A young lady presents with a 3-month Hx of palpitations, dizziness, and intense fear during work meetings. She feels scrutinized and fears harsh judgment from colleagues. Last week, she feigned illness to avoid a presentation, fearing criticism. These symptoms are exclusively tied to social or performance situations at work and do not occur when she is alone or in public spaces like a supermarket. What is the most likely diagnosis?

• Panic disorder

• Agoraphobia

• Social anxiety disorder (Social phobia)

• Generalized anxiety disorder

• Specific phobia, situational type

Answer explanation

The patient's symptoms are classic for Social Anxiety Disorder. The core feature is a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. Her fear of being judged in meetings and avoidance of a presentation are pathognomonic.

A 72 Y/O M presents for a routine annual check-up. He feels well and denies fever, weight loss, or night sweats. Hx is notable for HTN. O/E reveals palpable cervical and axillary lymph nodes, each ~1.5 cm, non-tender, and mobile. Spleen tip is palpable 2 cm below the left costal margin. Ix labs show: WBC 35,000/µL (normal 4,000-11,000) with 85% lymphocytes, Hb 12.8 g/dL, and Platelets 160,000/µL. Peripheral smear is ordered. Which of the following findings on the peripheral blood smear is most characteristic of this patient's most likely diagnosis?

• Auer rods

• Smudge cells

• Rouleaux formation

• Tear drop cells

• Hypersegmented neutrophils

Answer explanation

The vignette describes a classic presentation of Chronic Lymphocytic Leukemia (CLL)—an elderly, asymptomatic male with lymphadenopathy, splenomegaly, and marked lymphocytosis. Smudge cells (or basket cells) are fragile, abnormal lymphocytes that are crushed during the preparation of a peripheral blood smear. Their presence is highly characteristic of CLL.

An 82-year-old male with a history of chronic constipation presents with a 2-day history of crampy abdominal pain, vomiting, and obstipation. On physical examination, his abdomen is distended and tympanitic. Auscultation reveals high-pitched bowel sounds. There is no guarding or rebound tenderness, and his vital signs are stable. What is the most appropriate next investigation to confirm the diagnosis and identify the underlying cause?

• Abdominal X-ray (supine and erect views)

• CT scan of the abdomen and pelvis with contrast

• Urgent colonoscopy

• Barium enema

• Abdominal ultrasound

Answer explanation

The clinical picture strongly suggests a mechanical bowel obstruction. A CT scan with contrast is the gold-standard imaging modality in this setting. It is highly sensitive and specific for confirming the diagnosis, pinpointing the location and severity (the "transition point"), and, most importantly, identifying the etiology (e.g., malignancy, volvulus, adhesions). It can also detect urgent complications such as bowel ischemia or perforation, which are crucial for surgical planning.

A man undergoes a difficult laparoscopic cholecystectomy where a partial transection of the CBD is identified. The injury is repaired intraoperatively over a T-tube. Post-op, the patient is stable. The T-tube is scheduled for removal in 3 weeks. Prior to removal, the surgical team wants to confirm the integrity of the repair and patency of the biliary tract. Which of the following is the most appropriate investigation to perform before removing the T-tube?

• Magnetic Resonance Cholangiopancreatography (MRCP)

• T-tube Cholangiogram

• Liver Function Tests (LFTs)

• Endoscopic Retrograde Cholangiopancreatography (ERCP)

• Abdominal CT with IV contrast

Answer explanation

A T-tube cholangiogram is the gold-standard investigation in this scenario. It involves injecting contrast directly through the existing T-tube to radiographically visualize the entire biliary tree. It directly assesses the repair site for any leaks and confirms unobstructed flow of contrast into the duodenum, providing the necessary information to decide if the T-tube can be safely removed.

A healthy 34 Y/O G3P2 at 28 weeks gestation, with a BMI of 32 kg/m ², undergoes a 3-hour 100g OGTT after an abnormal 50g GCT. Her results are as follows: Fasting: 5.8 mmol/L 1-hour: 10.9 mmol/L 2-hour: 9.1 mmol/L 3-hour: 7.5 mmol/L Based on these results, what is the most likely diagnosis?

• Normal pregnancy

• Gestational diabetes mellitus (GDM)

• Impaired fasting glucose

• Pre-existing Type 2 diabetes mellitus

• Impaired glucose tolerance

Answer explanation

The diagnosis of GDM using the 100g OGTT is made when at least two of the four values are met or exceeded. The commonly used Carpenter and Coustan criteria are: Fasting ≥5.3, 1-hour ≥10.0, 2-hour ≥8.6, and 3-hour ≥7.8 mmol/L. This patient's values are elevated at three time points (Fasting, 1-hour, and 2-hour), confirming the diagnosis of GDM.

An adult pt with a newly diagnosed 5 cm rectal villous adenoma is admitted with severe secretory diarrhea. Despite 24h of aggressive IV fluid and potassium repletion, the stool output remains >4L/day, hampering preoperative stabilization. Vitals are stable, but serum K+ remains difficult to correct. Which adjunctive medication is most appropriate to help control this pt's refractory diarrhea?

• Loperamide

• Cholestyramine

• Indomethacin

• Ondansetron

• Furosemide

Answer explanation

The massive fluid and electrolyte secretion from villous adenomas is mediated by prostaglandins, particularly PGE2. Indomethacin, a non-steroidal anti-inflammatory drug (NSAID), effectively inhibits prostaglandin synthesis, thereby reducing the secretory diarrhea. It is a recognized adjunctive therapy to stabilize patients with severe, refractory symptoms before definitive surgical or endoscopic resection.

An adult M with a prosthetic aortic valve is being treated for infective endocarditis. He develops acute-onset, severe left hypochondriac pain that worsens with inspiration. O/E: Marked tenderness in the left upper quadrant. Which is the best imaging modality to investigate this specific complication?

• Abdominal X-ray

• Abdominal ultrasound

• CT abdomen with contrast

• MRI of the spleen

• Repeat TTE

Answer explanation

The clinical presentation is classic for a septic embolus to the spleen, causing a splenic infarct or abscess—a known and serious complication of left-sided infective endocarditis. A contrast-enhanced CT of the abdomen is the gold standard investigation to visualize the splenic parenchyma and identify wedge-shaped, non-enhancing areas (infarcts) or fluid collections (abscesses).

A 6 Y/O F is brought in for early physical development. O/E: Tanner stage 3 breast development and Tanner stage 2 pubic hair are present. Ix: Basal LH and FSH levels are in the pubertal range, with a correspondingly high estradiol. Bone age is advanced by 2 years. These findings are most consistent with which diagnosis?

• McCune-Albright Syndrome

• Premature Thelarche

• Gonadotropin-Dependent Precocious Puberty

• Non-classic Congenital Adrenal Hyperplasia

• Premature Adrenarche

Answer explanation

The combination of thelarche (breast development) and pubarche (pubic hair) with elevated gonadotropins (LH, FSH) and estradiol indicates premature activation of the entire hypothalamic-pituitary-gonadal (HPG) axis. This is the definition of gonadotropin-dependent, or central, precocious puberty (CPP). "Constitutional" is the idiopathic subtype of CPP.

A patient with HIV on a stable ART regimen presents with new-onset petechiae and mucosal bleeding. Ix: Isolated severe thrombocytopenia with a platelet count of 12 x 10⁹/L. Hemoglobin and WBC count are normal. A peripheral smear shows decreased platelets with some large forms. In addition to continuing ART, what is the most appropriate initial intervention for this specific hematological complication?

• Splenectomy

• Platelet transfusion

• High-dose corticosteroids

• Eltrombopag

• Immediate change of ART regimen

Answer explanation

This patient's presentation is classic for HIV-associated Immune Thrombocytopenic Purpura (ITP). The pathophysiology is immune-mediated platelet destruction, similar to primary ITP. The first-line treatment for severe, symptomatic ITP (both HIV-related and primary) is immunosuppression with high-dose corticosteroids (e.g., prednisone or dexamethasone) to reduce the autoantibody production and destruction of platelets.

A patient with hypertension and diabetes mellitus is started on Lisinopril. Routine labs are checked 2 weeks later. Which electrolyte abnormality is a well-known side effect of this medication?

• Hypokalemia

• Hyponatremia

• Hyperkalemia

• Hypercalcemia

• Hypomagnesemia

Answer explanation

Lisinopril is an ACE inhibitor. This class of drugs blocks the production of angiotensin II, which in turn reduces aldosterone secretion. Since aldosterone normally promotes potassium excretion in the kidneys, inhibiting its effect leads to potassium retention and hyperkalemia.