1. CR DR MOHSEN KHAYAT

2. A 28-year-old man comes to your office complaining of a 5-day history of nausea, vomiting, diffuse abdominal pain, fever to 38.4, and muscle aches. He has lost his appetite, but he is able to tolerate liquids and has no diarrhea. He has no significant medical history or family history, and he has not traveled outside the Kingdom.

3. He denies illicit drug use, or drinks alcohol. He takes no medications routinely, but he has been taking acetaminophen, approximately 30 tablets per day for 2 days for fever and body aches since this illness began.

4. On examination, his temperature is 100.8°F, heart rate 98 bpm, and blood pressure 120/74 mm Hg. He appears jaundiced, his chest is clear to auscultation, and his heart rhythm is regular without murmurs. His liver percusses 12 cm, and is smooth and slightly tender to palpation. He has no abdominal distention or peripheral edema.

5. Laboratory values are significant for a normal complete blood count, creatinine 1.1 mg/dL, alanine aminotransferase (ALT) 3440 IU/L, aspartate aminotransferase (AST) 2705 IU/L, total bilirubin 24.5 mg/dL, direct bilirubin 18.2 mg/dL, alkaline phosphatase 349 IU/L, serum albumin 3.0 g/dL, and prothrombin time 14 seconds.

6. ➤ What is the diffretial diagnosis of this condition? ➤ What is the most important immediate diagnostic test? ➤ What is the important serological test ➤ How can you treat this condition

7. Case 2

8. A 41-year-old Saudi male goes on a holiday in The Far East. He takes no malaria prophylaxis. On return to the Saudi she develops high fever and self-medicates at home with Fevadol®.

9. On presentation to hospital, she had a fever of 40 °C and looked markedly unwell, with a pulse of 130 bpm and BP 90/50 mmHg. He was commenced on IV ceftriaxone and quinine in casualty.

10. Despite this, she deteriorated rapidly, and after 2 hours is found to have a GCS of 3. His blood film is reported as showing trophozoites and schizonts of Plasmodium falciparum with a parasitaemia of 20%.

11. What is your DD (causes of coma in this patient) Which is most important as the next step in the management of this patient? What is the manifestatation of cerebral malaria How can you treat cerebral malaria What are the precautions taken for malaria prophelaxis

12. Case 3

13. A 61-year-old man is seen because of a fever. He was well until 2 months before, when he noted the onset of fatigue, fever, chills, and weight loss. Temperatures as high as 40°C have occurred in a cyclic manner (every 2 to 3 days), but resolve with acetaminophen.

14. He denies headaches, arthralgias, visual disturbances, abdominal pain, and diarrhea. His medical history is remarkable for asthma, environmental allergies for which he is undergoing immunotherapy, and a hiatal hernia. His family history is unremarkable.

15. The patient does not consume alcohol or smoke cigarettes. He is a retired fireman and has not traveled or had exposure to ill contacts. He has no pets or other animal exposures. There are none of the usually recognized risk factors for HIV infection. He is taking no medications

16. On physical examination, the patient is found to be a tired-appearing, elderly man. His blood pressure is 146/85 mm Hg; pulse, 106 beats per minute; respirations, 20 per minute; and temperature, 38.3°C.The head, eyes, ears, nose, and throat examination is remarkable for the finding of dry mucous membranes; his oropharynx is clear and the tympanic membranes are normal.

17. There is no lymphadenopathy except for a small, 1.5cm, non tender lymph node in the right inguinal area. The heart sounds are unremarkable except for a regular tachycardia. The lungs are clear to auscultation and percussion. Abdominal examination reveals normal bowel sounds, and no hepatosplenomegaly or masses are palpated.

18. Prostate and rectal findings are normal and a test for occult blood is negative. His skin appears jaundiced. The neurologic findings are normal.

19. A chest radiograph is normal. A CT scan of the abdomen reveals enlarged portacaval lymph nodes. The serum electrolyte values are normal, and the following laboratory data are reported: white blood cell count, 4,000/mm 3 ; hemoglobin, 11.4 g/dL; and platelet count, 134,000/mm 3. The differential count reveals high eosinophils.

20. The albumin content is 3.1 mg/dL; total bilirubin, 2.8 mg/dL; alanine aminotransferase, 31 IU/L; AST, 35 IU/L; alkaline phosphatase, 242 IU/L; and lactate dehydrogenase, 567 IU/L. All blood cultures are negative. The erythrocyte sedimentation rate is 110 mm per hour.

21. A PPD of Mycobacterium tuberculosis skin test is negative, as is the serum antinuclear antibody test.

22. A bone marrow biopsy specimen shows mild chronic inflammation and extensive granulomatosis.A needle biopsy specimen of the liver reveals sinusoidal dilatation, triaditis, bile stasis, and focal periportal fibrosis with granulomas and dilatation of the portal venous channels.

23. The patient is begun empirically on a regimen of isoniazid, ethambutol, and rifampin for a presumptive diagnosis of extrapulmonary tuberculosis, but there is little attendant improvement in his clinical status.

24. What is the likely diffretial diagnosis in this patient? What diagnostic test should be performed next? What is meant by theraputic trial,any role in diagnosis of FUO