A 32-year-old woman presents with complaints of oral pain. She has a medical history of asthma and currently uses a combination inhaler of fluticasone and salmeterol, having recently switched from using only a beclomethasone inhaler. Upon examination, she appears healthy but displays signs of significant oral candidiasis. What is the probable cause of her condition?
A 72-year-old man presents to hospital with progressive shortness of breath over the last four days and a low-grade fever. He has a past medical history of mild asthma for which he occasionally needs to use his salbutamol inhaler and has previously had bilateral knee replacements for osteoarthritis. He has smoked on average 5 cigarettes per day for the past 40 years and drinks a couple of glasses of wine per week. His travel history includes a holiday to Cyprus, from which he arrived back in the UK 5 days ago.
Examination revealed some right mid zone crackles and reduced breath sounds over this area. Observations revealed a temperature of 38.8ºC, heart rate of 110 bpm, blood pressure of 105/66 mmHg, respiratory rate of 22 breaths per minute and oxygen saturations of 91% on room air.
Blood tests revealed:
Hb 145 g/l
Platelets 290 * 109/l
WBC 9.4 * 109/l
Na+ 132 mmol/l
K+ 3.7 mmol/l
Urea 4.1 mmol/l
Creatinine 67 µmol/l
Urinary sodium concentration was measured and found to be 36 mmol/L (normal range 40-220 mmol/d). Which of the following investigations is most useful in the diagnosis of this condition?
A 60-year-old man has recently returned from a trip to India and is experiencing bloody diarrhoea and fevers for the past two weeks. He noticed rose coloured spots on his abdomen yesterday. He has no significant medical history except for a prosthetic aortic valve. His blood tests show elevated inflammatory markers and stool microbiology has identified a gram-negative bacillus as a non-typhoidal Salmonella. Sensitivities are pending. What is the most appropriate initial empiric management?
You are consulted to evaluate a 55-year-old Indian man who has presented to the Emergency Department (ED) from Heathrow airport. He reports a 3-week history of a productive cough with brown sputum, fevers, and drenching night sweats. His wife is concerned about the color of his sputum, which has been brown/red since the onset of his illness. The patient denies weight loss or hemoptysis. He is a non-smoker and had been in good health, except for a recent episode of diarrhea. He is a resident of a rural community in northeast India and is visiting family in London. On examination, he appears relatively well, with a heart rate of 95 beats per minute and respiratory rate of 20 breaths per minute. He has a productive cough with dark brown sputum, and auscultation reveals coarse crepitations at the right base with some bronchial breathing. The remainder of his physical examination is unremarkable.
You order routine microscopy sensitivity and culture (MC&S) and acid-fast bacilli (AFB) and tuberculosis PCR on his sputum, which are negative. His chest X-ray shows right lower zone consolidation. Laboratory investigations reveal a hemoglobin level of 110 g/L, platelets of 500 * 10^9/L, white blood cell count of 16.0 * 10^9/L with neutrophils of 10.0 * 10^9/L, lymphocytes of 2.0 * 10^9/L, eosinophils of 2.0 * 10^9/L, sodium of 138 mmol/L, potassium of 4.5 mmol/L, urea of 6.0 mmol/L, creatinine of 99 µmol/L, and CRP of 55 mg/L.
What is the most likely diagnosis?
A 60-year-old man is currently being treated in the ICU. He was admitted 10 days ago after experiencing a seizure at home. Due to his confusion and agitation, he was unable to provide a clear medical history, but his family reported that he had been feeling unwell for about two weeks prior to the seizure. The patient had initially presented with a fever, myalgia, anorexia, and intense itching on his left arm. As time passed, he became increasingly confused and agitated. The patient had recently returned to the UK after visiting his native India six months prior, during which time he was bitten by a dog in his family’s village. Although the wound was minor and healed without incident, his wife recalled the incident. The patient’s medical history was otherwise unremarkable, with the exception of hypertension, tablet-controlled type 2 diabetes, and gout.
Upon admission, the patient was highly agitated and disoriented, with hypersalivation and a refusal to eat or drink. Due to his agitation, a thorough examination was not possible, but no focal neurological symptoms were noted. After sedation, it was observed that striking a large muscle group with a tendon hammer led to a few seconds of mounding of the muscle.
The patient’s CSF protein level was 457 g/dL, with no abnormalities noted in the CSF microscopy. Rabies virus neutralizing antibodies were not detected in the CSF, but were detected in the serum.
At present, the patient is receiving end-of-life care and is sedated with midazolam delivered by a syringe driver. His family wishes to be present at his bedside.
What personal protective equipment should healthcare workers and family members use when in contact with the patient?
A 29-year-old electrician was referred to the hospital by his doctor. He had visited his GP a week ago, complaining of malaise, headache, and myalgia for three days. Despite being prescribed amoxicillin/clavulanic acid, his symptoms persisted and he developed a dry cough and fever. At the time of referral, he was experiencing mild dyspnea, a global headache, myalgia, and arthralgia. On examination, he appeared unwell, had a fever of 39°C, and had a maculopapular rash on his upper body. Fine crackles were audible in the left mid-zone of his chest, and mild neck stiffness was noted.
The following investigations were conducted: Hb 84 g/L (130-180), WBC 8 ×109/L (4-11), Platelets 210 ×109/L (150-400), Reticulocytes 8% (0.5-2.4), Na 129 mmol/L (137-144), K 4.2 mmol/L (3.5-4.9), Urea 5.0 mmol/L (2.5-7.5), Creatinine 110 µmol/L (60-110), Bilirubin 89 µmol/L (1-22), Alk phos 130 U/L (45-105), AST 54 U/L (1-31), and GGT 48 U/L (<50). A chest x-ray revealed patchy consolidation in both mid-zones. What is the most likely cause of his abnormal blood count?
A 35-year-old woman presented to the clinic with a 3-week history of fever, fatigue, and muscle pain. She also reported having mouth sores. She had traveled to Brazil 2 months ago to visit family and friends and had unprotected sexual intercourse during her trip. She has no known medical conditions. On examination, she had cervical lymphadenopathy but no hepatosplenomegaly. Aphthous ulcers were present on her buccal mucosa. The following investigations were conducted:
Haemoglobin (Hb): 132 g/l (normal range: 120-160 g/l)
White cell count (WCC): 3.8 × 109/l (normal range: 4.0-11.0 × 109/l)
Neutrophils: 1.8 × 109/l (normal range: 1.5-7.0 × 109/l)
Lymphocytes: 1.2 × 109/l (normal range: 1.5-4.0 × 109/l)
Platelets (PLT): 102 × 109/l (normal range: 150-400 × 109/l)
Bilirubin: 24 mmol/l (normal range: 1.7-20.5 mmol/l)
Alanine aminotransferase (ALT): 68 u/l (normal range: 7-55 u/l)
Blood film: Atypical reactive lymphocytes
HIV antibodies: Negative
What is the most likely diagnosis?
A 35-year-old woman presents to the clinic with complaints of fatigue, fevers, right upper quadrant pain, and diarrhea. She admits to occasional use of cocaine. On examination, she appears thin and has tender hepatosplenomegaly and lymphadenopathy. Her partner accompanies her and expresses concern. The following investigations are conducted:
Haemoglobin (Hb): 112 g/l (normal range: 135-175 g/l)
White cell count (WCC): 4.2 × 109/l (normal range: 4.0-11.0 × 109/l)
Platelets (PLT): 95 × 109/l (normal range: 150-400 × 109/l)
Sodium (Na+): 140 mmol/l (normal range: 135-145 mmol/l)
Potassium (K+): 4.5 mmol/l (normal range: 3.5-5.0 mmol/l)
Creatinine (Cr): 98 µmol/l (normal range: 50-120 µmol/l)
Alanine aminotransferase (ALT): 178 IU/l (normal range: 5-30 IU/l)
Alkaline phosphatase (ALP): 290 IU/l (normal range: 30-130 IU/l)
Computed tomography (CT) abdomen: Retroperitoneal, para-aortic lymphadenopathy, and hepatosplenomegaly
Small bowel biopsy: Acid-fast bacteria (AFB) seen, MTB PCR negative
What is the most likely diagnosis for this patient?
A 35-year-old woman presents to the Gastroenterology Clinic with a 3-week history of profuse watery diarrhoea. She has been experiencing intermittent cramping abdominal pain and episodes of nausea, but denies vomiting. Her appetite is reduced and she is now feeling extremely fatigued. There is no recent travel or change in diet. She has no significant medical history or regular medications.
On examination, her temperature is 36.5 °C. She appears pale and thin, but not jaundiced. Her heart rate is 98 bpm and regular and her blood pressure is 100/70 mmHg. She has generalised abdominal tenderness but no guarding or palpable masses. There are visible needle marks in her right antecubital fossa.
What is the most likely organism responsible for this patient’s symptoms?
A 47-year-old man presents to the emergency department with fever and dry cough for the last week. He also complains of myalgia and headaches which have been affecting his work as a construction worker. These headaches are variable in location, but usually worse behind his eyes. He is a non-smoker and has no significant past medical history of note.
On examination, he has coarse crackles in his left lung base. His abdomen is soft and non-tender. There is no rash. Heart sounds are normal, with no murmurs heard.
Initial investigations are done and a chest x-ray is requested.
Hb 142 g/L Male: (135-180)
Female: (115 – 160)
Platelets 410 * 109/L (150 – 400)
WBC 13.5 * 109/L (4.0 – 11.0)
Na+ 139 mmol/L (135 – 145)
K+ 4.5 mmol/L (3.5 – 5.0)
Urea 5.8 mmol/L (2.0 – 7.0)
Creatinine 105 µmol/L (55 – 120)
CRP 76 mg/L (< 5)
Bilirubin 15 µmol/L (3 – 17)
ALP 118 u/L (30 – 100)
ALT 72 u/L (3 – 40)
γGT 58 u/L (8 – 60)
Albumin 41 g/L (35 – 50)
What is the most appropriate treatment option?