medisense

• A 54 year old male patient has a history of cough productive of green sputum with shortness of breath and left pleuritic chest pain. His temperature is 38.4 C, respiratory rate 22 bpm, pulse 110bpm, WBC 12.4 x 109 /L and his CXR shows consolidation at the left base. What is the most likely causative organism for this presentation?

  This is a typical presentation of a community acquired pneumonia. The most common causative organism for community acquired pneumonias in the UK is Streptococcus pneumoniae.
• presented with a one week history of progressively worsening dyspnoea breath and a dry cough. On examination, he is cachectic, and he explains that he has been unintentionally losing weight for the past 6 months or so. He states he takes medicine to ‘help his AIDS’, but hasn’t taken any in a while. Blood tests show WCC 8.2 x 109 /L and on chest X ray there is patchy shadowing in both lung fields.

  This gentleman has a history of immunocompromise and poorly controlled HIV infection. When CD4 count reaches below 200, the pathognomonic opportunistic infection is pneumocystis jiroveci.
• A 30 year old hepatitis C positive IV drug user presents with a three week history of fever, sweats and some shortness of breath. His temperature is 37.6 °C, respiratory rate 30 bpm, pulse 110bpm, WCC 14 x 109/L. He has an erythematous and painful rash on his inner thigh, which is the likely origin of his sepsis. What is the most likely causative organism associated with this?

  This is the classical presentation of sepsis with a cellulitic source. The pathogen most commonly associated with cellulitis is staphylococcus aureus. 
• A 27 year old lady presents to AMU with a three day history of shortness of breath and malaise. She is experiencing haemoptysis and temperature symptoms. Her bloods show WCC 15.0 and CRP is 125. She is otherwise fit and well. She and her partner recently moved home to a building where she states the water piping ‘wasn’t quite ready yet’.

  L. pneumophila is found in natural water supplies and soil. It is also found in many recirculating and water supply systems. It causes haemoptysis and pleuritic chest pain. This patient likely contracted the system from her water piping.
• A 54 year old gentleman presents to ID clinic for follow up of his TB treatment. He has found it difficult to see objects in the distance, in addition to worries that he has become colour blind. Which of his medications is most likely to be causing this defect?

  Side-effects of ethambutol include loss of acuity, colour blindness, and restriction of visual fields. Patients should be advised to discontinue therapy immediately if they develop deterioration in vision - almost always followed by recovery of eyesight. Visual acuity should be tested by Snellen chart before treatment with ethambutol.
• Three weeks after a meal at a fast food cafe, a 21-year-old man develops malaise, fatigue, and loss of appetite. He notes passing dark urine. On examination, he has scleral icterus and right upper quadrant tenderness. Lab studies show serum AST of 62 U/L and ALT of 58 U/L. The total bilirubin concentration is 3.9 mg/dL, and the direct bilirubin concentration is 2.8 mg/dL. His symptoms abate over the next 3 weeks. On returning, he finds that it has been closed by the city's health department. Which serologic test result is most likely to be positive ?

  IgM anti-HDV
• A 38 year old man presents with fatigue and general malaise five days after returning from a working placement in Guinea. His fever is relapsing and remitting and is happening every day in an irregular pattern. On admission to AMU he develops a fit and is profoundly hypoglycaemic. Which of the following is the most likely causative organism?

  This is a presentation of severe malaria associated with end organ dysfunction. This, in conjunction with the irregular, daily pattern of fever is consistent with plasmodium falciparum infection.
• A 44 year old man has recently moved from Egypt, presents with bloody diarrhoea, RUQP, haematuria, and . He is treated with supportive management and antibiotics, however he fails to return for follow-up. Ten years later, the gentleman re-presents, with haematuria. Cystoscopy identifies SCC of the bladder. What is the most likely contributing organism?


  Abdominal pain, haematuria and bloody diarrhea are all symptoms of schistosomiasis. This is a protozoa which finds its host in the pancreas of freshwater snails. Chronic infection of S. haematobium leads to an increased risk of bladder cancer.
• A 19 year old man is brought into A&E after he has been vomiting, complaining of neck stiffness and not liking the lights being on. You see he has had a lumbar puncture done and the results have just returned and are as follows: • Appearance: clear • Opening pressure: elevatedWCC: >100 cells/µL (>90% PMN) • Glucose: low • Protein level: elevated (>50 mg/dL) Diagnosis?


  Bacterial meningitis has a clear or cloudy CSF with normal or elevated opening pressure. The high white cell count with mostly polymorphic neutrophils, low glucose and high protein are indicative of bacterial meningitis.
• A 68 year old woman is brought into hospital after becoming severely out of breath at home. Observations include a RR of 28 breathes per minute, BP of 85/53mmHg, HR of 103 beats per minute and O2 saturation of 87% on air. Blood urea is 6mmol/L and AMTS is 7/10 with no previous confusion. What is the CURB65 score for this patient?

  3. Her age is higher than 65. RR is below 30 breathes per minutes so no a point for that. Systolic BP below 90mmHg and diastolic BP below 60mmHg. Blood urea is below 7mmol/L so no point for that but she has new onset confusion.
• A 22 year old woman who lives in the barracks where she is a soldier has come into see the Doctor after feeling run down. She complains of a headache, vomiting and malaise for the last week and is just beginning to develop a dry cough. Examination reveals a low grade fever and 'target lesions' developing on her body.

  Living in small quarters makes the spread of mycoplasma pneumoniae very easy. She also has extra pulmonary symptoms of malaise and vomiting leading into a dry cough. Erythema multiforme is caused mainly HSV but one of the next major infective causes is mycoplasma pneumoniae.
• Streptococcus pneumoniae causes a much more typical clinical picture of pneumonia with a wet cough producing rusty sputum. Mycobacterium tuberculosis can cause cough and fatigue but would also be more likely to have weight loss and night sweats. Erythema multiforme is also not seen with mycobacterium tuberculosis. Whilst haemophilus influenzae can cause pneumonia it is more common in children rather than adults. Legionella pneumophilia can cause a dry cough which later becomes productive with some extra pulmonary symptoms but is more common with a high fever and without any skin changes.
• Benzathine penicillin 2.4 mega units IM is the first line treatment for syphilis and azithromycin 2g is used as second-line. Ceftriaxone and azithromycin 1g is used as a combination for gonorrhoea and doxycycline is used for chlamydia.