Infectious Disease
CANDIDATE INSTRUCTIONS
You are a resident year 1 doctor currently working in acute medicine. A 28-year-old patient, Jacob Smith, presented to your clinic complaining of episodes of fever associated with recent travel. His peripheral blood smears confirmed a diagnosis of malaria.
Given his diagnosis, prescribe the appropriate anti-malarial and regular analgesia for the patient.
2 Minutes Reading Time
5 Minutes Station Time
Total 7 Minutes
EXAMINER INSTRUCTIONS
Click and download the inpatient prescription chart below before the station starts. Provide the chart to the candidate as soon as the station starts. ONLY IF the candidate asks for anti-malarial guidelines, provide guidelines below ‘Patient Details’ for the candidate to read. Scroll down for patient details.
Patient Details
Name: Jacob Smith
Age: 28
Date of birth: 2nd November 1996
Weight: 75 kg
Height: 179 cm
Medications: Paracetamol
Consultant in charge: Dr Kumar
Hospital Number: K102938
Address: 5, 21 George Street, Grover GP19 80L
Hospital: OSCEVault University Hospital
Ward: 7
Allergies: Penicillin (anaphylaxis)
Guidelines for the Candidate
Malaria diagnosis and treatment guideline (2015) from the University College London Hospitals NHS Foundation Trust, UK:
Artesunate is the drug of choice for all patients with severe malaria: it has a rapid effect on parasite clearance and has been shown to reduce mortality compared to quinine in clinical trials in patients of all ages (SEAQUAMAT Lancet 2005; AQUAMAT Lancet 2010). If the patient has features of severe malaria consider managing in a specialist infection unit or High Dependency Unit with frequent medical review and accurate fluid balance. It is not uncommon for patients to develop an acute lung injury (especially if over hydrated) or to develop renal failure several days after admission.
The dose of Artesunate is 2.4mg/kg (ABW) given as an IV bolus at 0 hours, 12 hours, 24 hours and once daily thereafter. Artesunate has few side effects and there is no need to adjust for renal impairment or to monitor for cardiac toxicity. It does not promote hypoglycaemia.
Switch to an oral antimalarial drug once the patient is improving, parasaemia is falling and the patient can reliably swallow and complete a course of oral treatment. Many options are acceptable and it does not need to be an artemisinin-based compound, although Riamet (Artemether 20mg/Lumefantrine 120mg) is licensed and available in the UK at an adult dose (>35kg weight) of 4 tablets initially then a further 4 tablets at 8 hours, 24h, 36h, 48h and 60 hours.
Dihydroartemisinin/Piperaquine is an acceptable alternative ACT to Riamet
If the patient has already received IV artesunate then this can be prescribed as 4 tablets PO BD (12 hourly) for 3 days. It is good practice to examine daily blood films until the parasitaemia clears, or the patient is discharged; it is important to do so in severe cases. In most cases 48 hours of IV Artesunate followed by three days of oral ACT is sufficient treatment for cure. Occasionally, and particularly in patients with reduced ability to clear parasites (e.g. hyposplenism), a longer course of treatment may be required. If in doubt discuss with the HTD consultant on call.
Other oral switch options include (adult doses):
Doxycycline 200mg once daily for 7 days
Atovaquone-proguanil (Atovaquone 250mg/Proguanil 100mg) 4 tablets once daily for 3 days
Clindamycin 450mg 3 times daily for total 7 days (safe in pregnancy)
The full duration (including of artemisin combination treatment) of the second line drug should be prescribed irrespective of if the patient has already received IV quinine or artesunate.
MARK SCHEME
Patient Details
Allergies and Adverse Reactions
Guidelines
Once Only Medication
Regular Medications
Enter Your Score Here: /26
SCORE GUIDE
High Pass: > 21
Pass: > 16
Borderline Pass: 13 – 16
Fail: < 13
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