Immunity against mumps develops over a long time. There is nothing to be done except to proceed with the usual vaccination schedule.

Streptococcus pneumonia is the chief causative organism for lobar pneumonia in this age group patients. Typically patients present with rusty coloured sputum and a cough. Pneumocystis jiroveci is responsible for causing pneumocystis pneumonia among immunocompromised patients.

Phrenic nerve palsy causing hemidiaphragm paralysis is a very uncommon feature of thoracic aortic aneurysm.

Thoracic aortic aneurysms are usually asymptomatic however chest pain is most commonly reported symptom. Left hemidiaphragm paralysis, because of left phrenic nerve palsy, is a very rare presentation of thoracic aortic aneurysm.
Thoracic aortic aneurysm may present atypical symptoms such as dysphagia due to compression of the oesophagus; hoarseness due to vocal cord paralysis or compression of the recurrent laryngeal nerve; superior vena cava syndrome due to compression of the superior vena cava; cough, dyspnoea or both due to tracheal compression; haemoptysis due to rupture of the aneurysm into a bronchus; and shock due to rupture of the aneurysm.
Common causes of phrenic nerve palsy include malignancy such as bronchogenic carcinoma, as well as mediastinal and neck tumours. Phrenic nerve palsy can also occur due to a penetrating injury or due to iatrogenic causes arising, for example, during cardiac surgery and central venous catheterization. Many cases or phrenic nerve palsy are idiopathic.

This case is most likely RTA type II, due to decreased proximal bicarbonate reabsorption, which leads to metabolic acidosis, hypokalaemia, hyperchloremia, and <6 urine pH .

The patient has a non-functioning pituitary tumour as her hormone profile is normal.
Non-functioning pituitary tumours are relatively common. A large number of these tumours are incidentally found pituitary microadenomas (<1 cm) and are usually of no clinical importance.

Glucagon-like peptide 1 (GLP-1) is a 30-amino acid peptide hormone produced in the intestinal epithelial endocrine L-cells by differential processing of proglucagon. GLP-1 is released in response to meal intake.
The main actions of GLP-1 are to stimulate insulin secretion (i.e., to act as an incretin hormone) and to inhibit glucagon secretion, thereby contributing to limit postprandial glucose excursions. It also inhibits gastrointestinal motility and secretion and thus acts as an enterogastrone and part of the ileal brake mechanism. GLP-1 also appears to be a physiological regulator of appetite and food intake.
Decreased secretion of GLP-1 may contribute to the development of obesity, and exaggerated secretion may be responsible for postprandial reactive hypoglycaemia.

The question describes a patient who has had an ileal resection. Bile acids are reabsorbed in the distal ileum. Since this has been resected in this patient, one would expect her to have malabsorption of bile acids, causing her diarrhoea. This is a more likely correct answer than a Crohn’s flare, bacterial overgrowth, gastroenteritis, or tropical sprue, given the details included in the question prompt.

As the patient has early menopause, hormone replacement therapy (HT) is considered to be the first line of choice for prevention of bone loss and fracture in the early postmenopausal period for 5 years.

Treatment with ARB or ACE-I may slow further deterioration in renal function in this patient, as studies have shown that blocking of the RAS in type 2 diabetic patients improve renal function.

CURB Pneumonia Severity Score:
– Confusion (abbreviated Mental Test Score <=8) (1 point)
– Urea (BUN > 19 mg/dL or 7 mmol/L) (1 point)
– Respiratory Rate > 30 per minute (1 point)
– Blood Pressure: diastolic < 60 or systolic < 90 mmHg (1 point) Based on the CURB Pneumonia Severity Score, the patient has severe pneumonia. According to the 2009 Centres for Medicare and Medicaid Services (CMS) and Joint Commission consensus guidelines, inpatient treatment of pneumonia should be given within four hours of hospital admission (or in the emergency department if this is where the patient initially presented) and should consist of the following antibiotic regimens, which are also in accordance with IDSA/ATS guidelines. For non-intensive care unit (ICU) patients:
Beta-lactam (intravenous [IV] or intramuscular [IM] administration) plus macrolide (IV or oral [PO])
Beta-lactam (IV or IM) plus doxycycline (IV or PO)
Antipneumococcal quinolone monotherapy (IV or IM)

If the patient is younger than 65 years with no risk factors for drug-resistant organisms, administer macrolide monotherapy (IV or PO)

For ICU patients:
IV beta-lactam plus IV macrolide
IV beta-lactam plus IV antipneumococcal quinolone

If the patient has a documented beta-lactam allergy, administer IV antipneumococcal quinolone plus IV aztreonam.

The most suitable antibiotic therapy for this patient is therefore Intravenous co-amoxiclav + clarithromycin.