Acute dacryocystitis presents as inflammation of the lacrimal sac and is typically caused by infection. Symptoms of acute dacryocystitis can be pain, redness of the eye and swelling of the nasal aspect of the eye. The eye is usually watery and discharge can be expressed through the lacrimal punctum which is generally mucoid but can also be purulent. Patient can also present with fever.

Salbutamol stimulates beta-2 adrenergic receptors, which are the predominant receptors in bronchial smooth muscle (beta-2 receptors are also present in the heart in a concentration between 10% and 50%).

Stimulation of beta-2 receptors leads to the activation of enzyme adenyl cyclase that forms cyclic AMP (adenosine-mono-phosphate) from ATP (adenosine-tri-phosphate). This increase of cyclic AMP relaxes bronchial smooth muscle and decrease airway resistance by lowering intracellular ionic calcium concentrations. Salbutamol relaxes the smooth muscles of airways, from trachea to terminal bronchioles.

Increased cyclic AMP concentrations also inhibits the release of bronchoconstrictor mediators such as histamine and leukotriene from the mast cells in the airway.

Basal cell carcinoma is usually located on sun exposed sites. It has got many variants and clinically it presents as a slow growing mass/nodule with rolled margins and an ulcerated base.

Right ventricular volume overload is indicated by a parasternal heave and right axis deviation. Oxygen saturation in right atrium is higher than oxygen saturation of the inferior and superior vena cavae. So the most probable diagnosis is atrial septal defect.

Supraspinatus tendinopathy is a common and disabling condition that becomes more prevalent after middle age and is a common cause of pain in the shoulder. A predisposing factor is resistive overuse. This patient has the classic painful arc that is a sign of shoulder impingement characteristic of supraspinatus tendonitis.

Klinefelter syndrome (KS), the most common human sex chromosome disorder 47,XXY. It is characterized by hypogonadism (micro-orchidism, oligospermia/azoospermia) and gynecomastia in late puberty. If Klinefelter syndrome is not diagnosed prenatally, a patient with 47,XXY karyotype may demonstrate various subtle, age-related clinical signs that would prompt diagnostic testing. These include the following:
Infants: Hypospadias, small phallus, cryptorchidism.
Toddlers: Developmental delay (especially expressive language skills), hypotonia.
Older boys and adolescent males: Tall stature; delayed or incomplete pubertal development with eunuchoid body habitus; gynecomastia; small, firm testes; sparse body hair.

From childhood with progression to early puberty, the pituitary-gonadal function observed is within normal limits for 47,XXY males.
At mid puberty and later, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) concentrations rise to hyper-gonadotropic levels, inhibin B levels fall until they are undetectable, and testosterone levels are at low or low-normal levels after an initial increase.

Fragile X syndrome, also termed Martin-Bell syndrome or marker X syndrome, is the most common cause of inherited mental retardation, intellectual disability, and autism.
However, the patient here does not have any mental disabilities as he already works as a clerk, and that too would make Down’s Syndrome less likely.

Classic Kallmann syndrome (KS) and idiopathic hypogonadotropic hypogonadism (IHH) are rare genetic conditions that encompass the spectrum of isolated hypogonadotropic hypogonadism. Most patients have gonadotropin-releasing hormone (GnRH) deficiency, as suggested by their response to pulsatile GnRH therapy. Hypothalamic-pituitary function is otherwise normal in most patients, and hypothalamic-pituitary imaging reveals no space-occupying lesions. By definition, either anosmia or severe hyposmia is present in patients with Kallmann syndrome, in contrast to patients with idiopathic hypogonadotropic hypogonadism, whose sense of smell is normal.

Carcinoembryonic antigen (CEA) is a known tumour marker for colorectal cancer. It is not used diagnostically, but in patients with a known diagnosis of colorectal cancer associated with raised CEA levels, it can be used to monitor disease activity and help with the early identification of disease recurrence.

Tumour markers can be divided into:
1. Monoclonal antibodies
CA 125: Ovarian cancer, primary peritoneal cancer
CA 19-9: Pancreatic cancer
CA 15-3: Breast cancer

2. Tumour specific antigens
Prostate specific antigen (PSA): Prostatic carcinoma
Alpha-feto protein (AFP): Hepatocellular carcinoma, teratoma
Carcinoembryonic antigen (CEA): Colorectal cancer
S-100: Melanoma, schwannomas
Bombesin: Small cell lung carcinoma, gastric cancer

3. Enzymes
Alkaline phosphatase (ALP)
Neuron specific enolase (NSE)

4. Hormones
Calcitonin
Antidiuretic hormone (ADH)
Human chorionic gonadotropin (hCG)

The most probable diagnosis is Marfan’s syndrome because of a family history of cardiac death and heart murmurs. A characteristic feature is pain which radiates to the back. A wide pulse pressure and a diastolic heart murmur is suggestive of aortic dissection.

Nausea and vomiting are the common side effects of chemotherapy. Risk factors for the development of these symptoms include age<50 years, anxiety, concurrent use of opioids, and the type of chemotherapy administered. For patients at low risk of these symptoms, drugs such as metoclopramide may be used. For high-risk patients, however, 5-HT3 receptor antagonists such as ondansetron are often effective, especially if combined with dexamethasone.

Melanocytic naevi are skin tumours produced by melanocytes. They usually present in childhood but increase during puberty. The mnemonic A-B-C-D, is used by institutions to assess for suspicion of malignancy. The letters stand for asymmetry, border, colour, and diameter. If a mole starts changing in size, colour, shape or, especially, if the border of a mole develops ragged edges or becomes larger than a pencil eraser, it would be an appropriate time to consult with a physician. Other warning signs include if it begins to crust over, bleed, itch, or become inflamed.

In a patient with abnormal LFTs and UC, think primary sclerosing cholangitis (PSC). MRCP and liver biopsy is the best answer. MRCP will show classically beads on a string – intra and extrahepatic stricturing and dilation. Remember this finding!! Liver biopsy is required for official diagnosis (need tissue!).

The thymus is a lymphoid organ located in the anterior mediastinum. In early life, the thymus is responsible for the development and maturation of cell-mediated immunologic functions. The thymus is composed predominantly of epithelial cells and lymphocytes. Precursor cells migrate to the thymus and differentiate into lymphocytes. Most of these lymphocytes are destroyed, with the remainder of these cells migrating to tissues to become T cells.
DiGeorge’s syndrome (DGS) is a developmental abnormality affecting the thymus. The classic triad of features of DGS on presentation is conotruncal cardiac anomalies, hypoplastic thymus, and hypocalcaemia (resulting from parathyroid hypoplasia).

The most probable diagnosis in the given scenario would be body dysmorphic disorder or dysmorphophobia

It is a mental disorder where patients have a significantly distorted body image.

Diagnostic and Statistical Manual (DSM) IV criteria:
Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

Treatment:
Cognitive-behavioural therapy (CBT) is the most commonly used and most empirically supported intervention to improve body image.
Several drugs have been targets of study in anorexia nervosa treatment, including selective serotonin reuptake inhibitors, antidepressants, antipsychotics, nutritional supplementation, and hormonal medications.

The definition of negative predictive value is the probability that the individuals with truly negative screening test don’t have Chlamydia. The equation is the following: Negative predictive value = Truly negative/(truly negative + false negative) = 172 / (172 + 5) = 172 / 177

Entrapment of the median nerve by pronator teres causes a median nerve neuropathy, which is worse during pronation of the forearm. Examination should involve excluding carpal tunnel syndrome and pronation of the affected forearm against resistance, which brings on the pain. Unlike carpal tunnel syndrome, the median nerve proximal to the wrist may be tender to palpation.

Confusion in the patient refers to neurological symptoms that are more associated with thrombotic thrombocytopenic purpura than with haemolytic uremic syndrome. All the other symptoms present in both conditions similarly.

Smoking cessation is the most effective intervention in stopping the progression of COPD, as well as increasing survival and reducing morbidity. This is why smoking cessation should be the top priority in the treatment of COPD. Long term oxygen therapy (LTOT) may increase survival in hypoxic patients. The rest of the options dilate airways, reduce inflammation and thereby improve symptoms but do not necessarily increase survival.

A t test is a type of statistical test that is used to compare the means of two groups. It is one of the most widely used statistical hypothesis tests in pain studies. There are two types of statistical inferences: parametric and nonparametric methods. Parametric methods refer to a statistical technique in which one defines the probability distribution of probability variables and makes inferences about the parameters of the distribution. In cases in which the probability distribution cannot be defined, nonparametric methods are employed. T tests are a type of parametric method; they can be used when the samples satisfy the conditions of normality, equal variance, and independence. In this case the data is parametric, comparing two independent samples from the same population.

The most probable diagnosis considering hypochloraemia and the mild metabolic alkalosis as well as the history of GERD (requiring a high dose of PPI to control) would be bulimia.

Other options:
Diuretic abuse tends to give a hypochloraemic acidosis.
Gitelman syndrome also fits the diagnosis but, it is very rare compared to bulimia.
Inhaled steroid use and stress would not be responsible for such marked electrolyte derangement.

Other potential signs of bulimia nervosa would be parotid gland swelling and dental enamel erosion induced by regular vomiting.

Severe vitamin C deficiency results in scurvy, a disorder characterized by hemorrhagic manifestations and abnormal osteoid and dentin formation.
Vitamin C plays a role in collagen, carnitine, hormone, and amino acid formation. It is essential for bone and blood vessel health and wound healing and facilitates recovery from burns. Vitamin C is also an antioxidant, supports immune function, and facilitates the absorption of iron (see table Sources, Functions, and Effects of Vitamins).
Dietary sources of vitamin C include citrus fruits, tomatoes, potatoes, broccoli, strawberries, and sweet peppers. (See also Overview of Vitamins.)