Rishi Punak
Age: 26 years old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask about onset of symptoms
- Ask if flu-like symptoms have resolved or are still ongoing
- Ask about fever pattern: In malaria, fever is typically swinging (swinging pyrexia) – worse at night, improves during the day. Also, Malaria-related fever typically does not settle unless it is properly treated. Whereas, in hepatitis A, fever is continuous and usually lasts 5–7 days, occurring in the prodromal (pre-jaundice) phase
- Ask systematic (head-to-toe) Liver symptoms review: including jaundice, headache or confusion (which may suggest hepatic decompensation), nausea or vomiting, generalised itching, tremors (again suggesting hepatic decompensation), right upper quadrant abdominal pain, and any change in stool or urine colour.
- Ask about recent consumption of street food during travel
- Ask about use of illicit substances or over-the-counter medications
- Ask about tattoos or recent blood transfusions
- Ask about contact with others who have similar symptoms
- Take a brief sexual history
- Ask whether malaria prophylaxis or hepatitis A vaccination/prophylaxis was taken before travel.
- Ask about social history such as smoking and alcohol use.
- Ask about occupation (important for public health risk)
- Elicit ICE (Ideas, Concerns, Expectations)
- Give a likely diagnosis of hepatitis A infection due to recent travel and consumption of street food.
Example of explanation to patient
“Rishi, from everything you’ve told me, this sounds like a condition called hepatitis A. Hepatitis A is a viral infection (Or viral bug) that affects the liver. It spreads through contaminated food or water, often due to poor hygiene, and is passed in the stool of infected individuals. Your recent travel and eating of street food increase the likelihood of this infection.
One of the signs of hepatitis A is the yellowish discoloration of the eyes or skin, which happens when the liver is irritated. You also mentioned feeling generally unwell and having flu-like symptoms, which fits with this condition.
I know you’re worried about malaria. You’re right that malaria can cause similar symptoms, particularly fever and feeling unwell. However, malaria usually causes a persistent fever that gets worse and the yellowness of the eyes which you mentioned is less common. In your case, I suspect hepatitis A is more likely, but I agree it’s sensible to test for malaria as well to rule it out.
What are your thoughts?
In the meantime, you can take ibuprofen if you’re feeling any pain or discomfort. If you’re feeling itchy, especially at night, we can give you something like an antihistamine to help with that.
It can also help to stay in a cool, airy room, wear loose clothing, and avoid hot showers or baths. These little changes can make you more comfortable.
Because this infection can spread to others, especially through poor hand hygiene or contaminated food, I will need to notify the local health protection team. You don’t need to worry, this is routine and doesn’t mean you’re in trouble. It’s especially important in your case because you work with food, and they will guide us on the next steps to keep others safe. I would advise you to stay away from work until you’re no longer infectious — usually 7 days after the yellowing of your eyes or skin starts, or 7 days after symptoms like tiredness, nausea, or fever begin if you don’t develop any yellowing.
Also, anyone in your household, especially those who work in food-related jobs, should stay off work for now and wait for advice from the health protection team, even if they don’t have symptoms.
It’s also important to wash your hands thoroughly after using the toilet. If you’re sexually active, it’s best to avoid unprotected sexual contact for at least seven days after your symptoms started, to reduce the risk of passing the infection on.
You don’t need to worry about getting vaccinated for hepatitis A in the future, your body will develop natural immunity after this infection, so you’ll be protected going forward.
Management
- Offer a face-to-face appointment for blood tests including hepatitis serology, liver function tests (LFTs), kidney function (U+Es), full blood count (FBC), C-reactive protein (CRP), and malaria screen.
- Recommend maintaining a cool, well-ventilated environment, wearing loose clothing, and avoiding hot baths or showers to help manage itching.
- Consider prescribing chlorphenamine at night if itching is troublesome.
- Advise on using ibuprofen for pain if appropriate.
- Inform patient that Health Protection Unit (HPU) will be notified immediately — no need to wait for confirmation. This is especially important due to his role as a food handler. HPU will conduct contact tracing and provide guidance to prevent further spread.
- Advise that any close contacts, especially family members working in food-related roles, should stay off work and await guidance from the HPU, even if they are not currently symptomatic.
- Advise patient to stay away from work, school, or nursery until they are no longer infectious — typically 7 days after the onset of Jaundice, or 7 days after the start of symptoms such as fatigue, nausea, or fever if no jaundice occurs.
- Advise on hygiene practices such as thorough handwashing after using the toilet.
- If the patient is sexually active, advise against unprotected sexual activity (including oro-anal and oro-genital contact) until at least 7 days after the onset of jaundice or 7 days after symptoms begin if there is no jaundice.
- Advise patient to seek urgent medical attention if symptoms worsen, signs of dehydration occur, or new symptoms develop.
- Arrange follow-up in 1–2 weeks; consider repeating LFTs at that time if initial results are abnormal.
- Explain that hepatitis A vaccination is not required in the future, as he will now have natural immunity.
Learning point from this station:
Hepatitis A is a self-limiting viral infection of the liver, commonly acquired through contaminated food or water, especially in countries with poor sanitation. It presents with fever, yellowing of the eyes or skin, dark urine, pale stools, abdominal discomfort, and itching.
A key learning point is the ability to distinguish hepatitis A from malaria, particularly in returning travellers. While both can cause fever and malaise:
- Hepatitis A: Fever tends to settle after a few days and is often followed by yellow discoloration of the eyes, pale stools, dark urine, abdominal discomfort, and itching.
- Malaria: Fever is typically persistent or cyclical, often with rigors and chills, and yellowing of the eyes is less common. Malaria-related fever does not settle unless it is properly treated.
Clinicians should maintain an open mind and consider both conditions in the differential diagnosis of a febrile patient post-travel, as symptoms can overlap.
Hepatitis A is a notifiable condition; early recognition, clear patient communication, and appropriate public health measures are key. Patients recover fully and gain lifelong immunity, so future vaccination is not required.