Infectious Diseases 🦠

A 13 year old boy presents to the GP surgery. He complains of headaches, general muscle aches and neck stiffness. These symptoms began yesterday. He has been having a fever, profuse sweating, diarrhoea and malaise for the past week. He returned to the UK two months ago from a family vacation to West Africa and was vaccinated against yellow fever before his travels. Additionally, he completed a 6-week course of prophylaxis against malaria. On examination, he is oriented and co-operative. He has a yellow tinge on his skin. His heart rate is 100 beats/minute; blood pressure is 100/70mmHg, and body temperature is 38°C. Which of the following is the SINGLE best investigation to establish a definitive diagnosis?

A 28 year old phlebotomist is applying for a new job at a local hospital. She vaguely remembers having a booster for hepatitis B a few years ago but is unsure. Which serology would be positive if she has had immunity from her vaccination?

A 27 year old woman is brought to the Emergency Department as she had 2 episodes of fits within the past hour. She is confused at present and has been drowsy since morning. She has a severe headache. Her husband reports that she complained of feeling unwell during the past 10 days with a fever from time to time associated with rigours. She is in her 26th week of pregnancy and having attended an antenatal check last week, was told that she was having a healthy pregnancy. She and her husband have returned from a holiday to the Gambia a month ago. On examination, her blood pressure is 136/89 mmHg, heart rate is 110 beats/minute, and body temperature is 38.5°C. A urine dipstick test shows trace protein. Which of the following is the SINGLE most likely diagnosis?

A 69 year old woman lives in a nursing home following a stroke. She recently developed a reddish scaly rash on her trunk. She has many scratch marks on her limbs and trunk with linear burrows seen on her hands and feet. What is the SINGLE most appropriate treatment?

A 7 year old school boy has been diagnosed with meningococcal meningitis. What is the SINGLE most appropriate prophylactic management?

A 44 year old man has come to the clinic with concerns as his partner who he has lived with has developed chicken pox 2 days ago. His medical history includes rheumatoid arthritis and Crohn’s disease. He has been taking long term prednisolone and methotrexate to manage his symptoms. As a result of his complicated Crohn’s disease, he suffers with malabsorption. He gives a history of having chicken pox when he was 5 years old. On examination, there are no lesions nated an his skin. What is the SINGLE most appropriate action?

An 8 year old boy has red, itchy rash on his abdomen, face, arms and legs that has turned into fluid-filled blisters. A few days later they crusted over. What is the main mode of transmission of this condition?

A 30 year old man presents to the emergency department with difficulty breathing. He has returned from India 5 days ago. On examination, his throat reveals grey membranes on the tonsils and uvula. He has a fever, and enlarged anterior cervical lymph nodes. What is the SINGLE most likely diagnosis?

A 7 year old boy presented 10 hours after having a foot injury while playing football in the garden. A metal spike had gone through his shoes and pierced the bottom of his foot. The wound is heavily contaminated with soil. His immunisations are up to date. What is the SINGLE most appropriate management?

A 28 year old man presents to Accident & Emergency with the complaint of coughing up blood. He coughed up about a teaspoon of fresh blood this morning and he coughed up a few drops on his way to the hospital. He has had no other episodes of haemoptysis in the past. Upon further questioning, it is revealed that he has had a chronic cough for the past two months. He has no history of recent travel outside of the United Kingdom. He drinks alcohol socially and smokes around four cigarettes a day. He admits to smoking marijuana occasionally with his friends. The patient works as a packer in a busy loading bay for a large manufacturing company. He is extremely nervous and thinks that he might have cancer as he read on the internet that one of the symptoms of cancer is the coughing up of blood. Upon physical examination, the patient looks unwell and cachectic. Dullness to percussion can be appreciated over the right upper zone of his chest. A chest X-ray reveals right upper lobe consolidation with a bilateral pleural effusion. What is the SINGLE most appropriate investigation for this patient?

A 20 year old man with a known diagnosis of otitis media presents with a severe headache, and sensitivity to light. He is shivering, sweating and has a temperature of 38.9°C. What is the SINGLE most likely complication?

A 38 year old woman attends the Emergency Department after being bitten by a stray dog in a park. Her body language consists of exaggerated hand gestures, paced walking around the room and an anxious verbal tone. The woman states that the dog was foaming from the mouth and had bloodshot eyes. She had her last tetanus booster 20 years ago. There is a superficial laceration on the distal portion of her right forearm with no active bleeding. Local wound care and antibiotics have been provided. What is the next most appropriate management?

A 78 year old nursing home resident has an intensely itchy rash. White linear lesions are seen on the wrists and elbows, and red papules are present on his penis. What is the SINGLE most appropriate management?

An 8 week infant has been diagnosed as HIV positive. What is the SINGLE most appropriate immunization plan for the infant?

A surgeon was pricked by a needle used during an appendectomy. Basic first aid for the surgeon has been performed. After the operation, the patient was informed of the incident and gave her consent to be tested for blood-borne infections for the benefit of the surgeon. The patient states that she is a dental nurse, practises safe sexual intercourse and denies use of any intravenous drugs. She has never been tested for blood-borne infections. The surgeon remembers being immunised for hepatitis B but cannot remember the last time he received a booster for hepatitis B. What is the SINGLE most appropriate action for the patient and the surgeon on the day of the incident?

A 44 year old man obtained multiple penetrating wounds on his lower back with a knife 5 days ago. He was admitted to the hospital since the incident. He has been experiencing worsening lower back pain over the past 24 hours with chills, and rigours. He has a temperature of 40.1°C and a heart rate of 115 beats/minute. There is no discharge from the wounds and the wounds appear to be healing. He has type 2 diabetes mellitus and is on metformin. Blood culture was taken and he was started on intravenous antibiotics. His blood results show the following:

Haemoglobin 132 g/L (130-180)

White cell count 19 x 10^9/L (4-11)

Neutrophils 8.1 x 10^9L (2-7.5)

Platelets 340 x 10^9/L (150-400)

CRP 240 (<10)

The blood culture has shown evidence of Staphylococcus aureus growth. He continues to be unwell. What is the SINGLE most appropriate investigation for this condition?

A 41 year old lady is suffering from fever, sore throat and loss of appetite. Her symptoms have been persistent and worsening over the past few weeks. She has had a recent renal transplant and is currently on immunosuppressive medication. Serology was taken for toxoplasmosis and has returned with the presence of IgE antibodies which is interpreted as having a recent acquired infection. Her renal function is satisfactory. What is the SINGLE most appropriate treatment?

A 30 year old woman had unprotected sexual intercourse 48 hours ago with a man who is HIV positive and takes antiretroviral therapy. His last viral load a week ago was 1000 copies/mL. What is the SINGLE most appropriate action?

A 16 year old girl attends clinic with a sore throat and palatal petechiae. A full blood count was done which shows:

Haemoglobin 109 g/L

White cell count 25 x 109/L

Platelets 88 x 109/L

A Paul Bunnell test was shown to be positive. What is the SINGLE most likely diagnosis?

A 5 year old boy was brought to his GP with a temperature of 38.8°C and numerous pruritic vesicles on his chest and back. They appear in circular crops and initially started on his face before spreading to his chest and back. What is the SINGLE most appropriate management?

A 33 year old man returns to the UK from South America with an 8 weeks history of night sweats, fever, arthralgia, malaise and weight loss. He worked at a farm during his stay in South America. On examination, his spleen is enlarged. His temperature is 38°C. What is the SINGLE most likely diagnosis?

A 34 year old man who has a new diagnosis of haematological malignancy presents in the emergency department with bruises all over his abdomen. He has a temperature of 38.6°C. His respiratory rate is 25 breaths/minute, heart rate is 102 beats/minute and blood pressure is 80/50 mmHg. His blood results show:

White cell count 23 x 10^9/L

Neutrophils 0.4 x 10^9/L

He is commenced on meropenem. What is the SINGLE most likely diagnosis?

A 33 year old woman was admitted to the hospital with a fever of 38.9 °C and rigours. She has had 9 days of myalgia, fever and lethargy. She has vague abdominal pain and feels nauseous. She had redness in her eye for a few days prior to the sclera becoming yellow. She had returned from a trip where she travelled in rural Malaysia 2 weeks ago. She describes was swimming in lakes and rivers during her trip. On examination, her skin appears to be yellow. She has right upper quadrant tenderness. Blood tests were done and the laboratory results are as follows:

Alanine transferase (ALT) 99 U/L (5-35 U/L)

Aspartate transaminase (AST) 88 U/L (5-35 U/L)

Alkaline phosphatase (ALP) 182 U/L (30-150 U/L)

Gamma glutamyl transferase (GT) 53 U/L (8-60 U/L)

White blood cells 16 x 10^9/L (4-11 x 10^9/L)

Platelets 175 x 10^9/L (150-400 x 10^9/L)

What is the SINGLE most appropriate investigation in this scenario to confirm the diagnosis?

You are working in the Emergency Department when you encounter a needlestick injury in the evening whilst taking blood from an intravenous (IV) drug user who was admitted for abdominal pain. The needle that was used to take blood from the IV drug user pierced your right thumb. What is the SINGLE most appropriate management?

A 16 year old boy has generalized skin lesions that started 3 days ago. The skin lesions consist of macular, papular and vesicles and are concentrated more on his trunk There is erythema and tenderness surrounding the lesions. Pinkish fluid is seen secreted from a few of the vesicles. He has a temperature of 39.2°C. Which class of medication is most important in the management of his condition?

A 26 year old woman presents to her GP with a headache, photophobia and a fever. On examination, a generalized rash that does not blanch on pressure was observed. What is the SINGLE most appropriate initial management?

A 12 year old boy presents to the Emergency Department. His mother reports that he developed a headache and fever over the past 2 days. He is irritable and complains that the lighting is far too bright. He does not have a significant past medical history and on examination, his blood pressure is 100/70 mmHg, heart rate is 120 beats/minute, and body temperature is 38.5°C. On exposure, a few red coloured spots are noticed on his trunk and do not disappear on applying pressure with a glass slide. Ophthalmoscopy reveals a normal fundus. Nuchal rigidity was appreciated on passive flexion of the neck which resulted in flexion of the knee and discomfort. A lumbar puncture was subsequently performed and the CSF sample appears cloudy. Which of the following is the SINGLE most likely cause of this patient’s condition?

A 35 year old woman who is 20 weeks pregnant presents with an erythematous patch an her abdomen, which has been enlarging in the last few days. The rash is slightly itchy and she describes flu-like symptoms. She went for a camping trip 10 days ago. The erythematous rash is seen to produce an annular lesion with central clearing. She has no allergies to any known medication. What is the SINGLE most appropriate management?

A 74 year old female presents with headache and neck stiffness to the emergency department. Following a lumbar puncture, the patient was started on IV ceftriaxone. CSF culture reports as having listeria monocytogenes. What is the SINGLE most appropriate treatment?

An 82 year old man was brought into the Emergency Department with a low level of consciousness. His wife mentions that he had a severe headache for the last 20 hours and was very sensitive to light. He has a temperature of 39.0°C, a pulse of 118 beats/minute, a blood pressure of 80/55 mmHg and a respiratory rate of 32 breaths/minute. He is conscious but confused. Kernig’s sign was positive. High flow oxygen and intravenous fluids were immediately started and blood cultures were taken. What is the SINGLE most appropriate immediate action?

An intravenous drug addict has bitten a police officer on his neck. The police officer attends the Accident and Emergency alone. He had a tetanus booster injection 3 years ago after cutting his hand on glass while gardening. He has not had any hepatitis B vaccinations recently. On examination, there is broken skin, with deep penetrating bite marks with blood. What would you advise the police officer?

A 27 year old chef calls in sick from work as he started having bouts of diarrhoea, vomiting and abdominal cramps. He has a fever, body aches and feels unwell. What is the SINGLE most appropriate advice in regards to returning to work?

A 2 year old girl accompanied by her mother presents to the Emergency Department as she sustained a cut on her finger from a broken glass in the house earlier in the day. She has not received any immunisations because her mother was initially concerned about the side effects of the vaccine. There are no contraindications for her receiving the vaccine. What is the SINGLE most appropriate management?

A 22 year old boy presents to the Emergency Department. He complains of a painful headache, stiff neck and rigidity and finds the room lighting very uncomfortable on his eyes. These symptoms began yesterday. He has been having muscle aches, profuse sweating, and malaise for the past two days. He has been staying in a dorm with his fellow medical students. He returned to the UK two months ago from a medical elective where he spent 6 months in West Africa. He was vaccinated against yellow fever before his travels. Additionally, he completed a 6-week course of prophylaxis against malaria. On examination, he is oriented and co-operative. His heart rate is 105 beats/minute; blood pressure is 120/70mmHg, and body temperature is 38.8°C. Which of the following is the SINGLE best investigation to establish a definitive diagnosis?

A 20 week pregnant lady presents with intermittent fever, coughs, headaches, myalgia, gastric upset and mild confusion. She arrived from Ghana 12 days ago. She travelled there to visit her family. Before she left, she was prescribed chloroquine and proguanil and she took it as prescribed starting 1 week before entering Ghana. She is still taking chloroquine and proguanil as her doctor had asked her to continue it for 4 weeks after arriving in the United Kingdom. On examination, she has a yellowish tinge on her skin. What is the SINGLE most likely diagnosis?

A 33 year old man with Hodgkin’s lymphoma has chemotherapy 9 days ago. He develops a temperature of 39.0°C and signs of a chest infection. Blood count shows:

Haemoglobin 113 g/L

White cell count 2.3 x 10^9/L

Neutrophils 0.8 x 10^9/L

Platelets 150 x 10^9/L

What is the SINGLE most likely management?

A 22 year old lady comes to the hospital with complaints of fever, vertigo and pain in her right ear for the past 10 days. On physical examination, there are vesicles visible at the right external auditory meatus with an asymmetrical smile where the smile is seen on the left side of the face. What is the SINGLE most likely diagnosis?

A 65 year old man visited his local GP with complaints of difficulty and pain in swallowing. These symptoms have been occurring for approximately two weeks now. His appetite has also decreased and he has noticed some white patches on his tongue. His medical history is significant for non-insulin dependent diabetes mellitus, diagnosed two years ago. He claims that his condition is well controlled and that he is compliant with his medication. He also casually mentions that he quit smoking six years ago. During the consult, the patient appears to be in a generally good state of health. He reported a recent use of antibiotics for an upper respiratory tract infection that he recovered from a week ago. On examination, the patient’s vital signs, including his blood glucose level, were all found to be within normal limits. Examination of the head and neck region revealed no palpable lymph nodes. An extra-oral examination performed proved to be insignificant. An intra-oral examination of the patient revealed an extensive white plaque on the midline of the posterior dorsal portion of the tongue measuring approximately 1.5 centimetres in diameter. What is the SINGLE most likely treatment option for this patient?

A 68 year old woman has a sudden onset of pain and loss of hearing in her left ear and unsteadiness when walking. There are small lesions visible on her palate and left external auditory meatus. What is the SINGLE most likely diagnosis?

A 75 year old woman has weakness of the left side of her face and pain deep within the left ear. The ear pain was paroxysmal at first but after a day it became constant and radiates into the pinna. Now she hears ringing in her left ear. A mild left hearing loss was noted. There are blisters on the skin of the ear canal and auricle. What is the SINGLE most likely diagnosis?

A 25 year old man presents with painful ulcers on the penile shaft and prepuce. They started as an erythematous papular lesion which continued to develop into ulcers. His sexual partner has recently come back from Africa. He otherwise feels well and has no significant medical history. What is the SINGLE most likely organism causing his symptoms?

A 46 year old man is being investigated for indigestion. A jejunal biopsy shows deposition of macrophages in the lamina propria-containing granules which stain positive for Periodic Acid-Schiff (PAS). What is the SINGLE most likely diagnosis?

A 26 year old married man presents with a 4 day history of painful vesicles on his glans penis, buttocks and painful micturition. Neither himself or his wife has experienced a similar episode to this in the past. What is the most appropriate investigation?

A 30 year old homeless lady has cough, sputum and a fever for the past few months. She complains of night sweats and has lost 13 kg in the past 6 months. A chest X-ray was performed which showed apical involvement with infiltrates and cavitation in the upper lobe of the right lung. What is the next SINGLE most appropriate test to perform?

A 19 year old boy is brought into the Emergency Department by his parents as he has been having severe headaches, neck stiffness, and rigours. He has been having a fever for the past 8 days with myalgia and frontal headaches. He became confused and drowsy early hours of the morning. He has returned from Ghana 6 weeks ago. He completed his prophylaxis course against malaria 2 weeks ago. On examination, he is disoriented. His heart rate is 115 beats/minute; blood pressure is 120/75mmHg, and body temperature is 38.9°C. What is the SINGLE most likely diagnosis?

A 4 year old girl has recently developed a rash that is itchy and has turned into fluid- filled blisters. She started having the rash 24 hours ago with a fever. Chicken pox is suspected. She normally attends nursery 3 days a week. Her parents would like to know when she can return to the nursery. What is the SINGLE most appropriate advice?

A 45 year old man has developed an annular rash with a scaly edge on his thigh. The rash has been spreading over the last 3 weeks. He also complains of general aches and pains. What is the SINGLE most appropriate investigation?

A 60 year old woman presents with a two-day history of a blistering rash on her left ankle and calf. She has pain localized to her ankle. She does not have a fever. She had a similar presentation on the same area a year ago which resolved after taking antibiotics. She has an allergy to penicillin. A picture of her leg is seen below.

What is the SINGLE most appropriate medication to prescribe?

A 7 year old child is being investigations for active respiratory tuberculosis. He has dry cough and is unable to produce sputum. His parents have been informed about the passibility of a bronchoalveolar lavage which can be useful in diagnosis tuberculosis however the parents decline this invasive test. What is the SINGLE next method to acquire a sample to diagnose tuberculosis?

A 4 year old girl is brought by her mother into the Paediatric Accidents & Emergency with a history of fever, headache and vomiting for the past 2 days. Her mother records her fever at home and says that her fever has not gone below 39°C for the past 24 hours. She is drowsy and difficult to wake up. She had a seizure causing twitching of the right side of the body at home for 4 minutes an hour ago. Her respiratory rate is 40 beats/minute, oxygen saturation is 90%, temperature is 39.2°C, and capillary refill time is 3 seconds. Her Glasgow Coma Scale is recorded as 11. During examination, she tends to turn away from any source of bright light. What is the SINGLE most appropriate investigation that would lead to a diagnosis?

A 24 year old man attends the Emergency Department with severe abdominal pain after an injury to his abdomen while playing football. He has a history of fever, sore throat and cervical lymphadenopathy 10 days ago. Which organ is at risk of rupture with his history?

A 6 year old boy has been exposed to chickenpox. His cousin who was playing with him yesterday developed a vesicular rash today and was diagnosed as having chickenpox by her GP. The boy’s mother is concerned as he is taking oral prednisolone for the past 2 weeks as part of the management of nephrotic syndrome. He was started on 1mg/kg/day of prednisolone and has been asked to taper off slowly. He has no rash and feels well. He has had no contact with her today. His last renal profile which was done a day ago was seen to be normal. What is the SINGLE most appropriate management?

A 3 year old boy going to nursery has developed chicken pox. What advice will you give the parents?

A 30 year old man attends the Emergency Department after sustaining a deep puncture wound when he stepped on a digging fork while working in his garden. He has received all his childhood immunisations. His last tetanus booster vaccine was when he was aged 18. There is no active bleeding. His observations are within normal limits. He is afebrile. What is the SINGLE most appropriate management?

A 24 year old man develops itching worse at night and following a bath. Examination reveals a greyish white linear rash that can be seen on the flexor surface of the wrist and axillary folds. What is the SINGLE most likely diagnosis?

A 55 year old man attends the GP surgery with complaints of a white coat on the tongue and a mild burning sensation of his oral cavity. He also describes difficulty swallowing. His medical history includes COPD which he takes salbutamol occasionally and an inhaled corticosteroid everyday. He smokes an estimate of 5 to 10 cigarettes a day for the past decade. On examination, there are whte-yellowish patches seen on the tongue, palate and buccal mucosa. What is the SINGLE most appropriate management?

A 33 year old known drug abuser has swelling and erythema in his arm where he injects. He has a fever and appears sick. He is asking for morphine as the pain is severe and seems to be disproportionate to the clinical appearance. Bullae is seen on the skin of his arm. He was started on intravenous flucloxacillin but the infection has not responded to antibiotics and seems to be worsening. What is the SINGLE most likely diagnosis?

A 30 year old man from Australia returned from a business trip to Indonesia 6 days ago presenting with complaints of fever, headache, vomiting, joint and muscle ache. His headache is felt behind the eyes and has been present for the past 2 days. What is the SINGLE most likely diagnosis?

A 21 year old man has generalized skin lesions. The skin lesions consist of macular, papular and vesicles and concentrated more on his back and chest. There is erythema and tenderness surrounding the lesions. Pinkish white thick fluid is seen secreted from a few of the lesions. He has a temperature of 39.1°C. What is the SINGLE most appropriate medication to prescribe?

A 27 year old man presents with a deep penetrating wound on his foot after having stepped on a nail in a field. He said he had the full course of tetanus vaccine when he was in school and again at 18 years old. What is the SINGLE most appropriate management to be given?

A 33 year old man presents 3 weeks after a trip to North Africa with vomiting, malaise and fever. He has been having diarrhoea and abdominal pain. On examination, he appears unwell. He has a tender enlarged liver which is palpable at 2 cm below the right costal margin, and no palpable spleen. He has a heart rate of 94 beats/minute, blood pressure of 120/80 mmHg, and temperature of 39.5°C. His capillary refill time is 3 seconds. His blood test results are seen below,

Haemoglobin 101 g/L (130-180)

White cell count 14 x 10^9/L (4-11)

Platelets 198 x 10^9/L (150-400)

Serum alanine transferase (ALT) 198 U/L (5-35)

Aspartate transaminase (AST) 177 U/L (5-35)

What is the SINGLE most likely diagnosis?

A 54 year old smoker presents to Accident & Emergency with the complaint of a productive cough. He says that he coughs up about a tablespoon full of yellow sputum every day. He also complains of chest tightness and mentions noticing a fever as well. These symptoms have been present for the past 5 days. He smokes two packs of cigarettes per day and has been smoking for the past 20 years. Physical examination reveals the presence of herpes labialis on the patient’s lower lip. The patient’s observations are as follows:

Temperature 38.7°C

Blood pressure 150/95 mmHg

Heart rate 95 beats per minute

Respiratory rate 20 breaths per minute

Oxygen saturation 96% on room air.

Auscultation of his chest reveals breath sounds that are distant but clear with crackles heard at the right lung base. A chest X-ray that was subsequently done reveals a right lower zone consolidation. What is the SINGLE most likely organism responsible for causing pneumonia in this patient?

A 33 year old man comes from India with cough, fever and enlarged cervical lymph nodes. Histology reveals caseating granulomas found in the lymph nodes. What is the SINGLE most likely diagnosis?

A 21 year old male college student is referred by a general practitioner (GP) to the Accidents and Emergency Department at the hospital. The presence of a generalised non-blanching petechial rash, photophobia, neck stiffness, fever and vomiting raise the suspicion of meningitis. Empirical antibiotics are given and blood cultures are taken. When is the SINGLE most appropriate time to notify the local Health Protection Team about this condition?

A 44 year old woman with HIV attends the HIV clinic. Her last blood test shows her CD4 count to be at 160 cells/mm3. Her CD4 count has been persistently below 200 cells/mm3. The clinician suggests starting prophylactic antibiotics to prevent pneumocystis carinii pneumonia. What is the SINGLE most appropriate antibiotic?

A 36 year old lady with Hodgkin’s lymphoma has chemotherapy 8 days ago. She presents with a temperature of 39.5°C and left sided abdominal pain. Her pulse rate is 96 beats/minute. Full blood count was sent and bloods were taken for culture. What is the SINGLE most appropriate next action?

A 45 year old health worker presents to his general practice with a 2-month history of purulent, productive cough, and intermittent fevers. Over the past 3 weeks he has started coughing up blood. A chest X-ray was performed which is seen below.

His heart rate is 80 beats/minute, respiratory rate is 20 breaths/minute, oxygen saturation is 97% and a temperature is 38°. What is the next SINGLE most appropriate test to perform?

A 34 year old man from Zimbabwe is admitted with abdominal pain to the Emergency Department. He has general malaise. He has a temperature of 38.2°C. He also has urinary retention which started 24 hours ago. A CT scan reveals bladder calcification and evidence of obstructive uropathy. What is the SINGLE most likely causative organism?

A 38 year old woman presents feeling unwell with dysphagia and a lump on her neck. On examination, there is a 5 cm by 4 cm erythematous neck swelling lateral to the thyroid cartilage. The mass is warm to touch. She has a temperature of 38.9°C, a respiratory rate of 28 breaths/minute and a heart rate of 110 beats/minute. What is the SINGLE most appropriate action?

A 38 year old woman returned from Bangkok three days ago. She was travelling in Thailand for 3 weeks. She did not have any malaria prophylaxis before leaving the UK an her trip. She presents with a two-day history of high fever, generalised macular blanching rash, swollen cervical lymphadenopathy and generalised myalgia. The high fever is of sudden onset. She has a headache and feels nauseous. Her blood pressure is 110/70 mmHg, heart rate is 110 beats/minute, respiratory rate is 24 breaths/minute and her temperature is 38.6°C. What is the SINGLE most likely diagnosis?

A 39 year old man presents 3 weeks after a trip to North Africa with dark urine and a fever. He has complained of epigastric pain for the past few days. He has an enlarged, tender liver which is palpable at 2 cm below the right costal margin and no palpable spleen. He has a temperature of 39.5°C. His blood test results are seen below,

Haemoglobin 101 g/L (130-180)

White cell count 14 x 10^9/L (4-11)

Eosinophils 0.6 x 10^9/L (0.04-0.44)

Platelets 70 x 10^9/L (150-400)

Serum alkaline phosphatase (ALP) 260 U/L (30-150)

Serum alanine transferase (ALT) 102 U/L (5-35)

Serum urea 10 mmol/L (2.0-7)

Serum creatinine 193 μmol/L (70-150)

eGFR 58 mL/min (>90)

What is the SINGLE most likely diagnosis?

A 31 year old man presents to Accidents and Emergency with abdominal pain and watery diarrhoea with blood for the past 7 days. He had recently eaten food from a street market. His friend who ate in the same place had similar symptoms but she improved after 3 days. He does not take any medications. His blood test shows the following:

Haemoglobin 112 g/L (130-180)

White cell count 18 x 10^9/L (4-11)

Platelets 380 x 10^9/L (150-400)

Serum urea 22 mmol/L (2.0-7)

Serum creatinine 199 μmol/L (70-150)

eGFR 49 mL/min (>90)

What SINGLE most appropriate investigation will you perform to aid in the management of this patient?

A 38 year old woman from a low social-economic background, complains of hoarseness and dysphagia for the past few weeks. She has a cough that has lasted a few months. She has been feeling more lethargic and reports having a mild fever. She has lost 14 kg in the past two months. She has non-tender swelling bilaterally on the base of her neck. She is an intravenous drug user. What is the SINGLE most likely diagnosis?

A 17 year old man has acute pain and earache on the right side of his face. He has a temperature of 39.4°C and has extensive pre-auricular swelling that is tender on palpation bilaterally. He also complains of headache, malaise, and dry mouth. What is the SINGLE most likely diagnosis?

A 19 year old woman has had an expanding rash over her arm over the past 3 weeks. She has a low-grade fever, fatigue and joint pain which gradually worsened after the first week of the rash. The red rash that has been seen as expanding over the past few days. A picture of it can be seen below.

What is the SINGLE most appropriate investigation?

A 38 year old man worsening redness and pain on his left ankle. He has pain especially on the movement of his left ankle. The left ankle is swollen. There is no history of any injury to the ankle. He was subsequently admitted to the hospital requiring intravenous flucloxacillin. A swab of his left ankle was taken and the culture has revealed methicillin- resistant staphylococcus aureus. What is the SINGLE most appropriate treatment?

A 38 year old female, 32 weeks pregnant presents with thick white marks on the inside of her mouth for 3 weeks. Her mouth including her tongue appears inflamed on examination. She smokes 20 cigarettes a day despite advice to quit. What is the SINGLE most likely diagnosis?

A 68 year old woman is brought to the Emergency Department. She complains of a headache, and stiff neck since yesterday and finds it very uncomfortable to keep her eyes open. Her daughter reports that she has been warm to touch since yesterday and noticed 2-3 red spots on her back. Her blood pressure is 88/48 mmHg; heart rate is 132 beats/minute, and body temperature is 39°C. She experiences pain on passive extension of the knee when her hip is flexed. A non-blanching petechial rash is noted on examination on her back. She continues to look drowsy. Which of the following should be administered empirically?

A 67 year old man who is currently on chemotherapy treatment for a malignancy suddenly develops febrile neutropenia. He has been commenced on tazocin and gentamicin. He has recently commenced meropenem but his fever still remains at 39°C on the 4th day. Two blood tests and urine cultures have come back negative. Investigations performed this morning show:

Haemoglobin 104 g/L (130-190)

White cell count 0.5 x 10^9/L (4-11)

Platelets 35 x 10^9/L (1150-400)

What is the SINGLE best management?

A 58 year old woman attends the clinic for advice as her grandson who lives with her has developed chicken pax with the rash appearing 2 days ago. She is currently undergoing chemotherapy for breast cancer and has been using long term corticosteroids to manage her polymyalgia rheumatica. She has never had chicken pox before. On examination, there is no evidence of any rash. Serology for varicella zoster has been taken but results are likely to be delayed for more than 7 days of the initial contact. What is the SINGLE most appropriate management?

A 24 year old college student presents to A&E with nausea, vomiting, headache, neck stiffness and a fever of 38.4°C. He has a widespread petechial rash. What is the SINGLE most appropriate empirical antibiotic to be started immediately?

A 49 year old man with known HIV presents with a history of cough and shortness of breath. His CD4 count is measured at 350mm2. A chest X-ray was performed and shows lobar consolidation. He has a temperature of 38.1°C, a respiratory rate of 30 breaths/minute and a heart rate of 90 beats/minute. What is the SINGLE most likely causative organism?

A 25 year old woman presents with a painful shallow ulcer on the vulva. It started off as a superficial ulceration a few weeks ago. It is associated with painful inguinal lymphadenopathy. She is sexually active. What investigation is likely to identify the cause of the ulcer?

A 62 year old IV drug abuser is brought into the Emergency Department with complaints of fever, shivering, malaise, shortness of breath and a productive cough. Around 8 days ago he developed symptoms consistent with a flu-like illness. Initially there was an improvement in his condition but deteriorated over the past three days. He now has a temperature of 39°C, a pulse of 110 beats/minute, a blood pressure of 100/70 mmHg and a respiratory rate of 22 breaths/minute. A chest X-ray shows bilateral cavitations. What is the SINGLE most likely causative organism?

A 12 month old child who is HIV positive is due for his measles, mumps, and rubella (MMR) vaccine. His CD4 count is more than 800 cells/mL. What is the SINGLE most appropriate action?

A 45 year old homeless man attends the Emergency Department with coughing blood. It started a week ago but he did not seek medical attention. He has shortness of breath and has a chronic cough for the past 18 months. He has lost 20 kg over the past year. He has a temperature of 38.5°C, a heart rate of 101 beats/minute and a respiratory rate of 22 breaths/minute. A chest X-ray was performed which shows miliary deposits which are uniformly distributed on both lungs. What is the SINGLE most appropriate place to admit the patient?

A 33 year old male patient presents with a white patches in the mouth that can be wiped off and is easily removed leaving behind a red base which is painless. He has cracks at the corners of his mouth. What is the SINGLE most likely diagnosis?

A 33 year old man presents with an erythematous patch on his thigh, which has been enlarging in the last few days. He went for a camping trip in a forest a week ago. He has no allergies to any known medication. He is otherwise asymptomatic. What is the SINGLE most appropriate management?

A 36 year old homosexual man has multiple purple nodular lesions on his face and upper trunk measuring 1-2 cm across. It is not painful or itchy. What is the SINGLE most likely diagnosis?

A 35 year old lady has presented with a history of fever, headache, nausea, muscle and bone pains for 3 days. She arrived from Bangkok, Thailand 7 days back. She flew to Bangkok for a business trip and stayed there for 3 days. She did not take any prophylaxis for malaria. On examination, she has a fever of 38.5°C, heart rate is 115 beats/minute, blood pressure is 120/70 mmHg and respiratory rate is 22 breaths/minute. Throat examination revealed mild pharyngeal erythema. General physical examination revealed a widespread maculopapular rash. Her blood results show:

Haemoglobin 125 g/L (130-180)

White cell count 9 x 109/L (4-11)

Neutrophils 5.1 x 109/L (2-7.5)

Platelets 120 x 109/L (150-400)

Sodium 136 mmol/L (135-145)

Potassium 3.8 mmol/L (3.5-5)

Urea 5 mmol/L (2.0-7)

Creatinine 90 μmol/L (70-150)

eGFR >90 mL/min

Serum alkaline phosphatase (ALP) 190 U/L (30-150) Serum alanine transferase (ALT) 220 U/L (5-35)

What is the SINGLE most likely diagnosis?

A 29 year old lady with a history of intravenous drug use was investigated for symptoms of malaise and loss of appetite. Blood tests showed:

HBsAg negative

Anti-HBc positive

anti-HBs negative

HCV antibody reactive

HCV RNA detected

In addition to this, liver biopsy produced a histopathological sample that demonstrated moderate necrosis and inflammation with definite steatosis. What is the SINGLE most likely cause for these findings?

A 46 year old homeless man is seen in Accident & Emergency (A&E). He has a longstanding history of a productive cough as well as fevers and night seats. He als gives a history of weight loss over the past six months. His vital signs are as follow:

Temperature 36.8°C

Blood pressure 121/79 mmg

A heart rate of 68 beats per minute

Respiratory rate of 14th

He was referred to the medical team, who investigated further. An acid-fill bacilli test was done and found to be positive. What is the SINGLE most appropriate management of this patient?

A 15 year old boy had a patchy rash over his body following antibiotic treatment for sore throat. On examination, he has cervical lymph node enlargement and mild splenomegaly which is tender on palpation. What is the SINGLE most likely antibiotic that would have caused the rash?

A 14 year old boy has pain and swelling at the angles of the jaw bilaterally. He has a temperature of 38.4°C. He has been complaining of dry mouth and sore ears and he finds it difficult to talk. On examination, his scrotum is also swollen and oedematous and the testes are impalpable. What is the SINGLE most likely diagnosis?

A 23 year old man has been using intravenous drugs. You explain to him the dangers of this, including the risk of contracting a blood barne virus such as Hepatitis B. Which of the following laboratory tests will first become abnormal after acquiring acute hepatitis B infection?

A 33 year old African woman presents with episodes of fever with rigors and chills for the past year. Blood film shows ring form plasmodium with schuffner’s dots in red blood cells. He has started chloroquine. What is the SINGLE most appropriate drug to eradicate this infection?

A 35 week pregnant woman presents to the Antenatal Day Unit with productive cough and rigors. This is her first pregnancy and there have been no issues to date. She returned from Uganda two weeks ago from a family visit. She is suspected to have respiratory tuberculosis. What is the SINGLE most likely medication that should NOT be used in pregnancy?

A 5 year old boy has a sudden onset of fever and bilateral swelling at the angles of the jaw. He has ear pain when he chews. The GP saw him yesterday for bilateral parotid pain and prescribed him paracetamol. He currently has a temperature of 38.8°C. What is the SINGLE most appropriate next step?

A 62 year old man presents with tongue irritation, pain in his throat and a constant white coating of his tongue. He has a medical history of type II diabetes and COPD and is on metformin 500mg twice a day and an inhaled corticosteroid twice a day. On examination, he has creamy, loosely adherent plaques with a fur-like appearance. The lesions extend to the back of the tongue, the soft palate and buccal mucosa. There is no tonsillar enlargement. What is the SINGLE most appropriate management?

A 52 year old woman presents with the complaint of bloody diarrhoea. She has recently made a trip to Thailand and was travelling through the rainforest and eating the local cuisine. She returned back to the UK a week ago. Her symptoms are also accompanied by generalised abdominal pain and high fever. Her medical history includes taking methotrexate for her rheumatoid arthritis. A stool culture is done and demonstrates the presence of F gram-negative bacilli. From the list below, what is the most appropriate drug to give this patient?

A 24 year old man presents with a deep penetrating wound on his foot after having stepped on a nail in a field. The wound is deep. He does not remember if he had tetanus vaccines when he he was a child. What is the SINGLE most appropriate management to be given?

A 16 year old girl has a sore throat. She feels tired and weak. Oropharyngeal examination shows tonsillar enlargement which is exudative. Her GP prescribed her amoxicillin after which she developed a pruritic rash. What is the SINGLE most likely diagnosis?

A 73 year old woman living in a nursing home, presents with rashes on her finger webs and also at her axillary folds. She complains of itching which is more severe at night. What is the SINGLE most appropriate management?

A 25 year old man was admitted to the hospital with a fever of 38.8 °C and rigours. He complains of a 2 week history of general malaise, mild headaches, arthralgia and myalgia. He especially complained of bilateral calf pain. His past history is significant for a trip to the Caribbean from which he returned five days ago. He describes the trip to the Caribbean with his friends as being amazing and describes a host of activities such as swimming, hiking and fishing. Upon further questioning, he also revealed that he noticed a red discolouration of his eyes before they turned to yellow. The patient also mentions seeing “spots” on his skin. On physical examination, the patient appears to be jaundiced. Abdominal examination revealed generalised abdominal tenderness.

His vitals are as follows:

Blood pressure 98/56 mmHg

Heart rate of 122 beats per minute Respiratory rate of 18 breaths per minute

Oxygen saturation on room air 98%

Blood tests were done and the laboratory results are as follows:

Alanine transferase (ALT) 89 U/L (5-35 U/L)

Aspartate transaminase (AST) 60 U/L (5-35 U/L)

Alkaline phosphatase (ALP) 162 U/L (30-150 U/L)

Gamma glutamyl transferase (GT) 33 U/L (8-60 U/L)

White blood cells 15 x 10^9/L (4-11 x 10^9/L)

Platelets 180 x 10^9/L (150-400 x 10^9/L)

What is the SINGLE most appropriate investigation in this scenario to confirm the diagnosis?

A 26 year old man had presented to his GP 7 days ago with a history of yellowing of his eyes and skin along with fatigue and loss of appetite. The patient is an IV drug user. On examination, the patient is running a temperature of 38.1°C. His heart rate is 92 beats/minute, blood pressure is 120/70 mmHg and respiratory rate is 17 breaths/minute. Liver function tests were performed which show the following:

Bilirubin 49 μmol/L (3-17)

Alanine transferase (ALT) 118 U/L (5-35)

Aspartate transaminase (AST) 89 U/L (5-35)

Alkaline phosphatase (ALP) 148 U/L (30-150)

Gamma glutamyl transferase (Gt) 42 U/L (8-60)

What is the next most appropriate investigation to perform?

A 29 year old woman who is working in the kitchen of a local restaurant presents to the hospital. She gives a history of episodes of diarrhoea and vomiting over the past 72 hours. She can still take oral fluids. A stool sample was collected and sent for MCS testing. She is apyrexial and fully alert. A decision is made to discharge her with adequate advice on rehydration. She wants to know when she can return to work. What is the SINGLE most appropriate advice?

A 3 year old child was treated for bacterial meningitis and has recovered from it. She is now afebrile. What is the SINGLE most appropriate investigation to perform?

A 55 year old immunocompromised patient presents with dysphagia and pain on swallowing. He has a redness, fissuring and soreness at the angle of his mouth. What is the SINGLE most likely causative organism?

A 16 year old girl has had an enlarging mass in the right side of her neck for the past 2 weeks with a sore throat. She feels tired and weak. She has several smaller associated lymph nodes that are palpable at her axilla. Oropharyngeal examination shows tonsillar enlargement which is exudative. What is the SINGLE most likely diagnosis?

A 33 year old lady was at high-risk for Hepatitis-B and was started on vaccination. After 2 injections, she was found to be pregnant. What is the most likely serological result during antenatal screening to suggest vaccine immunization?

A 4 year old child is brought by his parents with a clean wound on his leg. He has never been immunised as his parents were worried about the side effects of the immunisations in the past. There are no contraindications to immunisation and the parents of the child are now open to the idea. The child’s parents would like advice on the best method to reduce risk of infections. What is the SINGLE most appropriate action?

A 34 year old woman who is 10 weeks of gestation attends the GP surgery. She recently had a history of fever, muscle aches and a swollen lymph node. She has a history of cytomegalovirus (CMV) infection a year ago. A blood test was done to check antibodies. Which antibodies will show a previous infection a year ago?

A 44 year old HIV positive man complains of a two week history of worsening headache, facial weakness and visual hallucinations. He also reports new onset of eye pain. He does not take his anti-viral therapy.

Investigations:

CD4 count 40 cells/mm3

An MRI head reveals multiple ring shaped contrast enhancing lesions.

What is the SINGLE most likely causative organism?

A 43 year old woman had a total abdominal hysterectomy for large fibroids. She continued as an inpatient as she was having abdominal pain post-surgery. During her post-operative stay, she was given co-amoxiclav intravenously initially which was converted to oral co-amoxiclav. She was discharged on the 5th postoperative day. On the 7th postoperative day, she develops a fever, abdominal pain and severe diarrhoea. Her stools are watery with no blood. There are two other patients in the same ward who have developed similar symptoms. What is the SINGLE most likely diagnosis?

A 40 year old man was rushed to the Emergency Department after collapsing at home. His wife reports that he had been complaining of a severe headache and stiff neck for the past 12 hours, which persisted despite taking paracetamol and he was becoming increasingly irritable. Additionally, he had been feeling unwell for the past three days with a sore throat and fever. On assessment, his blood pressure is 100/70 mmHg, heart rate is 110 beats/minute, and body temperature is 38.6°C. His GCS is 11, and on exposure, no rash was found. He was started on oxygen and intravenous fluids. Which of the following is the next appropriate step in the management of this patient?

A 55 year old man has auricular pain and tinnitus on his left ear for the past 2 weeks. It started off with pain in the ear followed by decreased hearing and ringing in the left ear. On inspection, a painful vesicular rash around the auditory canal is noted. He also has notable decrease in the hearing of the left ear. What is the SINGLE most likely diagnosis?

A 65 year old presents to the Emergency Department with a history of productive cough for the past 10 days. He feels unwell with malaise and shortness of breath. He visited his GP 2 weeks ago for aching muscles, chills, sweats, fatigue and a persistent dry cough. He was thought to have influenza then. His temperature is 38°C, heart rate is 100 beats/minute and respiratory rate is 24 breaths/minute. His blood pressure is 110/70 mmHg. A chest X-ray performed in the hospital shows bilateral cavitations. What is the SINGLE most likely causative organism?

A 14 year old girl presents to the Emergency department. Her mother reports that she developed a headache, fever and neck stiffness over the past 2 days. She also complains that the room lighting is far too bright and shields her eyes in the crook of her elbow. On examination, her blood pressure is 120/80 mmHg, heart rate is 95 beats/minute, and body temperature is 38.5°C. She does not have a rash and ophthalmoscopy reveals a normal fundus. Passive extension of the knee with the hip in flexion resulted in discomfort and resistance. A lumbar puncture subsequently performed indicates a high opening pressure of 28 cm. The CSF sample collected appears purulent. Which of the following is the SINGLE most likely cause of this patient’s condition?

A 13 year old girl complains of a 3 day history of hoarseness of voice associated with dry cough. She presents with a fever and malaise. On direct laryngoscopy, her vocal cords are seen to be grossly oedematous. What is the SINGLE next most appropriate investigation?

A 36 year old Jewish man presents with multiple purple papular lesions on his face and upper trunk measuring 1-2 cm across. It has been slowly growing over the last couple of years. It is not painful or itchy. What is the SINGLE most likely diagnosis?

A 70 year old man presents to the Emergency Department with fatigue, fever and a productive cough. He is currently on his 4th course of chemotherapy for small cell carcinoma of his lungs of which finished 8 days ago. On auscultation, there are coarse crepitations on his right lung base. He has a temperature of 38.6°C, respiratory rate of 17 breaths/minute, pulse of 85 beats/minute and a blood pressure of 120/80 mmHg. His blood results come back showing the following:

Haemoglobin 122 g/L

White cell count 1.1 x 10^9/L

Platelets 90 x 10^9/L

What is the SINGLE most appropriate action?

A 32 year old breast feeding mother has a painful, swollen, hard lump in her right breast which developed 2 weeks after having a normal vaginal delivery. She has a temperature of 38.1°C. A breast abscess is suspected. What is the SINGLE most likely organism?

A 30 year old man is seen in the Emergency Department with vomiting, muscle pain, petechial rash at his axilla and sensitivity to light. He has a temperature of 38.9°C. His blood pressure is 80/55 mmHg. He has a heart rate of 120 beats/minute. Which is the SINGLE most appropriate empirical antibiotic to be started immediately?

A 22 year old woman attends the GP clinic with complaints of a yellowish tinge on her skin. She had a recently sore throat and fever which started 12 days ago. She complains of severe lethargy over the past week. On examination, she has hepatosplenomegaly. She has cervical lymphadenopathy that extends to both the anterior chain and posterior triangle nodes. What is the SINGLE most appropriate investigation?

A 32 year old man has recently been to Thailand and returned with a sore throat, cervical lymphadenopathy, malaise and a mild fever. He developed these symptoms 8 weeks after returning to the UK. On examination of the throat, there is whitish exudate covering the tonsils. What is the SINGLE most likely infectious agent causing his symptoms?

A 5 year old child started having a fever two days ago associated with neck stiffness, chills, impaired consciousness and vomiting. He has a history of travel with his parents to Ghana and returned 6 weeks ago. Before he left to Ghana, he was started on malaria prophylaxis. A full blood count shows that the young child is anaemic. What is the SINGLE most likely diagnosis?

A 3 year old boy presents with a two day history of being unwell. He has a two hour old rash made up of urticarial and purpuric spots. His level of consciousness is decreased. He has a blood pressure of 80/50 mmHg, a respiratory rate of 30 breaths/minute, oxygen saturation of 94% on room air, a temperature of 39°C and a capillary refill time of 3 seconds. A urine dipstick was found to be unremarkable. What is the SINGLE investigation most likely to lead to a diagnosis?

A 48 year old man and his son are both seen in the hospital for severe episodes of bloody diarrhoea, abdominal pain, myalgia and fever. Their symptoms started 3 days after consumption of undercooked chicken during a family barbecue. Stool samples sent to microbiology confirmed the growth of gram-negative curved bacilli under temperature conditions between 37 to 42°C. What is the SINGLE most likely organism causing their symptoms?

A 40 year old man who recently travelled to Sudan 5 weeks ago presents with dark urine, rigours and a fever. On examination, a tender hepatomegaly was noted and his skin has a yellowish tinge. What is the SINGLE most likely diagnosis?

A 34 year old woman presents with the complaint of bloody diarrhoea. She is an entomologist and had been travelling for two weeks through the rainforests of Thailand when she began to experience watery diarrhoea accompanied by a fever. This progressed to bloody diarrhoea a few days later. Her symptoms are also accompanied by generalised abdominal pain and high fever. A stool culture is done and demonstrates the presence of gram-negative curved bacilli. Campylobacter jejuni is suspected based on microbiology from the outbreak of diarrhoea where she travelled to. From the list below, what is the SINGLE most appropriate drug to give this patient?

A 33 year old lady who works at a nursing home presents with itching. On examination, linear tracks on the wrist are seen. She says that 7 days ago she had come in contact with a nursing home resident with similar symptoms. What is the SINGLE most likely mechanism of itching?

A 23 year old homeless smoker has an ongoing productive cough. She takes recreational drugs and looks malnourished. She has lost 15 kg in the past year. There are several nontender swellings on both sides of her neck. On examination, she has crackles in her right upper lobe but is otherwise well and stable. A chest X-ray reveals upper labe infiltrates with cavitation on the right lung. What is the SINGLE most likely diagnosis?

A 29 year old woman has developed a yellowing of her skin and the white sclera of his eyes with flu-like symptoms over the past few days. She feels lethargic. She has a decreased appetite. Abdominal examination demonstrated mild tenderness in the right upper quadrant.

Investigations:

Bilirubin 51 μmol/L (3-17)

Serum alanine transferase (ALT) 499 U/L (5-35)

Serum alkaline phosphatase (ALP) 180 U/L (30-150)

Gamma glutamyl transferase (GT) 55 U/L (8-60)

What is the most appropriate next step?