Varicella zoster virus (VZV) presents in this way and the rash transforms from macules to vesicles. Pneumonitis is a common complication of VZV infection.

Subcutaneous (S/C) low-molecular-weight heparin (LMWH) is a preferred anticoagulant in pregnancy. Warfarin is contraindicated due to its teratogenic effects, especially in the first trimester and at term.

Pregnancy is a hypercoagulable state with the majority of VTE incidents occurring in the last trimester.

Hypercoagulability in pregnancy is caused by:
1. Increase in factors VII, VIII, X, and fibrinogen
2. Decrease in protein S
3. Uterus pressing on IVC causing venous stasis in legs

Management options include:
1. S/C LMWH preferred to IV heparin (less bleeding and thrombocytopaenia)
2. Warfarin contraindicated

Diseases that cause predominantly sensory loss include diabetes, uraemia, leprosy, alcoholism, vitamin B12 deficiency, and amyloidosis.
Those that cause predominantly motor loss include Guillain-Barre syndrome, porphyria, lead poisoning, hereditary sensorimotor neuropathies, chronic inflammatory demyelinating polyneuropathy, and diphtheria.

Othello syndrome (OS) is a type of paranoid delusional jealousy, characterized by the false absolute certainty of the infidelity of a partner, leading to preoccupation with a partner’s sexual unfaithfulness based on unfounded evidence. OS has been associated with psychiatric and neurological disorders including stroke, brain trauma, brain tumours, neurodegenerative disorders, encephalitis, multiple sclerosis, normal pressure hydrocephalus, endocrine disorders, and drugs.

Interleukin 1 alpha and interleukin 1 beta (IL1 alpha and IL1 beta) are cytokines that participate in the regulation of immune responses, inflammatory reactions, and hematopoiesis. It is secreted mainly by macrophages and monocytes and acts as a costimulator of T cell and B cell proliferation.

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.

Fc Receptors include the IgG receptors (FcγR), high-affinity IgE receptor (FcεRI), IgA and IgA/IgM receptors, and neonatal Fc receptor for IgG (FcRn). In particular, the FcγRs have been well known to play an important role in many biologic processes including those associated with the response to infection and cancer as well as in the pathogenesis of immune-mediated diseases. Fc receptors, the receptors for the Fc region of immunoglobulins, play an essential role in antibody-dependent immune responses. Fc receptors are detected on many types of hematopoietic cells including macrophages, neutrophils, dendritic cells, eosinophils, basophils, mast cells, and NK cells. Plasma cells produce five classes of antibodies, IgA, IgD, IgE, IgG and IgM. Fc receptors with an Ig superfamily related structure exist that correspond to each of these classes of immunoglobulins.

Among the given options, cognitive-behavioural therapy is the most likely to benefit a patient with schizophrenia.

Schizophrenia is a functional psychotic disorder characterized by the presence of delusional beliefs, hallucinations, and disturbances in thought, perception, and behaviour.

Clinical features:
Schneider’s first-rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions:

Auditory hallucinations of a specific type:
Two or more voices discussing the patient in the third person
Thought echo
Voices commenting on the patient’s behaviour

Thought disorder:
Thought insertion
Thought withdrawal
Thought broadcasting

Passivity phenomena:
Bodily sensations being controlled by external influence
Actions/impulses/feelings – experiences which are imposed on the Individual or influenced by others

Other features of schizophrenia include
Impaired insight (a feature of all psychoses)
Incongruity/blunting of affect (inappropriate emotion for circumstances)
Decreased speech
Neologisms: made-up words
Catatonia
Negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation).

Treatment:
For the initial treatment of acute psychosis, it is recommended to commence an oral second-generation antipsychotics such as aripiprazole, olanzapine, risperidone, quetiapine, etc.
Once the acute phase is controlled, switching to a depot preparation like aripiprazole, paliperidone, zuclopenthixol, fluphenazine, haloperidol, pipotiazine, or risperidone is recommended.
Cognitive-behavioural therapy (CBT) and the use of art and drama therapies help counteract the negative symptoms of the disease, improve insight, and assist relapse prevention.
Clozapine is used in case of treatment resistance.

Moxonidine and alpha-methyl dopa are centrally acting antihypertensives and modify blood pressure through modifying sympathetic activity.

Other options:
Verapamil is a calcium antagonist.
Minoxidil and hydralazine are both vasodilators.
Phenoxybenzamine is an alpha-blocker.

Adverse effects:
Dry mouth and somnolence were the most frequently reported adverse events, followed by headache, dizziness, nausea and allergic skin reactions.

To confirm the diagnosis, especially in patients with negative anti-Ro or anti-La antibodies, labial gland biopsy is done. In performing a labial biopsy, the surgeon typically makes a shallow 1/2 inch wide incision on either side of the inner lip after numbing the area with a local anaesthetic. Schirmer’s test determines whether the eye produces enough tears to keep it moist. This test can be done for ocular symptoms of Sjogren syndrome but is of no diagnostic importance as it can be positive with many other diseases.

The history and ECG findings are adequate to begin cardiac revascularization of this patient. There is no need for cardiac markers to confirm the diagnosis. Further delay in starting definite treatment is not recommended.

Hypothermia is defined as a core body temperature of < 35 °C.
Hypothermia may produce the following ECG changes:
-Bradyarrhythmia
-Osborne Waves (= J waves)
-Prolonged PR, QRS and QT intervals
-Shivering artefact
-Ventricular ectopics
-Cardiac arrest due to VT, VF or asystole

Allergic bronchopulmonary aspergillosis (ABPA) is a form of lung disease that occurs in some people who are allergic to Aspergillus. With ABPA, this allergic reaction causes the immune system to overreact to Aspergillus leading to lung inflammation. ABPA causes bronchospasm (tightening of airway muscles) and mucus build-up resulting in coughing, breathing difficulty and airway obstruction.

Treatment of ABPA aims to control inflammation and prevent further injury to your lungs. ABPA is a hypersensitivity reaction that requires treatment with oral corticosteroids. Inhaled steroids are not effective. ABPA is usually treated with a combination of oral corticosteroids and anti-fungal medications. The corticosteroid is used to treat inflammation and blocks the allergic reaction. Examples
of corticosteroids include: prednisone, prednisolone or methylprednisolone. Inhaled corticosteroids alone – such as used for asthma treatment – are not effective in treating ABPA. Usually treatment with an oral corticosteroid is needed for months.

The second type of therapy used is an anti-fungal medication, like itraconazole and voriconazole. These medicines help kill Aspergillus so that it no longer colonizes the airway. Usually one of these drugs is given for at least 3 to 6 months. However, even this treatment is not curative and can have side effects.

Hypotensive effect of streptokinase occurs during the streptokinase infusion which is usually transient. Acute mitral regurgitation due to rupture of papillary muscles, ventricular septal defects and reinfarctions (left or right) are known to cause hypotension after 24 hrs. Pulmonary embolism is less likely but cannot be excluded.

Acute epiglottitis is a life-threatening disorder with serious implications to the anaesthesiologist because of the potential for laryngospasm and irrevocable loss of the airway. There is inflammatory oedema of the arytenoids, aryepiglottic folds and the epiglottis; therefore, supraglottitis may be used instead or preferred to the term acute epiglottitis.

Acute epiglottitis can occur at any age. The responsible organism used to be Hemophilus influenzae type B (Hib), but infection with group A b-haemolytic Streptococci has become more frequent after the widespread use of Hemophilus influenzae vaccination.

The typical presentation in epiglottitis includes acute occurrence of high fever, severe sore throat and difficulty in swallowing with the sitting up and leaning forward position in order to enhance airflow. There is usually drooling because of difficulty and pain on swallowing. Acute epiglottitis usually leads to generalized toxaemia. The most common differential diagnosis is croup and a foreign body in the airway. A late referral to an acute care setting with its serious consequences may result from difficulty in differentiation between acute epiglottitis and less urgent causes of a sore throat, shortness of breath and dysphagia.

There is a high risk of bleeding due to recent surgery and heparin. So thrombolysis is not an option. The most appropriate management is percutaneous coronary intervention.

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.

Polycythaemia vera (PV) is associated with a low ESR.

PV, also known as polycythaemia rubra vera, is a myeloproliferative disorder caused by clonal proliferation of marrow stem cells leading to an increase in red cell volume, often accompanied by overproduction of neutrophils and platelets. It has peak incidence in the sixth decade of life, with typical features including hyperviscosity, pruritus, splenomegaly, haemorrhage (secondary to abnormal platelet function), and plethoric appearance. PV is associated with a low ESR.

Some management options of PV include lose-dose aspirin, venesection (first-line treatment), hydroxyurea (slightly increased risk of secondary leukaemia), and radioactive phosphorus (P-32) therapy.

In PV, thrombotic events are a significant cause of morbidity and mortality. 5–15% of the cases progress to myelofibrosis or acute myeloid leukaemia (AML). The risk of having AML is increased with chemotherapy treatment.

The diagnosis is Refsum’s disease. This is an autosomal recessive disorder that causes a sensorimotor peripheral neuropathy. It is caused by defective alpha oxidation of phytanic acid leading to its accumulation in tissues. Cardiac conduction abnormalities and cardiomyopathies may also occur.
Epiphyseal dysplasia causes a characteristic shortening of the fourth toe. Serum phytanic acid levels are elevated. Treatment is by dietary restriction of foods containing phytanic acid (dairy products, fish, beef and lamb).

Polymyalgia rheumatica, a syndrome characterized by proximal muscle pain and stiffness in older persons, generally is treated with prednisone. Dosages of 15 to 25 mg of prednisone per day can reduce inflammation considerably, although many patients relapse when therapy is tapered. Long-term (18 to 36 months) steroid treatment has been recommended by several studies, but this can result in multiple side effects, including osteoporosis, hypertension, cataracts, and hyperglycaemia. Methotrexate has been used to reduce inflammation in rheumatoid arthritis, systemic vasculitis, and giant cell arteritis, and in some studies has been combined with prednisone to treat polymyalgia rheumatica, decreasing the duration of treatment.

The most likely diagnosis is acute atrial fibrillation (AF) precipitated by acute pneumonia. History of fever, cough and the auscultation findings support it. So the most appropriate management is treating the pneumonia with antibiotics. Treating the underlying cause will reduce the heart rate. Other responses are helpful in the management of chronic AF.

Low body weight. Excessively low body weight — about 10 percent under normal weight — interrupts many hormonal functions in your body, potentially halting ovulation.
In Polycystic ovaries there is excess weight gain.

Night sweats are a B symptom in Hodgkin lymphoma (HL) and imply a poor prognosis.

HL is a malignant proliferation of lymphocytes characterised by the presence of distinctive giant cells known as Reed-Sternberg cells. It has a bimodal age distribution being most common in the third and seventh decades of life.

Staging of HL is done according to the Ann Arbor staging system:

Stage
I: Single lymph node region (I) or one extra lymphatic site (IE)

II: Two or more lymph node regions on same side of the diaphragm (II) or local extra lymphatic extension plus one or more lymph node regions on same side of the diaphragm (IIE)

III: Lymph node regions on both sides of the diaphragm (III) which may be accompanied by local extra lymphatic extension (IIIE)

IV: Diffuse involvement of one or more extra lymphatic organs or sites

Suffix
A: No B symptoms

B: Presence of at least one of the following: unexplained weight loss >10% baseline during 6 months before staging; recurrent unexplained fever >38°C; recurrent night sweats—poor prognosis.

Prolactinomas, benign lesions that produce the hormone prolactin, are the most common hormone-secreting pituitary tumours.
Based on its size, a prolactinoma can be classified as a microprolactinoma (< 10 mm diameter) or a macroprolactinoma (>10 mm diameter). If the prolactinoma is large enough to compress the surrounding normal hormone-secreting pituitary cells, it may result in deficiencies of one or more hormones (e.g., thyroid-stimulating hormone [TSH], growth hormone [GH], adrenocorticotropic hormone). However, the patient has microadenoma so it is unlikely to cause compression manifestations.
Hyperprolactinemia inhibits GnRH secretion from the medial basal hypothalamus and LH release from the pituitary.

Both long-acting calcium channel blockers and beta blockers improve symptoms of patients with SVT. Verapamil does not have adverse maternal or fetal side effects which would suggest that the use of verapamil in the treatment of supraventricular arrhythmias in pregnancy is safe and effective. Beta blockers are associated with intrauterine fetal growth restriction.

This patient has a combination of right cerebellar dysfunction with right-sided cranial nerve palsies (VI, VII, and VIII). The magnetic resonance imaging (MRI) shows a calcified meningioma within the right cerebellar pontine area, which would account for these findings. The cerebrospinal fluid (CSF) analysis shows oligoclonal bands, however, these are matched in the serum, which reflects a systemic inflammatory response from his rheumatoid arthritis.

The MRI scan and CSF analysis would not be consistent with progressive multiple sclerosis. The progressive nature of her symptoms would be against a diagnosis of brainstem infarct, and one would expect more pyramidal signs in the peripheral nervous system.

A very common complication after ERCP is post-ERCP pancreatitis, which based on the clinical scenario , this man has. The treatment for this is pain control, lots of intravenous fluids, and traditionally bowel rest, although more recent evidence suggests early feeding is better.

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 .

Anti-Sm antibodies are essential for diagnosis of SLE, especially in anti-dsDNA-negative patients. ANA are also found in 95% of the patients with SLE but they may also occur with other conditions like Juvenile inflammatory arthritis, chronic activity hepatitis, and Sjogren’s syndrome. Anti-Ro, although also found with SLE are more characteristic of Sjogren Syndrome. RF is usually associated with rheumatoid arthritis and cANCA with Wegener’s granulomatosis, Churg Strauss, and microscopic polyangiitis.

Class I indications (i.e., the benefit greatly outweighs the risk, and the treatment should be administered): -Structural heart disease, sustained VT
-Syncope of undetermined origin, inducible VT or VF at electrophysiologic study (EPS)
-Left ventricular ejection fraction (LVEF) ≤35% due to prior MI, at least 40 days post-MI, NYHA class II or III
-LVEF ≤35%, NYHA class II or III
-LVEF ≤30% due to prior MI, at least 40 days post-MI
-LVEF ≤40% due to prior MI, inducible VT or VF at EPS

Class IIa indications (i.e., the benefit outweighs the risk and it is reasonable to administer the treatment):
-Unexplained syncope, significant LV dysfunction, nonischaemic cardiomyopathy
-Sustained VT, normal or near-normal ventricular function
-Hypertrophic cardiomyopathy with 1 or more major risk factors
-Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) with 1 or more risk factors for sudden cardiac death (SCD)
-Long QT syndrome, syncope or VT while receiving beta-blockers
-Nonhospitalized patients awaiting heart transplant
-Brugada syndrome, syncope or VT
-Catecholaminergic polymorphic VT, syncope or VT while receiving beta-blockers
-Cardiac sarcoidosis, giant cell myocarditis, or Chagas disease