Dengue Fever

Text A
Dengue: virus, fever and mosquitoes
Dengue fever is a viral disease spread only by certain mosquitoes – mostly Aedes aegypti or “dengue
mosquitoes” which are common in tropical areas around the world.

There are four types of the dengue virus that cause dengue fever – Dengue Type 1, 2, 3 and 4. People
become immune to a particular type of dengue virus once they’ve had it, but can still get sick from the
other types of dengue if exposed. Catching di_erent types of dengue, even years apart, increases the risk
of developing severe dengue. Severe dengue causes bleeding and shock, and can be life threatening.

Dengue mosquitoes only live and breed around humans and buildings, and not in bush or rural areas.
They bite during the day – mainly mornings and evenings. Dengue mosquitoes are not born with dengue
virus in them, but if one bites a sick person having the virus in their blood, that mosquito can pass it on
to another human after about a week. This time gap for the virus to multiply in the mosquito means that
only elderly female mosquitoes transmit dengue fever. The mosquitoes remain infectious for life, and
can infect several people. Dengue does not spread directly from person to person.

Text B
Signs and Symptoms
Classic dengue fever, or “break bone fever,” is characterised by acute onset of high fever 3–14 days after
the bite of an infected mosquito. Symptoms include frontal headache, retro-orbital pain, myalgias,
arthralgias, hemorrhagic manifestations, rash, and low white blood cell count. The patient also may
complain of weight loss and nausea. Acute symptoms, when present, usually last about 1 week, but
weakness, malaise, and weight loss may persist for several weeks. A high proportion of dengue
infections produce no symptoms or minimal symptoms, especially in children and those with no
previous history of having a dengue infection.

Text C
Steps to take when seeing a suspected case of dengue fever
Step 1: Notify your nearest Public Health Unit immediately upon clinical suspicion.
Step 2: Take a comprehensive travel history and determine whether the case was acquired overseas or
locally.
Step 3: Note the date of onset of symptoms to identify the correct diagnostic test, as suitable laboratory
tests depend on when the blood sample is collected during the illness.
• Another useful test is full blood count. Cases often have leukopenia and/or thrombocytopenia.
The table below shows which test to order at which stage of illness:
Test Type PCR NS1 ELISA IgM IgG
Days after onset 0-5 days 0-9 days From day 5 From day 8
of symptoms onwards onwards
Step 4: Provide personal protection advice.
• The patient should stay in screened accommodation and have someone stay home to look after them.
• The patient should use personal insect repellent particularly during daylight hours to avoid mosquito
bites.
• All household members should use personal insect repellent during daylight hours.
• Advise family members or associates of the case who develop a fever to present immediately for
diagnosis.

Text D
Prior to discharge:
• Tell patients to drink plenty of _uids and get plenty of rest.
• Tell patients to take antipyretics to control their temperature. Children with dengue are at risk for
febrile seizures during the febrile phase of illness.
• Warn patients to avoid aspirin and anti-in_ammatory medications because they increase the risk of
haemorrhage.
• Monitor your patients’ hydration status during the febrile phase of illness. Educate patients and
parents about the signs of dehydration and have them monitor their urine output.
• Assess hemodynamic status frequently by checking the patient’s heart rate, capillary re_ll, pulse
pressure, blood pressure, and urine output. If patients cannot tolerate _uids orally, they may need IV
_uids.
• Perform hemodynamic assessments, baseline hematocrit testing, and platelet counts.
• Continue to monitor your patients closely during defervescence. The critical phase of dengue begins
with defervescence and lasts 24–48 hours.

Part A
• In which text can you find information about
1.The different types of dengue virus?
2. How fever presents in patients?
3 How dengue fever is transmitted?
4. The stages at which to conduct tests for dengue fever?
5. Monitoring and assessing a patient’s condition?
6. What advice to give patients to avoid mosquito bites?
7. Advice for patients regarding medication?

Questions 8 - 14
8. How long after being bitten by an infected mosquito does high fever occur?
9. What might patients with dengue fever complain of?
10. Which test should only be ordered 5 days after symptoms appear?
11. What other test is also useful when checking for dengue fever?
12. Who is at risk of seizures during the febrile stage of dengue?
13. What takes places in the most lethal cases of dengue?
14. How long does the most serious stage of dengue last?

Questions 15 - 20
15. Dengue fever does not spread _______________
16. In many ______________ dengue infections cause almost no symptoms.
17. Within three days of symptoms beginning a PCR or ____________ can be ordered.
18. To avoid haemorrhage patients mustn’t take anti-inflammatory medications or ________________.
19. Advise patients be cared for by someone at home in ________________ accommodation.
20. Patients must be made aware of the need to check their ______________________.
PART B

1.The main purpose of the guidelines is to advise staff on

(A) the procedure to follow when fitting an IV.
(B) how to check for issues with IV infusions.
(C) what to do before administering an IV.

Procedural Guidelines for Set-up and Administration of Intravenous Fluids

Intravenous (IV) fluids are infused directly into the veins of patients via a cannula in cases of severe
dehydration, electrolyte imbalance, blood loss, and in surgery. Intravenous lines can also be used for
administration of drugs directly into the blood of a patient, resulting in faster action. The guidelines
below illustrate the correct procedure for setting up and administering IV therapy.
Firstly, always check that the fluid bag is not damaged and that the liquid inside it is clear. Secondly,
there have been reports of incomplete patient notes, so it is crucial that you check for details such as
fluid type and expiration date and record these in the patient notes immediately. Thirdly, it is vital that
all clinical staff introduce themselves with their full name and role to all patients they engage with; only
after confirming patient details and obtaining their consent should one begin the IV set-up.
Finally, be extra diligent when calculating the drip rate as to avoid any errors. Feel comfortable to
approach a fellow colleague for assistance if uncertain at any stage.

2. The purpose of the email is to advise paediatricians to be

(A) mindful that parents may not always agree with the proposed treatment.
(B) aware that even minor illnesses can be distressing for parents.
(C) understanding and patient when explaining conditions to children.

For the attention of all paediatricians:

As a paediatrician, one must always remember that the patients are not the doctor’s only concern; we
must also factor in the anxious parents worried about their child. This can be an additional challenge for
staff in a department that is already busy and stressful, but a duty which must not be neglected. Parents
who seek paediatric care for minor conditions are not intentionally impinging on medical care for those
patients who more urgently need it. Therefore, time should be spent speaking to these parents and
offering reassurance and support as appropriate, rather than ignoring them or making them a last
priority. Ten to fifteen minutes spent in conversation with these families will save much more time in
the long-run and prevent countless bleeps and calls from them, which could otherwise have been
avoided. In addition, it is vital to be aware of alternative potential causes for the parental anxiety that
could be rooted in past events and experiences, or caused by problems in their personal life.

3. What is the email from the admin team asking front-line staff to do over
the next 6 months?
Charge a fee to patients who cancel their appointments three times.
(A) Call patients with a reminder 24 hours prior to their appointment.
(B) Inform patients of the changes
(C) to be implemented.
To all front-line medical staff,
Recently, we have been noticing a steady increase in no show appointments at the practice. Previously,
we did not have a concrete policy on cancellation deadlines or missed appointment fees. Given that no-
show appointments not only take up valuable time from our providers, but also prevent another patient
from utilizing these time slots, it is in our best interest to discourage patients from missing their
appointment. Going forward, office staff will call every patient at least 48 hours before their
appointment to remind them of the date and time of their appointment. If the patient cancels within 24
hours of their appointment time, office staff will make a note in the patient’s chart. If the patient has
more than three such cancellations, he or she will then be issued with a $25 fee to reschedule the
appointment. Patients who are using medical insurance are exempt from this fee and instead should
have their chart forwarded to a provider for further evaluation. We understand that this new policy may
result in some difficulties for staff, so we will allow fees to be waived in extreme circumstances. We will
also set the start date of this policy six months from today’s date, so all patients will have sufficient time
to be informed of the new rules. Please make sure that all patients are aware of these changes at the
end of each appointment.
Many thanks,
The admin team

4. The guidelines inform us that incisional hernias

(A) are caused by surgery.
(B) form when patients cut themselves.
(C) occur more frequently than other hernias.
Guidelines: Incisional Hernia
In 12–15% of abdominal operations, incisional hernias occur post-operatively. An incisional hernia
passes through an incision previously made during surgery, when the closure of abdominal tissues
fails to heal properly. Be sure to cover during check-ups: incisional hernias are the second most
common type of hernia.
Check for hernia
 Remember that the major risk with incisional hernias is strangulation: the organ in the hernia
devascularises and the
 Look for abnormal protrusion of tissue or organ through the cavity in which it is situated.
 Remember that hernias are most common in the abdomen but can also appear in the upper
thighs and groin region. tissue degenerates. This must be identified at the earliest opportunity
– delay can lead to septicaemia and shock.
 Treatment is mostly surgical: a mesh can be used to strengthen the area. Otherwise, open
and keyhole repairs remain an option, however, better outcomes have been reported with
the use of mesh repairs.

5. The main purpose of the guidelines is to advise staff on

(A) the procedure to follow when fitting an IV.
(B) how to check for issues with IV infusions.
(C) what to do before administering an IV.
Procedural Guidelines for Set-up and Administration of Intravenous Fluids
Intravenous (IV) fluids are infused directly into the veins of patients via a cannula in cases of
severe dehydration, electrolyte imbalance, blood loss, and in surgery. Intravenous lines can also be
used for administration of drugs directly into the blood of a patient, resulting in faster action. The
 guidelines below illustrate the correct procedure for setting up and administering IV therapy.
Firstly, always check that the fluid bag is not damaged and that the liquid inside it is clear.
Secondly, there have been reports of incomplete patient notes, so it is crucial that you check for
details such as fluid type and expiration date and record these in the patient notes immediately.
Thirdly, it is vital that all clinical staff introduce themselves with their full name and role to all patients
they engage with; only after confirming patient details and obtaining their consent should one begin
the IV set-up.
Finally, be extra diligent when calculating the drip rate to avoid any errors. Feel comfortable to
approach a fellow colleague for assistance if uncertain at any stage.

6. The purpose of this memo to staff is to Select one:

A. state the potential risks to patients who smoke electronic cigarettes.
B. provide information about the substances used in electronic cigarettes.
C. advise that no position has yet been reached about electronic cigarettes.

MEMO TO STAFF: ELECTRONIC CIGARETTES

Electronic Cigarettes are battery operated devices that heat a liquid (called ‘e-liquid’) to produce a vapour
that users inhale. Although the composition of this liquid varies, it typically contains a range of chemicals
including solvents and flavouring agents and may or may not contain nicotine.
Electronic Cigarettes are a topic of contention among public health and tobacco control advocates, some
of whom argue they don’t pose the same dangers to smokers as traditional cigarettes. Others however
argue that, Electronic Cigarettes should not be promoted as a lower threat option for smokers when their
long term safety is unknown.
There is currently insuifficient evidence to support claims that Electronic Cigarettes are safe, and further
research is needed to determine their long term safety. Asa result there will be no change to hospital
policy this time.

PART C
Text 1: The Paradox of Paranoia: An In-Depth Ana lysis of its Cognitive Roots and Societal Impact

Paragraph 1: Paranoia, a multifaceted psychological phenomenon, has long captured the curiosity of
researchers and clinicians alike. As one of the defining features of various mental disorders, including
paranoid schizophrenia, paranoid personality disorder, and delusional disorder, it presents a perplexing
puzzle to unravel. In the study of paranoia, one has to delve into the intricate web of paranoid cognition,
exploring its underlying cognitive mechanisms, the impact of societal factors, and the challenges it poses
in both clinical and everyday contexts.

Paragraph 2: At its core, paranoia manifests as excessive mistrust and suspicion toward others, often
accompanied by a sense of persecution. This cognitive disposition is rooted in the brain's intricate
network of perceptual and cognitive processes. Cognitive psychologists postulate that the "negativity
bias" - a cognitive tendency to attend more readily to threatening stimuli - plays a pivotal role in the
development of paranoid thoughts. This is corroborated by recent studies that reveal heightened
amygdala activation in individuals experiencing paranoia. Dr. Smith, a prominent researcher in cognitive
neuroscience, explicates this link, stating that "the hyperactivity in the amygdala in the context of
paranoia manifests an augmented sensitivity to potential threats."
Paragraph 3: Beyond its neurocognitive origins, paranoia also bears the imprint of societal and cultural
influences. In collectivist cultures, where interdependence and conformity are highly valued, paranoia
may arise as a protective mechanism against potential betrayals or social ostracism. This is captured in
the well known idiom, "once bitten, twice shy," which highlights the cognitive mechanism of learning
from past negative experiences. Moreover, researchers have observed an intriguing correlation between
experiences of social discrimination and heightened paranoid ideation. Professor Johnson's work posits
that "the stigmatization faced by certain social groups can foster a sense of victimhood and exacerbate
paranoid thoughts as a coping mechanism."

Paragraph 4: Paranoid thoughts can escalate into full-blown delusions, leading individuals to develop
implausible and unfounded beliefs about conspiracies or threats. Delusions are resistant to
counterevidence, perpetuating the cycle of paranoia. Renowned psychiatrist Dr. Williams explains that
"delusional thinking is characterized by the 'jumping to conclusions' cognitive style, where individuals
reach hasty judgments without considering all available evidence." This tendency to interpret
ambiguous stimuli negatively, also known as the "jumping to conclusions" bias, can further entrench
paranoid beliefs.

Paragraph 5: The relentless grip of paranoia not only strains cognitive processes but also wreaks havoc
on emotional well-being. Chronic paranoia is associated with heightened levels of anxiety and
hypervigilance. This chronic vigilance is aptly summarized by the phrase "looking over one's shoulder,"
which reflects the constant state of alertness that characterizes the paranoid individual. The perpetual
fear of being deceived or harmed can induce a state of chronic stress, leading to emotional exhaustion
and deteriorating mental health.

Paragraph 6: Paranoia takes a toll on interpersonal relationships, sowing seeds of suspicion and
undermining trust. The idiom "trust is like a fragile glass, once broken, hard to mend" elucidates the
profound impact of distrust on human connections. Individuals experiencing paranoia may interpret
neutral or even benevolent actions of others as malevolent, leading to interpersonal conflicts and social
isolation. This perpetuates a vicious cycle, further reinforcing their paranoid beliefs and distancing them
from genuine social support.

Paragraph 7: Given its complex nature, the treatment of paranoia presents substantial challenges to
mental health professionals. Cognitive-behavioral therapies (CBT) have shown promise in helping
individuals challenge and modify their paranoid thoughts. The principle of "cognitive restructuring" in
CBT involves questioning the validity of paranoid beliefs and considering alternative, more balanced
perspectives. As Professor Lee posits, "CBT empowers individuals to confront their negative automatic
thoughts and adopt a more rational and evidence-based approach to interpreting social cues."

Paragraph 8

Paranoia, with its roots in cognitive biases and societal influences, remains a fascinating yet formidable
enigma. Understanding the cognitive mechanisms underlying paranoia is essential for developing
effective interventions and support systems for those grappling with its disruptive effects. As society
grapples with mental health issues, nurturing empathy and fostering social inclusion become paramount
in dispelling the shadows of suspicion and embracing the light of understanding. Only through a
compassionate and multidisciplinary approach can we hope to unravel the paradox of paranoia and
pave the way toward a more empathetic and inclusive future.

7. What is the primary objective of researchers and clinicians in studying paranoia?

A) To study the challenges clinically and socially.
B) To investigate the impact of societal factors.
C) To explore its cognitive roots and societal impact.
D) To uncover the complex web of anxious beliefs.

8. According to Dr. Smith, the heightened activation of the amygdala in the context of paranoia
indicates:
A) A curtailed sensitivity to potential threats.
B) The boosted sensitivity to potential threats.
C) The hyperactivity in the context of paranoia.
D) The amygdala's role in the context of paranoia.

9. Why does the writer use the phrase 'once bitten, twice shy' in paragraph 37
A) To illustrate the prevalence of past events in paranoia.
B) To emphasize the need for evidence-based learning to paranoia.
C) To show the cognitive system of acquiring wisdom from former adverse situations.
D) To describe how the mind learns from negative events.

10. What is the defining characteristic of delusional thinking as explained by Dr. Williams?
A) Resilience to counter-evidence.
B) Hasty judgments based on limited evidence.
C) The ability to consider all available evidence.
D) A propensity to interpret ambiguous stimuli positively.

11. How is "looking over one's shoulder" a sign of chronic paranoia?

A) Heightened curiosity and inquisitiveness.
B) A sense of panic and emotional numbing.
C) Perpetually on guard and always being wary.
D) Emotional exhaustion and deteriorating mental health.

12. What effect does paranoia have on interpersonal relationships, according to the text?
A) It fortifies trust and connections.
8) It fosters genuine social support.
C) It undermines hope and leads to confrontations.
D) It discourages open communication and empathy.

13. How does CBT benefit paranoid people?

A) Challenge and modify their paranoid notions.
8) Suppress their emotions and anxieties.
C) Avoid paranoid thoughts to reduce stress.
D) Focus solely on the individual’s paranoid thoughts.
14. What is the ultimate goal of the writer in discussing paranoia and societal attitudes toward mental
health?
A) To analyze the history of paranoia in society.
B) To criticize current mental health treatments.
C) To promote a specific type of therapy.
D) To foster empathy and understanding.

Text 2: Are the best hospitals managed by doctors?

Doctors were once viewed as ill-prepared for leadership roles because their selection and training led
them to become “heroic lone healers.” However, the emphasis on patient-centered care and efficiency
in the delivery of clinical outcomes means that physicians are now being prepared for leadership. The
Mayo Clinic is America’s best hospital, according to the 2016 US News and World Report (USNWR)
ranking. Cleveland Clinic comes in second. The CEOs of both — John Noseworthy and Delos “Toby”
Cosgrove — are highly skilled physicians. In fact, both institutions have been physician-led since their
inception around a century ago. Might there be a general message here?

A study published in 2011 examined CEOs in the top-100 hospitals in USNWR in three key medical
specialties: cancer, digestive disorders, and cardiovascular care. A simple question was asked: are
hospitals ranked more highly when they are led by medically trained doctors or non-MD professional
managers? The analysis showed that hospital quality scores are approximately 25% higher in physician-
run hospitals than in manager-run hospitals. Of course, this does not prove that doctors make better
leaders, though the results are surely consistent with that claim.

Other studies find a similar correlation. Research by Bloom, Sadun, and Van Reenen revealed how
important good management practices are to hospital performance. However, they also found that it is
the proportion of managers with a clinical degree that had the largest positive effect; in other words, the
separation of clinical and managerial knowledge inside hospitals was associated with more negative
management outcomes. Finally, support for the idea that physician-leaders are advantaged in
healthcare is consistent with observations from many other sectors. Domain experts- “expert leaders”
(like physicians in hospitals) — have been linked with better organizational performance in settings as
diverse as universities, where scholar-leaders enhance the research output of their organizations, to
basketball teams, where former All-Star players turned coaches are disproportionately linked
to NBA success.

What are the attributes of physician-leaders that might account for this association with enhanced
organizational performance? When asked this question, Dr. Toby Cosgrove, CEO of Cleveland Clinic,
responded without hesitation, “credibility ... peer-to-peer credibility.” In other words, when an
outstanding physician heads a major hospital, it signals that they have “walked the walk”. The Mayo
website notes that it is physician-led because, “This helps ensure a continued focus on our primary
value, the needs of the patient come first.” Having spent their careers looking through a patient-focused
lens, physicians moving into executive positions might be expected to bring a patient-focused strategy.

In a recent study that matched random samples of U. S. and UK employees with employers, we found
that having a boss who is an expert in the core business is associated with high levels of employee job
satisfaction and low intentions of quitting. Similarly, physician-leaders may know how to raise the job
satisfaction of other clinicians, thereby contributing to enhanced organizational performance. If a
manager understands, through their own experience, what is needed to complete a job to the highest
standard, then they may be more likely to create the right work environment, set appropriate goals and
accurately evaluate others’ contributions.

Finally, we might expect a highly talented physician to know what “good” looks like when hiring other
physicians. Cosgrove suggests that physician-leaders are also more likely to tolerate innovative ideas like
the first coronary artery bypass, performed by René Favaloro at the Cleveland Clinic in the late ‘60s.
Cosgrove believes that the Cleveland Clinic unlocks talent by giving safe space to people with
extraordinary ideas and importantly, that leadership tolerates appropriate failure, which is a natural part
of scientific endeavor and progress.

The Cleveland Clinic has also been training physicians to lead for many years. For example, a cohort-
based annual course, “Leading in Health Care,” began in the early 1990s and has invited nominated,
high-potential physicians (and more recently nurses and administrators) to engage in 10 days of offsite
training in leadership competencies which fall outside the domain of traditional medical training. Core to
the curriculum is emotional intelligence (with 360-degree feedback and executive coaching),
teambuilding, conflict resolution, and situational leadership. The course culminates in a team-based
innovation project presented to hospital leadership. 61% of the proposed innovation projects have had a
positive institutional impact. Moreover, in ten years of follow-up after the initial course, 48% of the
physician participants have been promoted to leadership positions at Cleveland Clinic.

Text 2: Questions 15-22

15.In paragraph 1, why does the writer mention the Mayo and Cleveland Clinics?
A To highlight that they are the two highest ranked hospitals on the USNWR
B To introduce research into hospital management based in these clinics
C To provide examples to support the idea that doctors make good leaders
D To reinforce the idea that doctors should become hospital CEOs

16.What is the writer’s opinion about the findings of the study mentioned in paragraph 2?
A They show quite clearly that doctors make better hospital managers.
B They show a loose connection between doctor-leaders and better management.
C They confirm that the top-100 hospitals on the USNWR ought to be physician-run.
D They are inconclusive because the data is insufficient.

17.Why does the writer mention the research study in paragraph 3?

A To contrast the findings with the study mentioned in paragraph 2
B To provide the opposite point of view to his own position
C To support his main argument with further evidence
D To show that other researchers support him

18.In paragraph 3, the phrase ‘disproportionately linked’ suggests

A all-star coaches have a superior understanding of the game.
B former star players become comparatively better coaches.
C teams coached by former all-stars consistently outperform other teams.
D to be a successful basketball coach you need to have played at a high level.

19.In the fourth paragraph, what does the phrase “walked the walk,” imply about physician- leaders?
A They have earned credibility through experience.
B They have ascended the ranks of their workplace.
C They appropriately incentivize employees.
D They share the same concerns as other doctors.

20.In paragraph 6, the writer suggests that leaders promote employee satisfaction because
A they are often cooperative.
B they tend to give employees positive evaluations.
C they encourage their employees not to leave their jobs.
D they understand their employees’ jobs deeply.

21.In the seventh paragraph, why is the first coronary artery bypass operation mentioned?
A To demonstrate the achievements of the Cleveland clinic
B To present René Favaloro as an exemplar of a ‘good’ doctor
C To provide an example of an encouraging medical innovation
D To show how failure naturally contributes to scientific progress

22. In paragraph 8, what was the outcome of the course “Leading in Health Care”?
A The Cleveland Clinic promoted almost half of the participants.
B 61% of innovation projects lead to participants being promoted.
C Some participants took up leadership roles outside the medical domain.
D A culmination of more team-based innovations.