‘A.40 year old Vietnamese man who arrived in Darwin 6 weeks prior, presents with 5 days of headache, fever and malaise. What is the MOST LIKELY diagnosis? ) Malaria Correct (@]b) Typhoid fever ww . 7X / Tid) Flariasis Ge) Meningococcal meningitis Malaria is endemic in South-east Asia and a clinical presentation such as this should be regarded as malaria until proven otherwise. Its symptoms are usually non- specific, with headache, fevers and malaise being the most common symptoms. Typhoid fever has an incubation period of 7 to 21 days, with an average of 14 days. Although headache and fever are common symptoms, one would expect other symptoms such as abdominal pain and diarrhoea, Dengue fever has an incubation Period of only 5-8 days, followed by sudden headache, fevers and severe myalgias (’The Dandy Walker Syndrome"). A rash typically develops on the third to fifth day. Filiariasis (due to Wucheria bancrofti) can present as a lymphangitis, with recurrent fever and inflammation overlying the affected lymphatic vessel. Finally meningococcal meningitis has @ rapid clinical course and the patient would be unlikely to present with such a long clinical history. Photophobia, neck stiffness and altered conscious state could also be expected. (The Merck Manual of Diagnosis and Treatment Available www.merck. i" ht?flle=/mrkshared/mmanual/section13/cha .isp%3Freaion%3Dmerckcomt malari mihi anchor )(Murtagh 3 (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 114-6) (Harrison's Online Available: accessmedicine.com/content.aspx?aID=77546&searchStr=clinical--features+of tmalaria#searchTerm ) Question 38 Peter presents with a painfyl tefheye associated with a sudden loss of vision. Which of the following conditions & NOY usually associated with pain in or around the eye? Be) Amaurosis fugex —_ Wo Po Correct (db) Retrobulbar neuritis JO) Acute angle closure glaucoma [B]4) Temporal arteritis [Ble) Anterior uveitis §// 4 Amaurosis fugax is the painless temporary loss of vision in one eye associated with an embolus temporarily lodging in a retinal arteriole. {Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 1338) (Harrison's Online Available: eww. ‘content aspx?all 3575) 35 75&searchStr=amaurosis+fuaxét5 Question 39 ‘A 62 year old housewife presents because of pain in her left cheek precipitated by eating or touching her face just under the left eye. This pain lasts for 30 to 60 seconds, The patient is most likely to benefit from: a) Dental attention Jb) Penicillin[a] ¢) Blockade of the infraorbital nerve (aij 3) Carbamazepine Correct Ge) Corticosteroids Facial pain analysis requires a disparate approach, Neuralgia, particularly Trigeminal heuralgia, are common causes and are more prevalent in women over 50 years. Neuraigias are characterised by paroxysmal, fleeting, almost electric shock-like episodes that are caused by demyelinating lesions of nerves that result in the activation of a CNS pain-generating mechanism. The pain of Trigeminal neuralgia, which can be in any branch of the Trigeminal nerve, usually lasts a minute or two. A characteristic feature Is the initiation of pain by stimuli applied to certain areas of the face, lips, or tongue, or by movement of these parts, The adequate stimulus to precipitate an attack is a tactile one and possibly a tickle, rather than a noxious or thermal stimulus. Carbamazepine is the drug of choice for Trigeminal neuralgi Dental pain Is common, with provocation by hot, cold or sweet foods being typical. Pain with chewing itself may be due to Trigeminal neuralgia, temporomandibular dysfunction or giant cell arteritis with jaw claudication, (Harrison's Online Available www.accessmedicin sspx?al 106249 ) (Murtagh 3 (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 581-2) = Question 40 ‘The most important muscle used for inspiration is:[ja) External intercost Hb) Diaphragm Correct [aJo) Sealenes d) Rectus abdominis ) Internal intercostals In resting healthy individuals, contraction of the diaphragm is responsible for the majority of inspiration. Clinically, itis important to remember that that the diaphragm is innervated by the C3/4/5 spinal segments, (mostly C4/5) via the Phrenic nerves. Loss of function of this segment, either from trauma or metastatic malignancy, will result in the loss of the function of the diaphragm and all intercostal muscles, The patient will die of respiratory exhaustion in three days unless respiration Is supported. Unilateral phrenic nerve damage (i.e, bronchogenic carcinoma), causes unilateral hemi diaphragmatic paralysis which can cause @ 20% loss of inspiratory effort. This is, remarkably, quite asymptomatic. (Harrison's Online Available www.accessmedicine.com/content.aspx?alD=83738 ) (Roberts F (2000) Respiratory physiology. Updates in Anaesthesia, Issue 12, p1-3 Available www.nda.ox.ac.uk/wfsa/html/ui2/u1211_O1.htm )