CANDIDATE INSTRUCTIONS

You are a resident doctor on your general practice rotation. A 28-year-old patient, Jacob Smith, presented to your clinic complaining of episodes of fever.

Please obtain a full history from this patient
At 8 minutes, the examiner will stop you to ask you some questions.

2 Minutes Reading Time

10 Minutes Station Time

Total 12 Minutes

Follow up on this case with this:

Prescribing

EXAMINER INSTRUCTIONS

Timing Instructions: At 8 minutes, stop the candidate and ask the following questions:

Question 1: What are your differential diagnoses?

Answer 1:

Malaria
Traveller's diarrhoea
Dengue
Influenza
Typhoid

Question 2: What is the most likely diagnosis?

Answer 2: Malaria

Question 3: What is the gold standard investigation for malaria?

Answer 3: Microscopy of thick and thin blood films

Question 4: What would be your immediate management plan?

Answer 4: Urgent referral to infectious disease or secondary care (medical assessment unit) to allow testing with same-day results

Malaria

PATIENT INSTRUCTIONS

Name: Jacob Smith
Age: 28 Years Old
Date of Birth: 2nd November1996
Location: General Practice
Occupation: Business owner
“I have been feeling quite unwell. I have been getting these episodes of fever and chills.”
Fever
- Onset: 1 week ago
- Progression: Roughly the same over time
- Exacerbating Factors: Nothing comes to mind
- Relieving Factors: Nothing.
- Associated symptoms: I have been feeling really low in energy levels ever since this all started.
- Timing: I noticed I get these fever episodes once every 2 days
- Precipitating Factors : Cannot seem to think of anything that may have caused this
- Recent illness: None
- Recent trauma: None
- Recent travel:
  - “I recently travelled to Bali with my wife for our honeymoon 3 weeks ago. We stayed there for about a week.”
  - Only if asked: “As part of our trip we went trekking in the rainforest. We had countless mosquito bites from that day.”
  - Only if asked: “We did not take any malaria prevention medications before our travel.”
- Previous episodes: Never had anything like this before
- Ideas: “Have I just got some persistent flu that’s not going away?”
- Expectations: “Some medications that could hopefully give me my energy back, I haven’t been able to work properly with how tired I feel.”
- Concerns: “Nothing particularly concerns me.”
- Bowel habits: I have been getting some diarrhoea lately.
- Urinary habits: Normal.
- Appetite: Appetite has been worse than usual.
- Diet: My wife usually cooks for us at home, we try to stick to a healthy diet.
- Sleep: Normal
- Weight: No change
- Pain in the chest/abdomen: None
- Headaches: None
- Cardiology: Normal
- Ophthalmology: Normal
- Neurology: Normal
- Dermatology: I have noticed my skin has been becoming a little yellow lately
- Musculoskeletal: I have been getting these muscle and joint pains too.
Previous hospital admissions:
- Fractured ankle 5 years ago
- Pneumonia 7 years ago
Previous surgeries:
- Right ankle fixation 5 years ago
Medical conditions:
- I am usually fit and well
Medications: None
Over the counters:
- Paracetamol (for fever)
Allergies:
- Penicillin (anaphylaxis)
Everyone is healthy and well. Wife is well.
- Smoking: Never
- Alcohol: Typically a pint or two of beer on the weekends.
- Recreational drugs: Never
- Exercise: Regularly. Huge enthusiast of outdoor activities.
- Ill contacts: None
- Home: Lives with wife at home.
- Occupation: Business owner

MARK SCHEME

Introduction

Introduces self with full name and role

Washes hand

Identifies patient with at least 2 identifiers

Explains purpose of consultation and gains consent

Ideas, Expectations & Concerns

Explore ideas, concerns, and expectations

Presenting Complaint

Establishes presenting complaint on initial presentation

History of Presenting Complaint

Onset ℹ

Asking about onset is important to help differentiate different causative pathogens based on their incubation period. Parasitic infections tend to take longer (weeks to months) from initial infection to symptom onset. This is contrary to influenza which takes 1 to 3 days to disease presentation.

Progression

Exacerbating Factors

Relieving Factors

Associated Symptoms

Timing ℹ

Timing is important when differentiating between different species of plasmodium in malaria. Typical timing of paroxysm of fevers happens every 48 hours in Plasmodium Vivax, Plasmodium Falciparum and Plasmodium Ovale (Tertian fever), but occurs every 72 hours in Plasmodium Malariae (Quartan fever)

Precipitating Factors ℹ

When suspecting an infection, asking about precipitating factors can give a clue. In a patient who thinks they may have been bitten by mosquitoes, diseases such as Malaria and Dengue are suspected. Similarly, in patients who think they have symptoms after a tick bite, Lyme disease can be taken into consideration.

Previous Episodes

Systems Review

Systems Review (at least six) ℹ

In a patient with malarial infection, they may present with cough, fatigue, malaise, arthralgia and myalgia. Less commonly, they may also experience anorexia, nausea and vomiting, diarrhoea or become jaundiced.

Asked about recent illness

Asked about recent travel ℹ

Asking about recent travel is extremely important as it gives a clue on the type of infection based on the location of travel. In this case, the patient travelled to Southeast Asia, a Malaria-endemic area. When asking about travelling history, take note to ask about any particular activities the patients might have taken on whilst travelling as these may also give an idea on risk factors associated with their infection. In this case, the patient went trekking in the jungle, which houses innumerable mosquitoes, a carrier for malaria.

Asked about recent trauma

Past Medical History

Previous hospital Admissions

Previous surgeries

Any known past medical conditions

Drug History

Asked about medication use

Ask for allergies and the allergic reaction

Establish any over the counter medication use

Family History

Establish any relevant family history

Social History

Explore smoking status

Explore alcohol use

Explore recreational drug use

Explore diet

Ask about exercise

Explore living situation, home and activities of daily living

Ask about ill contacts ℹ

Ill contacts are important to allow contact tracing. In England, Malaria is a notifiable disease and all cases should be notified to public health.

Questions

Identifies at least 3 appropriate differential diagnoses

Identifies the most likely diagnosis

Correctly identifies the gold standard investigation for Malaria

Correctly states the immediate management plan

Patient Scores

Rate how well the candidate has performed from a patient’s perspective out of 5 points.

Enter Your Score Here: /48

SCORE GUIDE

High Pass: > 39

Pass: > 29

Borderline Pass: 24 – 29

Fail: < 24

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Fever

CANDIDATE INSTRUCTIONS

EXAMINER INSTRUCTIONS

PATIENT INSTRUCTIONS

MARK SCHEME

SCORE GUIDE

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