Question1

Question 1

18 year old female presents with nausea and vomiting of a week’s duration. 3 days prior to presentation she developed fever, headache, and chills. The headache was generalized but later became so severe with associated malaise. She has had a similar presentation a month ago following surgery. She took diclofenac and paracetamol 2 days before reporting to the hospital.
Vitals
T = 38.1oC​​​
P = 91bpm​​
R = 18cpm​​
SpO2 = 97%#
BP = 120/80mmHg

1. What is/are your differential diagnosis(es)?
2. State any five investigations you would do for this patient?
3. How would you treat this patient at the emergency?
4. What are some of the likely complications that can

Answer 1

1. What is/are your differential diagnosis(es)?
   - Malaria
   - Enteric Fever
   - Urinary Tract Infection
   - Early Cyesis
   - Surgical Site infection
2. State any five investigations you would do for this patient?
   - FBC
   - UPT
   - Urine R/E
   - Urine C/S
   - BF for MPs
   - Typhoid IgG/IgM
   - Pelvic Scan
   - Wound Swab for R/E and C/S
3. How would you treat this patient at the emergency?
   - Laboratory investigation
   - IVF R/L 2.5L and DNS 2L x 24hrs
   - IV paracetamol 1g stat
   - IV metoclopramide 10mg stat/IV promethazine 25mg stat
   - IV cefuroxime 1.5g stat
4. What are some of the likely complications that can develop in this lady?
   - Severe Dehydration
   - Sepsis
   - Acute Kidney Injury
   - Typhoid Ileal Perforation
   - Pyelonephritis

Question 2

42 year old female, reported to the emergency with a 2 week history of palpitations and dizziness. Palpitations occurred at rest and worsened with moderate exacerbation. Dizziness was usually brought on by standing quickly from a sitting position. She also has easy fatigability, nausea, and loss of appetite. However, lower abdominal pains, chest pains, vomiting, melena stools and haematuria were all absent.
She also admits to a 3 month history of intermittent bleeding vaginally for which she took a pelvic scan. It revealed multiple uterine fibroids and she has been taking herbal medications for about a month now. The rest of the history is unremarkable.
Examination findings
T = 37.1oC​​P = 107bpm​​SpO2 = 94%
R = 22cpm​​BP = 110/90bpm
Ill looking patient with palmar and conjunctival pallor, tinge of jaundice, hydration satisfactory, and not in respiratory distress
CVS – Normal heart sounds with a haemic murmur
RS – Normal findings
Abdomen – No abnormalities detected
CNS – Stable
Preliminary lab findings (Full Blood Count)
HB – 5.2 g/dl​​MCV – 65 fL​​MCH – 23.4 pg
WBC – 8.8 x 109/L​Gran – 4.5 x 109/L​​Lymph – 2.0 x 109/L

Answer all questions
1. State two (2) differential diagnoses
2. What abnormalities can you detect in the vital signs?
3. What does the lab result reveal in this patient?
4. State any three (3) things you would do for this patient as part of your management.

Answer 2

1. Severe Anaemia/Iron Deficiency Anaemia (1 mark)
   Bleeding Uterine Fibroids (1 mark)
2. Tachycardia/Elevated pulse rate (1 mark)
   Raised blood pressure (1 mark) NOT Hypertension
3. Microcytic Hypochromic Anaemia (2 marks)
4. Blood Transfusion (2 marks)
   Oxygen therapy (1 mark)
   Pre-medication of furosemide before transfusion (1 mark)

Question 3

A 17 year old male reported with severe pains in the left thigh which started about 5 days ago. He is a known sickle cell disease patient, genotype SS. The pain is throbbing, was not relieved by oral paracetamol and becomes very worse when he tries walking. There is associated swelling of the thigh, fever and chills. The rest of the history is unremarkable.
Examination findings
T = 38.4oC​​P = 107bpm​​SpO2 = 96%
R = 20cpm​​BP = 100/70mmHg
Ill looking patient, febrile, mildly dehydrated, and in severe pain.
Status localis
Very tender left thigh with associated swelling and differential warmth. Tenderness on passive flexion and extension of the left hip and knee joint

Preliminary lab findings (Full Blood Count)
HB – 8.4 g/dl​​MCV – 81 fL​​​MCH – 28.4 pg
WBC – 21.8 x 109/L​Gran – 15.5 x 109/L​​Lymph – 2.0 x 109/L

Answer all questions
1. What is/are your differential diagnosis(es)?
2. What two (2) necessary investigations would you carry out for this patient?
3. What would be your immediate management of this patient?

Answer 3

1. Sickle Cell Disease
   Mild Anaemia
   Acute Osteomyelitis
   3 marks
2. X-ray – left thigh
   Blood culture
   C-reactive Protein/ESR (erythrocyte sedimentation rate)
   Blood film for Malaria Parasites
   2 marks
3. Analgesia (opioid analgesics; NSAIDS)
   - Morphine, Pethidine, Paracetamol, Ibuprofen, Diclofenac
   Antibiotics
   - Clindamycin, Metronidazole,
   IV fluids
   - Normal Saline
   5 marks

Question 4

A 25 year old male, complains of weight loss and weak erections of 3 months duration. He is a known diabetic on insulin but has defaulted treatment for about 6 months now due to financial complications. There is a history of polyuria, polydipsia, polyphagia, blurred vision and numbness of both lower extremities. He also complains of mild chest pains with onset after exertion which he noticed about 2 weeks ago. There are no other symptoms. The rest of the history yielded no additional information
Examination findings
T = 36.4oC​​P = 92bpm​​SpO2 = 97% (room air)
R = 22cpm​​BP = 90/70mmHg​RBS = 18.2mmol/l
Patient is ill looking with pallor, moderate dehydration and wasted.
CVS – Normal findings
RS – Normal findings
Abdomen – No abnormalities detected
CNS – Stable
Preliminary lab findings (Full Blood Count)
HB – 8.4 g/dl​​MCV – 69 fL​​MCH – 25.4 pg
WBC – 8.8 x 109/L​Gran – 4.5 x 109/L​​Lymph – 2.0 x 109/L
Urine R/E
Blood – neg​​Proteins – neg​​Glucose - ++​​Ketones - +
Pus Cells – 2/1​Epithelial cells – 5/1

Answer all questions
1. What is/are your differential diagnosis(es)? [5 marks]
2. What 2 necessary laboratory investigations would you request for the patient? [2 marks]
3. A physician assistant decided to administer antibiotics as part of his treatment plan for this patient.
In your opinion, is this decision accurate? State your reason(s). [1 mark]
4. What 2 complications is obvious in this patient’s presentation? [2 marks]

Answer 4

1. Diabetes Mellitus
   Diabetic Ketoacidosis (key diagnosis)
   Moderate Anaemia
   Erectile dysfunction
   Myocardial Infarction
2. Blood Urea/Creatinine
   ECG
   Lipid profile
   Arterial blood gases (ABGs)
   Liver function tests
3. Yes. Empirical antibiotic treatment is administered in diabetic ketoacidosis
4. Diabetic retinopathy
   Myocardial Infarction
   Erectile dysfunction
   Diabetic neuropathy