KFP – Infectious diseases

Charlotte Price, aged 24, presents with a 3-day history of worsening dysuria, increased urinary frequency and suprapubic discomfort. She denies any haematuria or fever. She is otherwise well and is not pregnant. Charlotte is sexually active with one male partner. She has not had any new sexual partners in the past 6 months. She uses condoms inconsistently. She has no significant medical history.

Medications: Nil regular

Allergies: Nil known

Past history: Recurrent UTIs, last episode 8 months ago

Social history: Works as a barista, lives with her partner

Examination findings: Afebrile, suprapubic tenderness, no costovertebral angle tenderness

Investigations: Urine dipstick: positive for leukocytes and nitrites. Midstream urine (MSU) sent for microscopy, culture and sensitivity (MCS).

What is the most appropriate immediate management? Select three (3) from the following list:

Benjamin Harris, aged 67, presents with a 2-week history of persistent cough producing purulent sputum, fatigue, low-grade fever and night sweats. He has also noticed some unintentional weight loss over the past month. He denies haemoptysis or chest pain. He migrated from Vietnam 20 years ago and lives with his wife and two grandchildren. He has not travelled recently.

Past history: Type 2 diabetes mellitus, hypertension

Medications: Metformin, perindopril

Social history: Ex-smoker (30 pack years, ceased 10 years ago), retired mechanic

Examination findings: Temperature 37.8°C, RR 20, SpO2 96% RA, scattered crackles in right upper zone

Investigations: Chest X-ray shows right upper lobe cavitation with surrounding infiltrate (see image)

[Insert Image Here]

What are the most appropriate next steps in management? Select four (4) from the following list:

William Scott, aged 55, presents to your rural general practice with a 1-week history of worsening fever, rigors, headache, myalgia and fatigue. He returned from a camping trip in the Daintree region of Far North Queensland 10 days ago. He recalls removing several ticks during the trip. He denies cough or dysuria. He has no known chronic medical conditions.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works as a park ranger, lives with wife, non-smoker, occasional alcohol

Examination findings: Temp 38.9°C, HR 102, BP 112/68 mmHg, RR 18, SpO2 98% RA. Diffuse maculopapular rash over trunk and limbs. No meningism, normal cardiorespiratory exam. Mild hepatomegaly noted.

Investigations: FBC: WCC 3.2 x10^9/L (4.0–11.0), Platelets 95 x10^9/L (150–400), CRP 78 mg/L (0–10), LFTs: mildly elevated ALT and AST.

What are the most appropriate next steps in management? Select four (4) from the following list:

Sophie Mendes, aged 28, presents with a 5-day history of sore throat, fever, malaise and a maculopapular rash. She recently returned from a holiday in Bali, where she attended a music festival. She is unimmunised and unsure if she received childhood vaccines. She has had no cough or dyspnoea but reports photophobia and mild conjunctivitis over the last two days. Several of her travel companions have also developed similar symptoms.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works in early childhood education, lives with flatmates

Examination findings: Febrile (38.4°C), erythematous rash on face and trunk, non-purulent conjunctivitis, cervical lymphadenopathy, faint white spots on buccal mucosa near molars (Koplik spots)

Investigations: None yet performed

What are the most appropriate next steps in management? Select four (4) from the following list:

George Kallis, aged 76, presents with a 24-hour history of fever, confusion, nausea, and new-onset right upper quadrant abdominal pain. He was discharged from hospital 10 days ago following an elective laparoscopic cholecystectomy. His wife reports that he has become progressively more lethargic and disoriented. He is normally independent and has no history of cognitive impairment.

Medications: Rosuvastatin, metformin

Allergies: Nil known

Past history: Type 2 diabetes, hyperlipidaemia

Social history: Lives with wife, retired, non-smoker

Examination findings: Temp 38.6°C, BP 100/60 mmHg, HR 110, RR 20, SpO2 95% RA. Mild jaundice noted. Right upper quadrant tenderness with guarding.

Investigations: FBC: WCC 16.4 x10^9/L (4.0–11.0), CRP 185 mg/L (0–10), LFTs: ALP 220 U/L (30–110), GGT 180 U/L (5–50), ALT 85 U/L (0–45), Bilirubin 36 µmol/L (0–20)

What are the most appropriate next steps in management? Select four (4) from the following list:

Fatima Almasi, aged 34, presents with a 3-day history of worsening vulval discomfort, dysuria, and multiple painful genital ulcers. She is sexually active with a new male partner and reports no similar symptoms previously. She denies systemic symptoms. She has not travelled recently and is otherwise well. No regular medications. She is not currently pregnant and uses condoms inconsistently.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works as a retail assistant, lives alone

Examination findings: Afebrile, normal observations. Multiple shallow, tender ulcerations with erythematous base on labia minora. No inguinal lymphadenopathy. No vaginal discharge or cervical motion tenderness.

What are the most appropriate next steps in management? Select four (4) from the following list:

James Wu, aged 43, presents with a 4-day history of high fevers, malaise, and generalised body aches. He returned from Papua New Guinea (PNG) 2 weeks ago, where he spent 6 weeks working in a remote village. He did not take malaria prophylaxis and recalls being bitten by mosquitoes frequently. He reports chills, sweating, and nausea but no vomiting or diarrhoea. No cough, sore throat or urinary symptoms. He is otherwise healthy and takes no regular medications.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works in construction, lives with wife and two children

Examination findings: Temp 39.4°C, HR 105, BP 110/70 mmHg, RR 18, SpO2 97% RA. Mild scleral icterus, no rash. Abdominal exam: mild hepatosplenomegaly. No focal findings on cardiorespiratory or neurological exam.

What are the most appropriate next steps in management? Select four (4) from the following list:

Lena Dobrev, aged 32, presents with a 6-week history of persistent, watery, foul-smelling diarrhoea associated with intermittent cramping abdominal pain and fatigue. She recently returned from a backpacking trip through Peru, Bolivia, and Ecuador. She reports drinking untreated water and eating from street vendors. She denies fever, blood in stool or significant weight loss. No one else in her group is currently symptomatic.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Vegan, works in hospitality

Examination findings: Vitals normal. Mild diffuse abdominal tenderness, no masses, normal bowel sounds, no signs of dehydration.

What are the most appropriate next steps in management? Select four (4) from the following list:

Max Thompson, aged 7, is brought in by his mother with a 2-day history of fever, irritability and refusal to walk due to pain in his left leg. She reports no trauma. He had a sore throat about one week ago which resolved without antibiotics. Max is usually well, fully immunised, and active. He has no chronic illnesses.

Medications: Nil

Allergies: Nil known

Past history: Unremarkable

Social history: Lives with parents and two siblings, attends primary school

Examination findings: Temp 38.5°C, HR 110, BP 98/60 mmHg. Non-weight bearing on left leg. Warmth, swelling and tenderness over proximal left femur. Passive movement is painful. No skin lesions or joint effusion noted. Mild lymphadenopathy in cervical chain.

What are the most appropriate next steps in management? Select four (4) from the following list:

Rachel El-Amin, aged 23, presents with fever, fatigue, and a diffuse maculopapular rash that started 2 days ago. She also reports a sore throat and painful swallowing. She recently returned from a humanitarian trip to rural Timor-Leste, where she worked in a local school and lived with host families. She is unsure of her immunisation history but believes she received childhood vaccines. She has no chronic conditions and is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Non-smoker, student teacher, lives in a shared house

Examination findings: Temp 38.7°C, HR 100, BP 112/72 mmHg. Diffuse non-blanching rash over trunk and limbs, non-exudative pharyngitis, posterior cervical lymphadenopathy, and splenomegaly. No conjunctivitis. No hepatomegaly.

What are the most appropriate next steps in management? Select four (4) from the following list:

David Sorrenson, aged 61, presents with a 5-day history of worsening productive cough, pleuritic chest pain, fever and dyspnoea. He has a past history of COPD and was hospitalised with an exacerbation last winter. He is up to date with influenza and pneumococcal vaccinations. He lives alone in a rural town and is independent with activities of daily living.

Medications: Tiotropium inhaler, salbutamol as needed

Allergies: Nil known

Past history: COPD (moderate), hypertension

Social history: Ex-smoker (40 pack-years), drinks 2–3 standard drinks on weekends

Examination findings: Temp 38.2°C, HR 96, RR 22, BP 128/74 mmHg, SpO2 91% on room air. Crackles and bronchial breath sounds in the right lower zone. No peripheral oedema or calf tenderness.

Investigations: CXR: Right lower lobe consolidation with air bronchograms. CRP 142 mg/L. WCC 13.1 x10^9/L. UEC normal. ECG normal sinus rhythm.

What are the most appropriate next steps in management? Select four (4) from the following list:

Jasmine Te Paea, aged 4, is brought to your rural general practice by her father due to a 1-day history of fever, decreased appetite, and a painful, red rash around her mouth and on her hands. She attends daycare and several other children in her class are reportedly unwell. She has no significant medical history, is fully immunised, and normally well.

Medications: Nil

Allergies: Nil known

Past history: Unremarkable

Social history: Attends daycare 4 days/week, lives with parents and older brother

Examination findings: Temp 38.3°C. Vesicular lesions with erythematous base on palms, soles, and around the mouth. Mild pharyngitis noted. No signs of dehydration or systemic illness.

What are the most appropriate next steps in management? Select four (4) from the following list:

Thomas O’Neill, aged 70, presents with a 3-day history of new painful vesicular rash on the left side of his chest. He describes burning and tingling pain that started 48 hours before the appearance of the rash. He is otherwise well but has a history of hypertension and osteoarthritis. He lives alone and is independent in daily activities.

Medications: Perindopril, paracetamol PRN

Allergies: Nil known

Past history: Hypertension, osteoarthritis

Social history: Retired teacher, non-smoker, drinks socially

Examination findings: Grouped vesicles on an erythematous base in a unilateral dermatomal distribution (T5–T6) not crossing the midline. No evidence of superinfection. No systemic symptoms.

What are the most appropriate next steps in management? Select four (4) from the following list:

Amira Saleh, aged 29, presents with a 2-week history of persistent low-grade fever, night sweats, anorexia and a dry cough. She is originally from Sudan and arrived in Australia on a humanitarian visa 6 months ago. She lives in temporary housing with her husband and two young children. She has no known chronic medical conditions. There is no history of recent overseas travel or known contact with tuberculosis.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Homemaker, non-smoker, not currently working

Examination findings: Temp 37.9°C, HR 88, BP 118/74 mmHg, SpO2 97% RA. Chest exam: decreased breath sounds in the right upper zone, no crepitations or wheeze.

Investigations: CXR shows right upper lobe cavitary lesion (see image).

[Insert Image Here]

What are the most appropriate next steps in management? Select four (4) from the following list:

Emily Nguyen, aged 26, presents with a 5-day history of worsening sore throat, fever, and fatigue. She also reports difficulty swallowing and tender lumps in her neck. She has no cough or rhinorrhoea. She is a medical student currently in her final placement in a metropolitan hospital. She has not travelled recently and is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Unremarkable

Social history: Lives in shared accommodation, non-smoker

Examination findings: Temp 38.4°C, HR 88, BP 118/76 mmHg. Bilateral tonsillar enlargement with exudates, marked tender cervical lymphadenopathy, no rash or hepatosplenomegaly. No respiratory distress or drooling.

What are the most appropriate next steps in management? Select four (4) from the following list:

Nathan Bell, aged 36, presents to your clinic with a 3-day history of painful urination, purulent penile discharge, and mild testicular discomfort. He is sexually active with multiple male partners and reports inconsistent condom use. He denies systemic symptoms. He has no significant past medical history and has never been tested for STIs.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works in hospitality, lives alone, drinks socially, non-smoker

Examination findings: Afebrile. Purulent urethral discharge noted at meatus. No inguinal lymphadenopathy. Mild tenderness over left epididymis, no swelling or erythema.

What are the most appropriate next steps in management? Select four (4) from the following list:

Helen Armstrong, aged 81, presents with her daughter due to increasing confusion over the past two days, reduced oral intake, and low-grade fever. She lives in a residential aged care facility. Staff report that she has been less responsive and more drowsy since yesterday. She has a background of hypertension, atrial fibrillation, and early-stage dementia.

Medications: Metoprolol, warfarin, donepezil

Allergies: Nil known

Past history: Hypertension, atrial fibrillation, dementia

Social history: Lives in residential aged care, dependent for most ADLs

Examination findings: Temp 37.9°C, HR 92 (irregular), BP 102/68 mmHg, RR 20, SpO2 95% RA. Alert but disoriented. No focal neurological signs. Suprapubic tenderness noted. No cough or abnormal chest sounds. Urine offensive in smell and cloudy.

What are the most appropriate next steps in management? Select four (4) from the following list:

Zainab Yusuf, aged 40, presents with fever, malaise, and a painful swelling in her left axilla that has increased over the past 48 hours. She returned from a visit to a remote village in northern India 10 days ago, where she had close contact with farm animals and consumed unpasteurised dairy products. She denies cough or urinary symptoms. No chronic medical conditions.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with partner, works as a nurse

Examination findings: Temp 38.6°C, HR 96, BP 118/74 mmHg. Left axilla tender with 3 cm fluctuant lymph node. No overlying skin changes. No rash, no hepatosplenomegaly.

What are the most appropriate next steps in management? Select four (4) from the following list:

Oliver Tran, aged 15, presents with a 4-day history of fever, headache, photophobia and a blotchy red-purple rash on his lower limbs. He is drowsy and complains of neck stiffness. His mother states he had been well until three days ago when he developed a mild fever and sore throat. He is otherwise fit and well with no chronic illnesses.

Medications: Nil

Allergies: Nil known

Past history: Up-to-date with immunisations

Social history: Lives with parents and attends high school

Examination findings: Temp 39.5°C, HR 120, BP 100/60 mmHg, RR 24, SpO2 97% RA. Drowsy but arousable. Positive Brudzinski’s sign. Purpuric rash on lower limbs. No focal neurological deficits.

What are the most appropriate next steps in management? Select four (4) from the following list:

Lucy Hartwell, aged 30, presents with a 7-day history of persistent fever, dry cough, fatigue, and headache. She denies dyspnoea or chest pain. Several colleagues from her open-plan office have reported similar symptoms. She is otherwise well and has no chronic medical conditions. She has not travelled recently or had known contact with COVID-19 cases.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Office worker, lives with partner, non-smoker

Examination findings: Temp 38.1°C, HR 84, BP 116/72 mmHg, RR 18, SpO2 98% RA. Chest clear to auscultation, mild pharyngeal erythema. No rash or lymphadenopathy.

Investigations: CXR: bilateral patchy infiltrates. CRP mildly elevated. FBC: normal WCC. SARS-CoV-2 PCR negative.

What are the most appropriate next steps in management? Select four (4) from the following list:

Sarah McEwan, aged 35, presents with a 2-week history of vaginal discharge that has become increasingly malodorous and grey-white in colour. She reports mild vulval irritation but no dysuria or pelvic pain. She is sexually active with a male partner and does not use condoms consistently. She has no systemic symptoms and is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Recurrent bacterial vaginosis (BV)

Social history: Office worker, non-smoker, drinks socially

Examination findings: Normal external genitalia. Thin homogenous grey vaginal discharge with fishy odour. No cervical motion tenderness. No adnexal masses or tenderness.

What are the most appropriate next steps in management? Select four (4) from the following list:

Ahmed Ghali, aged 48, presents with a 2-day history of high fevers, rigors, malaise, and right upper quadrant pain. He recently migrated from Egypt and reports being treated for hepatitis C several years ago. He has no other known chronic conditions and does not consume alcohol. On further questioning, he mentions intermittent episodes of similar pain over the last month, but this is the first time he has had a fever.

Medications: Nil

Allergies: Nil known

Past history: Previously treated hepatitis C

Social history: Lives with extended family, currently unemployed

Examination findings: Temp 39.1°C, HR 104, BP 110/70 mmHg, RR 20, SpO2 97% RA. Jaundice present. Tender hepatomegaly. No rebound or guarding. Bowel sounds normal.

Investigations: LFTs: ALT 105 U/L, AST 130 U/L, ALP 310 U/L, GGT 190 U/L, Bilirubin 46 µmol/L. WCC 14.2 x10^9/L. Abdominal ultrasound reveals a 5 cm hypoechoic lesion in the right hepatic lobe.

What are the most appropriate next steps in management? Select four (4) from the following list:

Jackson Reid, aged 11, is brought in by his mother with a 3-day history of a worsening itchy scalp. She has noticed him scratching frequently and reports seeing small white specks in his hair. He is otherwise well and attends primary school. No other family members are symptomatic.

Medications: Nil

Allergies: Nil known

Past history: Asthma (mild, seasonal)

Social history: Lives with parents and younger sister, attends school regularly

Examination findings: Numerous nits and a few live lice noted on inspection of the scalp, especially behind the ears and at the nape of the neck. No secondary bacterial infection or lymphadenopathy.

What are the most appropriate next steps in management? Select four (4) from the following list:

Samuel Adisa, aged 53, presents with a 5-day history of general malaise, muscle aches, and a new, spreading rash. He returned from a trip to Townsville 2 weeks ago where he had been kayaking in freshwater creeks. He recalls having a minor abrasion on his leg that became submerged in muddy water. He denies cough or gastrointestinal symptoms. He has no significant medical history.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Engineer, lives with wife, no recent overseas travel

Examination findings: Temp 38.7°C, HR 98, BP 112/76 mmHg. Generalised myalgia and conjunctival suffusion. Non-blanching erythematous rash over lower limbs. Right calf is tender but not swollen. No jaundice. Lungs clear.

Investigations: CRP 92 mg/L, WCC 12.8 x10^9/L, LFTs: mildly elevated ALT/AST. Urine dipstick: protein ++, blood +.

What are the most appropriate next steps in management? Select four (4) from the following list:

Isla Morgan, aged 3, is brought in by her parents with a 2-day history of low-grade fever, irritability, and a vesicular rash around her mouth and on her hands. She attends daycare, where several other children have been unwell with similar symptoms in recent days. She is drinking and eating less than usual but is otherwise alert and playful.

Medications: Nil

Allergies: Nil known

Past history: Immunisations up to date, no chronic illness

Social history: Attends daycare 3 days per week, lives with both parents and a 6-month-old sibling

Examination findings: Temp 37.8°C. Multiple small vesicles with erythematous base around the mouth and on palms. Mild erythema of the oropharynx without ulcers. No lymphadenopathy. No signs of dehydration or systemic illness.

What are the most appropriate next steps in management? Select four (4) from the following list:

Andrew Hall, aged 38, presents with a 3-week history of worsening rectal discomfort, mucopurulent rectal discharge, and tenesmus. He is a man who has sex with men (MSM) and reports unprotected receptive anal intercourse with multiple partners. He denies fever or abdominal pain. No urinary symptoms are reported. He is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives alone, works as a graphic designer

Examination findings: Afebrile. Mild perianal erythema. Rectal exam: mucoid discharge, no masses or significant tenderness. No inguinal lymphadenopathy. No skin lesions.

What are the most appropriate next steps in management? Select four (4) from the following list:

Daniel Kerr, aged 46, presents with fatigue, anorexia, nausea, and dark urine for the past 5 days. He returned from a business trip to Vietnam two weeks ago. He recalls eating street food and had one episode of vomiting while overseas, which resolved. He does not drink alcohol and has no known liver disease. No history of intravenous drug use or blood transfusions.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with wife and two children, non-smoker, office-based job

Examination findings: Temp 37.6°C, HR 78, BP 118/70 mmHg. Mild right upper quadrant tenderness. No hepatomegaly or splenomegaly. Scleral icterus noted. No rash or lymphadenopathy.

Investigations: LFTs: ALT 820 U/L, AST 670 U/L, ALP 160 U/L, GGT 90 U/L, Bilirubin 58 µmol/L. INR 1.0, normal UEC. FBC: mild lymphocytosis.

What are the most appropriate next steps in management? Select four (4) from the following list:

Miriam Collins, aged 64, presents with a 6-day history of worsening dry cough, low-grade fever, fatigue, and mild breathlessness. She has a background of type 2 diabetes and mild asthma. She received an influenza vaccination earlier in the year. Her husband had similar symptoms one week ago. She is a retired teacher and lives in suburban Sydney.

Medications: Metformin, salbutamol inhaler PRN

Allergies: Nil known

Past history: Type 2 diabetes, asthma (mild intermittent)

Social history: Lives with husband, non-smoker, no recent travel

Examination findings: Temp 37.9°C, HR 88, RR 20, BP 126/76 mmHg, SpO2 96% on room air. Chest: mild scattered wheeze, no crackles. No rash or lymphadenopathy. No signs of respiratory distress.

Investigations: CXR: Normal. FBC: normal. CRP 28 mg/L. COVID-19 and influenza PCR: pending.

What are the most appropriate next steps in management? Select four (4) from the following list:

Yvonne Gatt, aged 72, presents with a 4-day history of fever, chills, dysuria, and new-onset confusion. She lives in a residential aged care facility. Staff report she has become increasingly disoriented and lethargic. She has a history of hypertension and osteoarthritis. No recent travel or antibiotic use.

Medications: Perindopril, paracetamol

Allergies: Nil known

Past history: Hypertension, osteoarthritis

Social history: Lives in aged care, uses a walker for mobility

Examination findings: Temp 38.3°C, HR 96, BP 104/68 mmHg, RR 22, SpO2 96% RA. Disoriented to time and place. Suprapubic tenderness. No rash or focal neurological signs.

Investigations: Urinalysis: nitrites positive, leucocytes +++, blood ++. CRP 110 mg/L, WCC 15.1 x10^9/L. No prior urine culture results available.

What are the most appropriate next steps in management? Select four (4) from the following list:

Emily Zhao, aged 25, presents with a 10-day history of painless genital ulcer and new-onset generalised rash. She reports having unprotected sex with a new male partner 6 weeks ago. The ulcer has since healed, but over the last few days she developed a widespread non-itchy rash involving her trunk, limbs, and palms. She denies fever or systemic symptoms. No previous STI testing.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works in retail, single, drinks socially, no recent travel

Examination findings: Afebrile, normal vitals. Diffuse maculopapular rash involving palms and soles. No oral lesions. No lymphadenopathy. No genital ulcer currently visible.

What are the most appropriate next steps in management? Select four (4) from the following list:

Robert Mills, aged 59, presents with a 2-week history of worsening cough, weight loss, fatigue, and night sweats. He has a history of type 2 diabetes and was recently released from prison 4 months ago. He currently lives in a community housing facility. He has not travelled overseas in the past 10 years.

Medications: Metformin

Allergies: Nil known

Past history: Type 2 diabetes

Social history: Former smoker (40 pack-years), lives in supported accommodation, no alcohol or drug use currently

Examination findings: Temp 37.8°C, HR 92, BP 128/78 mmHg, RR 20, SpO2 95% RA. Cachectic appearance. Chest auscultation: crackles in upper zones bilaterally. No peripheral oedema or lymphadenopathy.

Investigations: CXR: bilateral upper lobe cavitary lesions. Sputum: pending. FBC: normocytic anaemia, mild leukocytosis. ESR elevated.

What are the most appropriate next steps in management? Select four (4) from the following list:

Alana Fitzroy, aged 31, presents with a 4-day history of fever, chills, muscle aches, and a spreading erythematous rash on her lower right leg. She recalls nicking her shin while shaving a few days ago and noticed the area becoming red and swollen. She has no allergies or past medical conditions. She works as a barista and is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with flatmates, no recent travel

Examination findings: Temp 38.4°C, HR 92, BP 120/78 mmHg. Right shin: warm, erythematous area approximately 12 x 8 cm, with indistinct borders. Mild swelling and tenderness to palpation. No fluctuance or discharge. No lymphangitis or systemic instability.

What are the most appropriate next steps in management? Select four (4) from the following list:

James Li, aged 42, presents with a 3-day history of painful swelling in his right groin and low-grade fever. He is a long-distance truck driver and reports unprotected sex with a female sex worker in northern Queensland 4 weeks ago. He also describes a painless genital ulcer that resolved spontaneously about 2 weeks ago. He is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives alone, smokes 5 cigarettes/day, drinks occasionally

Examination findings: Temp 37.8°C. Right inguinal region: tender, fluctuant mass with overlying erythema. No visible genital ulcer. No rash or systemic signs.

What are the most appropriate next steps in management? Select four (4) from the following list:

Rebecca Doyle, aged 36, presents with a 5-day history of worsening sore throat, fever, and increasing difficulty swallowing. She reports muffled voice, severe unilateral throat pain, and trismus. She has had recurrent tonsillitis in the past but this is the worst episode. She is a primary school teacher and non-smoker. No known recent contacts with infectious mononucleosis.

Medications: Paracetamol PRN

Allergies: Nil known

Past history: Recurrent tonsillitis (non-surgical)

Social history: Lives with partner, non-smoker, no recent travel

Examination findings: Temp 38.9°C, HR 102, BP 116/74 mmHg. Mild trismus noted. Right tonsil swollen and deviated towards midline. Uvula displaced to the left. Tender right submandibular lymphadenopathy. No rash or hepatosplenomegaly.

What are the most appropriate next steps in management? Select four (4) from the following list:

Rajiv Patel, aged 29, presents with a 2-week history of persistent diarrhoea, bloating, fatigue, and mild weight loss. He recently returned from a backpacking trip through Southeast Asia, where he drank untreated water and ate local street food. He denies fever, vomiting, or blood in the stool. He has not taken antibiotics recently and has no chronic medical conditions.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Non-smoker, works in IT, lives with partner

Examination findings: Temp 36.8°C, HR 78, BP 120/72 mmHg. Mild abdominal bloating. No tenderness or organomegaly. Normal bowel sounds. No signs of dehydration.

What are the most appropriate next steps in management? Select four (4) from the following list:

Kaitlyn Moore, aged 24, presents with a 1-day history of sudden onset high fever, headache, and severe body aches. She returned from Bali 5 days ago, where she stayed in a resort and spent time outdoors during the day. She denies any respiratory or urinary symptoms. She is otherwise well and fully vaccinated.

Medications: Oral contraceptive pill

Allergies: Nil known

Past history: Nil significant

Social history: Lives with flatmates, non-smoker, works in retail

Examination findings: Temp 39.2°C, HR 100, BP 110/70 mmHg, RR 18, SpO2 98% RA. Appears flushed and uncomfortable. No rash or focal findings. No neck stiffness or photophobia. No bleeding or bruising.

What are the most appropriate next steps in management? Select four (4) from the following list:

Leonard Ho, aged 67, presents with a 3-week history of a chronic, non-healing ulcer on his right lower leg. He reports it began as a small insect bite following a camping trip in regional Victoria. The lesion has slowly enlarged and become ulcerated, but is painless and not purulent. He has no systemic symptoms. He is otherwise well, with a history of hypertension.

Medications: Amlodipine

Allergies: Nil known

Past history: Hypertension

Social history: Retired, frequently hikes and camps in regional areas

Examination findings: A 2 cm ulcer with undermined edges and yellowish base on the posterior right calf. Surrounding skin is non-erythematous and non-tender. No lymphangitis or systemic signs.

What are the most appropriate next steps in management? Select four (4) from the following list:

Ella Santos, aged 21, presents with a 3-day history of fever, headache, and a painful vesicular rash around the genital area. She reports burning and tingling before the lesions appeared. This is her first episode of genital symptoms. She is sexually active with one new male partner in the past month. No history of STIs. She is distressed and has difficulty passing urine due to pain.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: University student, lives in shared accommodation, no recent travel

Examination findings: Temp 38.1°C. Multiple small grouped vesicles with erythematous base on external genitalia. No lymphadenopathy. No vaginal discharge or cervical motion tenderness.

What are the most appropriate next steps in management? Select four (4) from the following list:

Tomás Delgado, aged 45, presents with a 4-week history of chronic cough, intermittent fevers, night sweats, and unintentional weight loss. He recently immigrated from the Philippines, where he worked in construction. He has no known HIV status and is not currently taking any medications. He denies smoking or alcohol use.

Medications: Nil

Allergies: Nil known

Past history: Nil documented

Social history: Recently arrived migrant, living with extended family in a metropolitan area

Examination findings: Temp 37.7°C, HR 84, BP 122/76 mmHg, RR 18, SpO2 96% RA. Thin appearance. Chest exam reveals crackles in right upper zone. No peripheral oedema or clubbing. No lymphadenopathy.

Investigations: CXR: Right upper lobe consolidation with cavitation. FBC: normocytic anaemia. ESR elevated.

What are the most appropriate next steps in management? Select four (4) from the following list:

Anna Black, aged 6, is brought in by her mother with a 2-day history of a sore throat, fever, and a red, sandpaper-like rash on her trunk and limbs. She also complains of a headache and mild abdominal pain. She attends primary school and there have been recent reports of similar illness in her class. No sick contacts at home.

Medications: Nil

Allergies: Nil known

Past history: Immunisations up to date, otherwise well

Social history: Lives with parents and younger brother

Examination findings: Temp 38.9°C, HR 110, RR 20, BP 98/60 mmHg. Generalised fine erythematous rash with rough texture, more prominent in the groin and axillae. Erythematous oropharynx with enlarged tonsils, fine white exudate, and a ‘strawberry tongue’. No lymphadenopathy or signs of dehydration.

What are the most appropriate next steps in management? Select four (4) from the following list:

Mohammed Aziz, aged 34, presents with a 5-day history of fever, headache, and myalgia, followed by the onset of jaundice. He recently returned from visiting relatives in rural Bangladesh, where he consumed local food and water. He is otherwise healthy and has no history of liver disease. He reports dark urine and pale stools but no abdominal pain or bleeding symptoms.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: IT consultant, lives with wife and two children in metropolitan Sydney

Examination findings: Temp 37.9°C, HR 84, BP 118/74 mmHg, scleral icterus noted. Abdomen soft, mild hepatomegaly, no tenderness or splenomegaly. No rash or lymphadenopathy.

Investigations: ALT 1250 U/L, AST 1100 U/L, ALP 140 U/L, GGT 85 U/L, Bilirubin 72 µmol/L. INR 1.1. FBC: WCC normal, mild thrombocytopenia.

What are the most appropriate next steps in management? Select four (4) from the following list:

Freya Jensen, aged 5, is brought in by her father with a 1-day history of high fever and lethargy. She woke this morning complaining of a sore neck and has since developed a widespread petechial rash. She is normally healthy and attends preschool. Her vaccinations are up to date, including meningococcal B and ACWY.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with parents and younger sibling

Examination findings: Temp 39.4°C, HR 140, BP 92/55 mmHg, RR 26, SpO2 97% RA. Drowsy but rousable. Neck stiffness noted. Non-blanching petechial rash on trunk and lower limbs. Capillary refill 3 seconds. No focal neurological deficits.

What are the most appropriate next steps in management? Select four (4) from the following list:

Neil Armstrong, aged 39, presents with a 6-day history of worsening pain and swelling in his left scrotum, associated with dysuria and fever. He is sexually active with both male and female partners and reports recent unprotected anal and oral sex. No previous history of STIs. He denies nausea or vomiting. He is otherwise well.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works in hospitality, drinks socially, smokes occasionally

Examination findings: Temp 38.2°C, HR 92, BP 122/76 mmHg. Left hemiscrotum swollen and tender, epididymal tenderness noted, testis not enlarged separately. Cremasteric reflex present. No inguinal lymphadenopathy or skin changes.

What are the most appropriate next steps in management? Select four (4) from the following list:

Margaret Daly, aged 83, presents with a 2-day history of confusion, urinary frequency, and low-grade fever. She lives independently and has no recent falls or trauma. Her daughter reports she’s been ‘off her food’ and not drinking well. She has a background of hypertension, osteoarthritis, and mild cognitive impairment.

Medications: Amlodipine, paracetamol

Allergies: Nil known

Past history: Hypertension, osteoarthritis, mild cognitive impairment

Social history: Lives alone with home care assistance 3 times per week

Examination findings: Temp 37.8°C, HR 90, BP 106/64 mmHg, RR 20, SpO2 98% RA. Alert but disoriented. Mild suprapubic tenderness. No costovertebral angle tenderness. Chest clear. No focal neurological deficits.

Investigations: Urinalysis: nitrites positive, leucocytes +++, blood ++. CRP 75 mg/L, WCC 13.2 x10⁹/L. eGFR 48 mL/min/1.73m² (baseline ~55).

What are the most appropriate next steps in management? Select four (4) from the following list:

Luke Patterson, aged 17, presents with a 5-day history of sore throat, fatigue, low-grade fever, and swollen neck glands. He also reports mild headache and reduced appetite. He is in Year 12 and has missed several days of school. No recent travel or known sick contacts. His mother is concerned about possible glandular fever.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with parents, non-smoker, plays rugby

Examination findings: Temp 38.1°C, HR 86, BP 120/72 mmHg. Bilateral tender cervical lymphadenopathy. Tonsillar enlargement with white exudate. Mild splenomegaly. No rash or hepatomegaly.

What are the most appropriate next steps in management? Select four (4) from the following list:

Hassan Almasi, aged 60, presents with a 3-week history of chronic dry cough, mild shortness of breath, fatigue, and unintentional weight loss. He was treated for pulmonary tuberculosis in Iran 20 years ago. He migrated to Australia 3 years ago. He denies fever or haemoptysis. He is a non-smoker and has no other medical conditions.

Medications: Nil

Allergies: Nil known

Past history: Pulmonary TB (treated successfully overseas)

Social history: Lives with adult son, no recent travel, non-smoker, no occupational dust exposure

Examination findings: Temp 36.8°C, HR 76, BP 124/76 mmHg, RR 18, SpO2 98% RA. Thin appearance. Chest clear to auscultation. No clubbing, lymphadenopathy or skin lesions.

Investigations: CXR: Right upper lobe fibronodular changes with areas of cavitation. FBC: normal. ESR mildly elevated. HIV negative.

What are the most appropriate next steps in management? Select four (4) from the following list:

Jodie Nguyen, aged 32, presents with a 1-day history of fever, malaise, and a painful red lesion on the right side of her face. She reports that the area started as a small patch of redness near her cheekbone yesterday, but rapidly spread overnight. She denies trauma or insect bites. She is otherwise well and has no chronic medical conditions.

Medications: Combined oral contraceptive pill

Allergies: Nil known

Past history: Nil significant

Social history: Works as a chef, lives with her partner

Examination findings: Temp 38.3°C, HR 94, BP 122/76 mmHg. Bright red, oedematous, sharply demarcated area over the right cheek extending to the periorbital region. Skin is tender and warm. No crepitus or fluctuance. No lymphadenopathy. No visual changes.

What are the most appropriate next steps in management? Select four (4) from the following list:

Callum Robertson, aged 48, presents with a 2-week history of general malaise, low-grade fevers, night sweats, and weight loss. He also reports recent onset of exertional dyspnoea and has noticed his ankles are mildly swollen. He has a history of rheumatic heart disease and underwent mitral valve repair 4 years ago. No recent dental work or known infections.

Medications: Warfarin

Allergies: Nil known

Past history: Rheumatic heart disease, mitral valve repair

Social history: Non-smoker, moderate alcohol intake, works as a teacher

Examination findings: Temp 37.9°C, HR 88, BP 118/72 mmHg. Mild bilateral ankle oedema. Systolic murmur heard at apex. No skin lesions, petechiae, or splinter haemorrhages noted. No focal neurological signs.

What are the most appropriate next steps in management? Select four (4) from the following list:

Sophie Tran, aged 26, presents with a 4-day history of painful urination, increased urinary frequency, and lower abdominal discomfort. She also reports new-onset vaginal discharge and mild postcoital spotting. She is sexually active with a new male partner and uses condoms inconsistently. No fever, flank pain, or nausea. No significant past medical history.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with housemates, university student

Examination findings: Temp 37.4°C, HR 78, BP 112/72 mmHg. Mild suprapubic tenderness. No costovertebral angle tenderness. Pelvic exam: mucopurulent cervical discharge, cervical motion tenderness. No adnexal masses or tenderness.

What are the most appropriate next steps in management? Select four (4) from the following list:

Benjamin Howard, aged 52, presents with a 7-day history of worsening pain, swelling, and redness of his left great toe. He is a known type 2 diabetic with poor glycaemic control. He noticed a small blister last week that has since ruptured. He now has foul-smelling discharge and difficulty walking. No fevers or chills. He is otherwise well.

Medications: Metformin, gliclazide

Allergies: Nil known

Past history: Type 2 diabetes (HbA1c 9.1%), peripheral neuropathy

Social history: Works in logistics, lives with partner, smokes 10 cigarettes/day

Examination findings: Temp 37.6°C, HR 88, BP 130/78 mmHg. Left great toe: ulcer at tip, 1.5 cm diameter, with purulent discharge and erythema extending 2 cm around. No crepitus or systemic signs. Dorsalis pedis pulse weak. Reduced sensation to monofilament testing.

What are the most appropriate next steps in management? Select four (4) from the following list: