EMQ: 22
a)
Sarcoidosis
b)
Malaria
c)
Dressler’s syndrome
d)
Whipple’s disease
e)
Lymphoma
f)
Polymyalgia rheumatica
g)
Infective endocarditis
h) Retroperitoneal
fibrosis
i)
Typhoid fever
j)
Tuberculosis
1) A 45-year-old homeless male, who drinks 50 units of
alcohol a week and smokes heavily, is admitted with a history of fever, cough
and loss of weight.
On examination he looks emaciated, his trachea is
deviated to the left, there is flattening of the upper part of his chest on
the left hand side, chest movements are decreased on the left hand side, upper
zone, breath sounds are vesicular and there are fine crepitations in the left
upper zone
Answer: j) tuberculosis
In a homeless alcoholic presenting with cough, fever and
loss of weight; tuberculosis must be one of the first conditions one would
consider. The physical signs suggest a chronic illness (emaciation) and left
apical fibrosis. Thus the most likely diagnosis is tuberculosis.
2) A 26-year-old male who has been on a holiday to Kenya
presents with fever accompanied by chills and rigors. On examination of his
abdomen his spleen is just palpable below the left costal margin
Answer: b) malaria
The history of fever with chills and rigors after
returning form Kenya would immediately make one think of malaria. The finding
of splenomegaly would also be in favour of this diagnosis.
3) A 32-year-old male presents with a history of fever
with night sweats and loss of weight. On examination he has cervical, axillary
and inguinal lymphadenopathy and hepatosplenomegaly.
Answer: e) lymphoma
The history suggests a chronic illness but does not give
a significant clue. However the findings on examination would make one think
of lymphoma.
4) A 40-year-old businessman presents with fever and loss
of weight of a few weeks duration. He gives a history of having had a dental
extraction 2 months prior to presentation.
On examination he is febrile, there is clubbing and
erythematous macules on his palms. His pulse rate is 110 beats per minute;
regular, jugular venous pressure is not raised. The apex beat is at the 5th
left intercostal space in the mid-clavicular line and there is a pan systolic
murmur at the apex and this radiates to his axilla.
Answer: g) infective endocarditis
The history of dental extraction should make one think of
infective endocarditis. The clinical features of clubbing and Janeway lesions
(erythematous macules on his palms) are in favour of this suspicion. The
findings suggestive of mitral regurgitation would make the diagnosis more
likely.
5) A 26-year-old male presents with a history of fever.
He has been on a backpacking holiday in India. On examination he is febrile,
there is an erythematous rash on his trunk, his spleen is palpable. His pulse
rate is 60 beats per minute.
Answer: i) typhoid fever
The history of travel to India with possible exposure to
contaminated food or water (backpacking) would make one think of typhoid
fever. The rash (rose spots) would be further evidence in favour of this
diagnosis. The other supporting evidence is splenomegaly and the relative
bradycardia.
Revision Tip
Study the causes of fever
ACES for PACES pages 70-71
