonged clotting time or DIC). Significant risk of mortality due to hepato-renal disease up to 50% n 7-10 days after symptom onset. Mandatory reporting inc. WHO. Admission to hospital for supportive care.
Dx on Serum ELISA.
The Returned Traveler
a) Dengue Fever b) Cholera c) Malaria d) Typhoid Fever e) Yellow Fever f) Melioidosis g) Leishmaniasis h) Amoebiasis i) Giardiasis j) Strongyloides k) Cutaneous Larva migrans
Q. Foul smelling profuse diarrhoea. Bloating and cramping
i) Giardiasis
Tx Tinidazole 2gm stat PO or Metronidazole 400mg Q8H PO 5 - 7 days
The Returned Traveler
a) Dengue Fever b) Cholera c) Malaria d) Typhoid Fever e) Yellow Fever f) Melioidosis g) Leishmaniasis h) Amoebiasis i) Giardiasis j) Strongyloides k) Cutaneous Larva migrans
Q. Low grade fluctuating abdominal pain, Bloating, Recurrent diarrhoea, Eosinophillia,
j) Strongyloides
Dx: Serum ELISA Faecal OCP x 3 (to exclude concomitant Giardia infection) Severe infection can be precipitated by high dose steroids.
Tx: Ivermectin 200mcg/kg on day 1 and day 14. Beware of cutaneous reactions.
The Returned Traveler
a) Dengue Fever
b) Cholera
c) Malaria
d) Typhoid Fever
e) Yellow Fever
f) Melioidosis
g) Leishmaniasis
h) Amoebiasis
i) Giardiasis
j) Strongyloides
k) Cutaneous Larva migrans
Q. Itchy serpiginous lesion
k) Cutaneous larvae migrans
Tx Ivermectin 200mcg/kg as a single dose
Weightloss in child.
a) Diabetes mellitus
b) Adrenal Insufficiency (Addison’s)
c) Eating DIsorder
d) Viral Gastroenteritis
e) Inflammatory Bowel Disease
f) Coeliac Disease
g) Child Neglect
h) Lactose Intollerance
i) Malignancy
j) Cystic Fibrosis
k) Cyclic Vomiting
l) Hyperthyroidism
m) Lead Poisoning
n) Giardiasis
Q. 2 YO child, weight loss, anorexia, abdominal pain, sporadic vomiting, irritability, constipation and developmental delay. Low Socioecconomic, Urban dwelling.
m) Lead poisoning
Ix: Serum Lead level (>0.24 umol/L)
Sources: Inhalation and ingestion especially lead based paint commonly found in deteriorating urban housing built prior to the 1970s
12 - 36 mo is highest risk age due to increased hand to mouth.
Weightloss in child.
a) Diabetes mellitus
b) Adrenal Insufficiency (Addison’s)
c) Eating DIsorder
d) Viral Gastroenteritis
e) Inflammatory Bowel Disease
f) Coeliac Disease
g) Child Neglect
h) Lactose Intollerance
i) Malignancy
j) Cystic Fibrosis
k) Cyclic Vomiting
l) Hyperthyroidism
m) Lead Poisoning
n) Giardiasis
Q. 12 MO Refugee from Sudan, weight loss, recurrent bacterial lower respiratory tract infections, chronic cough, sinusitis, frequent bulky foul smelling stools.
j) Cystic Fibrosis
Newborn screening detects the majority of cases in developed countries as early detection leads to improved outcomes.
CF affects the Respiratory tract causing an obstructive airway picture (chronic bronchitis) on CXR and spirometry. Bronchiectasis is usually a feature and recurrent infections esp S. aureus and H. influenzae are common in early childhood.
Sinus disease is present in the majority of CF patients and frequently results in a bacterial rhinosinusitis.
Pancreatic insufficiency is present in > 2/3 of patients often commencing at birth resulting in malabsorption of fats (steatorrhoea) and protein. CF-related diabetes develops in up to 25% by 20 years of age with an overall lifetime prevalence of up to 50%
Weightloss in child.
a) Diabetes mellitus
b) Adrenal Insufficiency (Addison’s)
c) Eating DIsorder
d) Viral Gastroenteritis
e) Inflammatory Bowel Disease
f) Coeliac Disease
g) Child Neglect
h) Lactose Intollerance
i) Malignancy
j) Cystic Fibrosis
k) Cyclic Vomiting
l) Hyperthyroidism
m) Lead Poisoning
n) Giardiasis
Q. 5 Yr old idigenous child at aboriginal community centre with weightloss, steatorrhoea, fatigue, abdominal pain, flatulence and burping. symptomshave been coming and going for last 6 months.
n) Giardiasis
Symptoms are consistent with chronic giardiasis where patients can lose up to 20% of body weight and stools while loose are not usually classified as diarrhoea.
Acquired lactose intollerance post infection is common (up to 40%) and may persist for many weeks
Ix by Stool microscopy may require 3 specimens for a 90% detection rate.
Weightloss in child.
a) Diabetes mellitus
b) Adrenal Insufficiency (Addison’s)
c) Eating DIsorder
d) Viral Gastroenteritis
e) Inflammatory Bowel Disease
f) Coeliac Disease
g) Child Neglect
h) Lactose Intollerance
i) Malignancy
j) Cystic Fibrosis
k) Cyclic Vomiting
l) Hyperthyroidism
m) Lead Poisoning
n) Giardiasis
Q. 4 YO child weightloss, vomiting, anorexia and fatigue on examination: dry mucosa, sunken eyes, decreased cap refill and BP, increased resp rate. BSL 2.3
b) Adrenal Insufficiency. (Adrenal Crisis)
Key features are fatigue, nausea and vomiting. with dehydration, hypoglycaemia and electrolyte disturbance (hyponatremia and hyperkalemia) (Adrenal crisis)
Addison’s disease is primary adrenal insufficiency and involves adrenal gland dysfunction.
2ndry adrenal insufficiency is a pituitary dysfunction (decreased adrenocorticotropic hormone, ACTH)
Tertiary is a hypothalamus dysfunction (Corticotropin releasing hormone, CRH)
Diagnosis of Addisons disease involves decreased cortisol and increased ACTH. It is confirmed on the short synthetic ACTH (synacthen) test.
Congenital Adrenal Hyperplasia is the most common cause of adrenal insufficiency in infants
Weightloss in child.
a) Diabetes mellitus
b) Adrenal Insufficiency (Addison’s)
c) Eating DIsorder
d) Viral Gastroenteritis
e) Inflammatory Bowel Disease
f) Coeliac Disease
g) Child Neglect
h) Lactose Intollerance
i) Malignancy
j) Cystic Fibrosis
k) Cyclic Vomiting
l) Hyperthyroidism
m) Lead Poisoning
n) Giardiasis
2 YO child lost weight over the last 48 hours with nausea, vomiting, fevers, decreased appetite and abdo pain. 6 watery stools in the last 24 hours, no blood.
d) Viral gastroenteritis
WHO define diarrhoea as 3 or more loose or watery stools/day
Most children will have at least 2 episodes of viral Gastroenteritis by the age of 2.
Vomiting typically lasts for 24-48 hrs, diarhoea lasts for 5-7 days
Red flags: Age < 6mo or weight <8 kg, High fever, Blood or melena, large volumes of diarrhoea, dehydration or hypovolemia, inability to administer fluids, complicating underlying illness (eg. immunodeficiency), increased drowsiness or decreased GCS.
Stool MCS is performed in special circumstances - e.g. persistent diarrhoea (> 7 days), immunocompromised, or in institutional outbreaks.
Children > 12mo and immunocompetent dont require serum studies
Management focused on fluid and electrolyte replacement, reassurance and safety netting.
Weightloss in child.
a) Diabetes mellitus
b) Adrenal Insufficiency (Addison’s)
c) Eating Disorder
d) Viral Gastroenteritis
e) Inflammatory Bowel Disease
f) Coeliac Disease
g) Child Neglect
h) Lactose Intollerance
i) Malignancy
j) Cystic Fibrosis
k) Cyclic Vomiting
l) Hyperthyroidism
m) Lead Poisoning
n) Giardiasis
Q. 12 Mo old child, previously thriving. anorexia, irritability, lethargy, abdominal bloating, offensive stools.
f. Coeliac Disease.
Coeliac Disease (gluten-sensitive enteropathy) prevalence is 1.2% males and 1.9% females.
Three types of tests exist.
- Antibody testing while consuming gluten is first line when low index of suspicion eg. few symptoms or asymptomatic coeliac screening in presence of other auto-immune disease (Addison’s, thyroid, diabetes, etc @ 3yo). tTG-IgA. For children < 2 yo: tTG-IgA + DGP-IgG. Perform when low clinical suspicion .
- Duodenal biopsy - when high index of suspicion alone (Ab testing not required) or low suspicion but positive Abs (tTG-IgA or DGP-IgG).
- Genetic testing HLA-DQ2 and DQ8. - negative test result excludes Coeliac (high Sn, low Sp)
Note: if Dermatitis Herpetiformis (image) is confirmed on biopsy - no further testing is required - Assume Coeliac Disease.
