CASE INFORMATION
Case ID: IVD-001
Case Name: James Cooper
Age: 34 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: A78 (Infectious disease other), A77 (Arbovirus infection)
COMPETENCY OUTCOMES
| Competency Domain | Competency Element |
|---|---|
| 1. Communication and Consultation Skills | 1.1 Elicits a comprehensive travel and exposure history 1.2 Provides clear, reassuring explanations of diagnosis and management 1.3 Engages the patient in shared decision-making regarding treatment and follow-up |
| 2. Clinical Information Gathering and Interpretation | 2.1 Conducts a systematic history to identify potential insect-borne exposures 2.2 Recognises red flags suggestive of severe vector-borne infections 2.3 Orders and interprets appropriate diagnostic tests |
| 3. Diagnosis, Decision-Making and Reasoning | 3.1 Formulates a differential diagnosis including insect vector diseases 3.2 Uses clinical reasoning to determine the most likely diagnosis based on exposure and symptoms 3.3 Recognises severe manifestations requiring urgent care |
| 4. Clinical Management and Therapeutic Reasoning | 4.1 Provides appropriate symptomatic management 4.2 Refers for specialist or hospital care when indicated 4.3 Discusses preventive strategies for future exposure |
| 5. Preventive and Population Health | 5.1 Provides advice on vector-borne disease prevention (mosquito repellents, travel precautions) 5.2 Considers public health implications for notifiable diseases |
| 6. Professionalism | 6.1 Ensures a patient-centred and culturally sensitive approach |
| 7. General Practice Systems and Regulatory Requirements | 7.1 Documents and notifies relevant public health authorities when required |
| 9. Managing Uncertainty | 9.1 Recognises the need for empirical treatment in undifferentiated febrile illness |
| 10. Identifying and Managing the Patient with Significant Illness | 10.1 Identifies red flags requiring escalation to hospital care |
CASE FEATURES
- Febrile illness in a returned traveller from Southeast Asia.
- Symptoms suggestive of an arboviral infection (e.g., dengue, chikungunya, Ross River virus).
- Differentiation from other causes of fever, including malaria and bacterial infections.
- Discussion of vector control and travel health precautions.
CANDIDATE INFORMATION
INSTRUCTIONS
Review the following patient record summary and scenario.
Your examiner will ask you a series of questions based on this information.
You have 15 minutes to complete this case.
The time for each question will be managed by the examiner.
The time allocation for each question is roughly as follows:
- Question 1 – 3 minutes
- Question 2 – 3 minutes
- Question 3 – 3 minutes
- Question 4 – 3 minutes
- Question 5 – 3 minutes
PATIENT RECORD SUMMARY
Patient Details
Name: James Cooper
Age: 34 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- Nil known
Medications
- None regularly
- Took paracetamol for fever over the last 3 days
Past History
- No significant medical history
- No history of chronic illness or immunosuppression
Social History
- Recently returned from a 2-week trip to Thailand and Vietnam.
- Reports multiple mosquito bites during the trip.
- Works as a teacher, no occupational exposure risks.
- No alcohol or drug use.
Family History
- No family history of tropical or infectious diseases.
- No history of autoimmune conditions.
Vaccination and Preventative Activities
- Up to date with routine vaccinations.
- Did not take malaria prophylaxis before travel.
SCENARIO
James, a 34-year-old male, presents with fever, headache, muscle aches, and joint pain that started three days ago, shortly after returning from Thailand and Vietnam. He reports feeling fatigued and unwell, with episodes of chills and sweating, but no respiratory symptoms or gastrointestinal upset.
He recalls being bitten by mosquitoes while overseas but did not develop a rash initially. However, he now notices a faint rash on his trunk and mild bruising.
Your role is to assess James’ symptoms, formulate a differential diagnosis, arrange appropriate investigations, and provide management advice.
EXAMINATION FINDINGS
General Appearance: Looks unwell but alert
Temperature: 38.5°C
Blood Pressure: 110/70 mmHg
Heart Rate: 95 bpm
Respiratory Rate: 18 breaths per minute
Oxygen Saturation: 98% on room air
Skin: Mild, non-itchy maculopapular rash over trunk, few scattered petechiae
Lymph Nodes: Mildly enlarged cervical lymph nodes
Cardiovascular: No murmurs, normal heart sounds
Abdominal Examination: Soft, mild right upper quadrant tenderness, no hepatosplenomegaly
Neurological Examination: No focal deficits, alert and orientated
EXAMINER ONLY INFORMATION
QUESTIONS
Q1. How would you assess James for a potential insect vector disease?
- Prompt: What key aspects of history would you focus on?
- Prompt: How would you differentiate between possible vector-borne infections?
Q2. What investigations would you order, and why?
- Prompt: What initial blood tests are necessary for diagnosing vector-borne diseases?
- Prompt: How do you differentiate between dengue, malaria, and other causes of febrile illness?
Q3. How would you manage James’ condition in a general practice setting?
- Prompt: What supportive treatments would you provide?
- Prompt: When is hospital admission necessary?
Q4. How would you educate James about vector-borne diseases and prevention for future travel?
- Prompt: What measures can be taken to reduce the risk of insect-borne infections?
- Prompt: What vaccines or prophylactic treatments are recommended for travel to endemic areas?
Q5. What public health considerations are relevant in this case?
- Prompt: Which infections require notification to public health authorities?
- Prompt: How would you advise James regarding potential transmission risks?
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Q1: How would you assess James for a potential insect vector disease?
A structured approach involves history-taking, clinical assessment, and differential diagnosis formulation.
1. Comprehensive History-Taking
- Travel history: Locations visited (Thailand, Vietnam), urban vs rural exposure.
- Insect exposure: Mosquito bites, daytime vs nighttime bites.
- Onset and progression: Fever pattern, duration, associated symptoms.
- Associated symptoms:
- Dengue: Retro-orbital pain, rash, bleeding tendencies.
- Malaria: Cyclical fever, chills, sweats.
- Chikungunya/Ross River virus: Polyarthritis, joint swelling.
- Typhoid fever: Stepwise fever, gastrointestinal symptoms.
- Vaccination history: Japanese encephalitis, yellow fever.
- Medication history: Malaria prophylaxis adherence.
2. Physical Examination
- Vital signs: Hypotension/tachycardia suggesting shock.
- Skin: Rash, petechiae, jaundice.
- Neurological: Signs of encephalitis or meningism.
- Abdominal: Hepatosplenomegaly (suggests malaria, dengue).
Conclusion: James’ high fever, rash, and mosquito exposure raise suspicion for dengue or other arboviral infections.
Q2: What investigations would you order, and why?
1. Initial Blood Tests
- FBC: Thrombocytopaenia (dengue), leukopenia (viral infections).
- LFTs: Elevated transaminases (dengue, malaria).
- Electrolytes and renal function: Dehydration, AKI risk.
2. Specific Tests for Vector-Borne Diseases
- Dengue NS1 antigen and IgM/IgG.
- Malaria thick and thin smears or rapid antigen test.
- Chikungunya and Ross River virus serology.
3. Other Considerations
- Blood cultures: Rule out typhoid or bacterial sepsis.
- Urinalysis: Proteinuria (suggests severe dengue).
Conclusion: These investigations help confirm the diagnosis and guide management.
Q3: How would you manage James’ condition in a general practice setting?
1. Supportive Care
- Oral/IV hydration: Prevent complications of dehydration.
- Paracetamol for fever (avoid NSAIDs due to bleeding risk).
- Monitoring for warning signs: Severe dengue, organ failure.
2. Criteria for Hospital Referral
- Severe dengue signs: Persistent vomiting, mucosal bleeding.
- Hypotension or shock.
- Neurological involvement: Encephalitis, altered consciousness.
3. Public Health Considerations
- Notify authorities if confirmed vector-borne disease.
- Contact tracing and community awareness.
Conclusion: James requires supportive care, close monitoring, and possible hospital referral if deterioration occurs.
Q4: How would you educate James about vector-borne diseases and prevention for future travel?
1. Personal Protection Measures
- Insect repellents (DEET, picaridin).
- Long-sleeved clothing, bed nets in endemic areas.
2. Vaccination and Prophylaxis
- Japanese encephalitis vaccine for high-risk travel.
- Malaria prophylaxis in endemic regions.
3. Early Symptom Recognition
- Seek medical care for fever after travel.
- Avoid NSAIDs if dengue is suspected.
Conclusion: Preventive education reduces future risk of vector-borne diseases.
Q5: What public health considerations are relevant in this case?
1. Notification Requirements
- Dengue, malaria, chikungunya, Ross River virus are notifiable diseases in Australia.
- Immediate notification to the local public health unit if confirmed.
2. Local Transmission Risk
- Assess risk of secondary transmission via local mosquitoes.
- Inform public health for mosquito control measures.
3. Travel-Related Advice
- Advise against blood donation for 4 weeks post-travel.
- Monitor for delayed complications (e.g., post-viral arthritis, fatigue).
Conclusion: This case has important public health implications requiring notification and vector control strategies.
SUMMARY OF A COMPETENT ANSWER
- Comprehensive history and travel assessment to determine exposure risk.
- Orders appropriate blood tests to differentiate vector-borne infections.
- Provides supportive care and escalates if severe illness is suspected.
- Educates on insect vector disease prevention and future travel precautions.
- Understands the public health implications and notification requirements.
PITFALLS
- Failure to consider malaria as a differential.
- Prescribing NSAIDs in suspected dengue, increasing bleeding risk.
- Not recognising warning signs requiring hospital referral.
- Neglecting public health reporting responsibilities.
- Inadequate travel health advice for future prevention.
REFERENCES
- Australian Government Department of Health on Dengue Fever and Arboviral Diseases
- World Health Organization (WHO) on Dengue and Severe Dengue
- Australian Immunisation Handbook on Travel Vaccinations
MARKING
Each competency area is on the following scale from 0 to 3.
☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD