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৪৮তম বিশেষ বিসিএস [স্বাস্থ্য] ⎯ মেডিকেল অংশ [Archived]

পরীক্ষা৪৮তম বিশেষ বিসিএস [স্বাস্থ্য] ⎯ মেডিকেল অংশ [Archived]তারিখতারিখ অনির্ধারিতসময়20 minutes
মোট প্রশ্ন৪০
সিলেবাস
Exam - 4 Medicine-04 5. Connective Tissue Disorder Rheumatoid arthritis and reactive arthritis Degenerative joint diseases including cervical spondylosis Gout 6. Medical Psychiatry · Anxiety neurosis · Depression · Dissociative disorder · Somatoform disorder, etc. 7. Nutritional, Metabolic and Environmental diseases: Protein energy malnutrition, Obesity, Diseases due to vitamin deficiency and excess 8. Geriatric Medicine · Common Genetic Disorders · General principles of treating elderly · Health problems of the elderly 9. Water and Electrolytes and Acid-base Homeostasis · Diagnosis and treatment of specific fluid and electrolytic disorders 10. Common Immunologic Disorders 11. Helminthic diseases: · Nematodes · Trematodes 12. Terminal Care 13. Communication Skill
প্রশ্ন দেখুনঅনুশীলন
ঘনত্ব
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উত্তরিতবর্তমানপুনরায় দেখুনঅসম্পূর্ণ

৪৮তম বিশেষ বিসিএস [স্বাস্থ্য] ⎯ মেডিকেল অংশ [Archived]

৪৮তম বিশেষ বিসিএস [স্বাস্থ্য] ⎯ মেডিকেল অংশ [Archived] · তারিখ অনির্ধারিত · ৪০ প্রশ্ন

১.
A 45-year-old woman presents with symmetric joint pain, morning stiffness lasting >1 hour, and fatigue. On examination, she has swelling in the MCP and PIP joints. Which of the following autoantibodies is most likely to be positive in this patient?
  1. ক
    Anti-cyclic citrullinated peptide (anti-CCP)
  2. খ
    Anti-dsDNA
  3. গ
    Anti-Jo-1
  4. ঘ
    Anti-centromere
ব্যাখ্যা
Symmetric small joint (MCP/PIP) involvement and morning stiffness suggest rheumatoid arthritis (RA). Anti-CCP is highly specific for RA (more than rheumatoid factor). Anti-dsDNA is seen in SLE, anti-Jo-1 in polymyositis, and anti-centromere in CREST syndrome.
২.
A 28-year-old man develops acute arthritis, conjunctivitis, and urethritis 2 weeks after a diarrheal illness. Which of the following HLA associations is most likely in this condition?
  1. ক
    HLA-B27
  2. খ
    HLA-DR4
  3. গ
    HLA-B5
  4. ঘ
    HLA-DQ2
ব্যাখ্যা
Reactive arthritis (Reiter’s syndrome) presents with arthritis, conjunctivitis, and urethritis (classic triad) after GI/GU infections (e.g., Chlamydia, Shigella). HLA-B27 is strongly associated. HLA-DR4 is linked to RA, HLA-DQ2 to celiac disease.
৩.
A 60-year-old man presents with neck pain, stiffness, and tingling in both hands. MRI reveals osteophytes compressing the spinal cord. Which of the following is the most likely diagnosis?
  1. ক
    Rheumatoid arthritis
  2. খ
    Cervical spondylosis with myelopathy
  3. গ
    Ankylosing spondylitis
  4. ঘ
    Multiple sclerosis
ব্যাখ্যা
Cervical spondylosis (degenerative osteoarthritis) causes osteophytes and spinal cord compression (myelopathy). RA affects synovial joints (not osteophytes), and ankylosing spondylitis causes bamboo spine.
৪.
A 50-year-old obese man with hypertension presents with sudden, excruciating pain and swelling in the first metatarsophalangeal (MTP) joint. Synovial fluid analysis shows needle-shaped, negatively birefringent crystals. Which of the following is the best initial treatment?
  1. ক
    Allopurinol
  2. খ
    Colchicine
  3. গ
    Methotrexate
  4. ঘ
    Prednisone
ব্যাখ্যা
Acute gout is treated with colchicine, NSAIDs, or steroids. Allopurinol (xanthine oxidase inhibitor) is for chronic prophylaxis, not acute attacks.
৫.
A patient with recurrent gout develops tophi on the ears and fingers. Serum uric acid is persistently elevated. Which of the following medications is contraindicated in this patient?
  1. ক
    Probenecid
  2. খ
    Febuxostat
  3. গ
    Hydrochlorothiazide
  4. ঘ
    Pegloticase
ব্যাখ্যা
Thiazides (e.g., HCTZ) reduce uric acid excretion, worsening gout. Probenecid (uricosuric), febuxostat (XOI), and pegloticase (urate oxidase) are used for gout.
৬.
A patient with a history of unexplained paralysis and memory gaps undergoes evaluation. There is no neurological cause. Which of the following is the most likely diagnosis?
  1. ক
    Major depressive disorder
  2. খ
    Dissociative disorder
  3. গ
    Schizophrenia
  4. ঘ
    Bipolar disorder
ব্যাখ্যা
Dissociative disorders present with amnesia, identity alteration, or functional neurological symptoms without organic cause.
৭.
A patient with obesity (BMI 38) and obstructive sleep apnea is considering bariatric surgery. Which of the following is the most appropriate long-term monitoring?
  1. ক
    Serum folate
  2. খ
    Vitamin B12 and iron
  3. গ
    Vitamin A
  4. ঘ
    Zinc
ব্যাখ্যা
Post-bariatric surgery, malabsorption of B12, iron, calcium, and vitamin D is common due to reduced gastric acid/intrinsic factor.
৮.
A chronic alcoholic presents with ataxia, confusion, and horizontal nystagmus. Which of the following vitamin deficiencies is most likely?
  1. ক
    Thiamine (B1)
  2. খ
    Niacin (B3)
  3. গ
    Vitamin C
  4. ঘ
    Vitamin K
ব্যাখ্যা
Wernicke’s encephalopathy (ataxia, confusion, nystagmus) is caused by thiamine deficiency. Niacin deficiency causes pellagra (dermatitis, diarrhea, dementia).
৯.
Which autoantibody is most specific for Systemic Lupus Erythematosus (SLE) and typically correlates with disease activity, especially renal involvement?
  1. ক
    Anti-Ro/SSA
  2. খ
    Anti-La/SSB
  3. গ
    Anti-Sm
  4. ঘ
    Anti-dsDNA
ব্যাখ্যা
Anti-dsDNA (double-stranded DNA) antibodies are highly specific for SLE (present in ~60-80% of patients) and their titers often fluctuate with disease activity, particularly in lupus nephritis. Anti-Sm antibodies are also highly specific but less sensitive. Anti-Ro/SSA and Anti-La/SSB are associated with SLE but also Sjogren's syndrome.
১০.
A 28-year-old male develops oligoarthritis (affecting a few joints), conjunctivitis, and urethritis approximately 2 weeks after a bout of infectious diarrhea. Which of the following is the most likely diagnosis?
  1. ক
    Gout
  2. খ
    Septic Arthritis
  3. গ
    Reactive Arthritis
  4. ঘ
    Psoriatic Arthritis
ব্যাখ্যা
The classic triad of arthritis, urethritis, and conjunctivitis (can't see, can't pee, can't climb a tree), occurring after a gastrointestinal or genitourinary infection, is highly indicative of Reactive Arthritis (formerly Reiter's syndrome).
22:40
 
 
১১.
Which of the following extra-articular manifestations is characteristic of severe, long-standing Rheumatoid Arthritis?
  1. ক
    Butterfly rash
  2. খ
    Scleritis
  3. গ
    Calcinosis cutis
  4. ঘ
    Oral ulcers
ব্যাখ্যা
Scleritis (inflammation of the sclera) and episcleritis are significant ocular manifestations of RA, indicating more severe systemic disease. Other extra-articular features of severe RA include rheumatoid nodules, vasculitis, Felty's syndrome (RA, splenomegaly, neutropenia), and lung involvement (e.g., interstitial lung disease, pleural effusion).
১২.
Which of the following is the primary pathological feature of Osteoarthritis (OA)?
  1. ক
    Autoimmune synovial inflammation
  2. খ
    Cartilage degradation and loss
  3. গ
    Urate crystal deposition
  4. ঘ
    Enthesitis
ব্যাখ্যা
Osteoarthritis is primarily a disease of articular cartilage, characterized by progressive cartilage degradation, loss, and fibrillation. This is accompanied by subchondral bone remodeling, osteophyte formation, and mild synovial inflammation.
১৩.
The definitive diagnostic gold standard for Gout is:
  1. ক
    Elevated serum uric acid level
  2. খ
    Clinical presentation of podagra
  3. গ
    Identification of negatively birefringent, needle-shaped crystals in synovial fluid
  4. ঘ
    Radiographic evidence of "punched-out" erosions
ব্যাখ্যা
While elevated uric acid, podagra, and radiographic changes are suggestive, the definitive diagnosis of gout is made by aspirating synovial fluid from the affected joint and visualizing characteristic negatively birefringent, needle-shaped monosodium urate (MSU) crystals under a polarized light microscope.
১৪.
A patient with long-standing, untreated gout develops painless, chalky-white nodules on the helix of his ear and around his elbow joints. These characteristic deposits are known as:
  1. ক
    Gouty nodules
  2. খ
    Osteophytes
  3. গ
    Tophi
  4. ঘ
    Heberden's nodes
ব্যাখ্যা
Tophi are pathognomonic (distinctive) subcutaneous or articular deposits of monosodium urate crystals that occur in chronic, untreated hyperuricemia. They are characteristic of chronic tophaceous gout and can lead to joint destruction and deformity. Heberden's nodes are osteophytes in osteoarthritis.
১৫.
A patient reports persistent feelings of sadness, anhedonia (loss of interest or pleasure), significant weight loss, insomnia, and fatigue for the past 6 weeks. Which of the following is the most likely diagnosis?
  1. ক
    Bipolar Disorder
  2. খ
    Generalized Anxiety Disorder
  3. গ
    Major Depressive Disorder
  4. ঘ
    Dissociative Identity Disorder
ব্যাখ্যা
Major Depressive Disorder (MDD) is characterized by a persistent depressed mood or anhedonia for at least 2 weeks, along with several other symptoms (e.g., changes in appetite/weight, sleep disturbance, fatigue, feelings of worthlessness/guilt, difficulty concentrating, suicidal ideation). The duration of symptoms (6 weeks) fits the diagnostic criteria for MDD.
১৬.
A 30-year-old individual presents with excessive and uncontrollable worry about various aspects of life (work, finances, health, family) for the past 7 months. They also report difficulty sleeping, muscle tension, and restlessness. Which psychiatric disorder is most consistent with this presentation?
  1. ক
    Panic Disorder
  2. খ
    Social Anxiety Disorder
  3. গ
    Generalized Anxiety Disorder (GAD)
  4. ঘ
    Obsessive-Compulsive Disorder (OCD)
ব্যাখ্যা
Generalized Anxiety Disorder (GAD) is characterized by excessive, uncontrollable, and often irrational worry about multiple events or activities, occurring more days than not for at least 6 months. It is typically accompanied by physical symptoms like restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.
১৭.
A child presents with severe protein-energy malnutrition characterized by marked muscle wasting, loss of subcutaneous fat, and severe growth retardation, but relatively preserved appetite. There is no significant edema. This presentation is most consistent with:
  1. ক
    Kwashiorkor
  2. খ
    Marasmus
  3. গ
    Marasmic-Kwashiorkor
  4. ঘ
    Rickets
ব্যাখ্যা
Marasmus is a form of severe protein-energy malnutrition characterized by extreme wasting of muscle and fat, leading to a "skin and bones" appearance. It results from severe caloric deficiency. Unlike kwashiorkor, edema is absent or minimal, and appetite may be relatively preserved.
১৮.
A 50-year-old man with chronic kidney disease presents with bone pain, muscle weakness, and pathological fractures. Blood tests show low serum calcium, low phosphate, and elevated alkaline phosphatase. Which vitamin deficiency is the most likely underlying cause?
  1. ক
    Vitamin C
  2. খ
    Vitamin B12
  3. গ
    Vitamin D
  4. ঘ
    Vitamin K
ব্যাখ্যা
The clinical features of bone pain, muscle weakness, and fractures, combined with the laboratory findings of low calcium, low phosphate, and high alkaline phosphatase (indicating increased bone turnover), are classic for osteomalacia (adult form of rickets). This is primarily caused by Vitamin D deficiency, which impairs calcium and phosphate absorption and mineralization of bone matrix. Chronic kidney disease can impair Vitamin D activation, making it a common cause of osteomalacia.
১৯.
Which of the following is a common acute symptom of Vitamin A toxicity (hypervitaminosis A)?
  1. ক
    Night blindness
  2. খ
    Dry eyes (xerophthalmia)
  3. গ
    Pseudotumor cerebri (intracranial hypertension)
  4. ঘ
    Dermatitis with photosensitivity
ব্যাখ্যা
Acute Vitamin A toxicity can occur from ingesting very large doses (e.g., polar bear liver). Key acute symptoms include headache, nausea, vomiting, blurred vision (due to papilledema), and potentially confusion, indicating elevated intracranial pressure (pseudotumor cerebri).
২০.
Beyond articular involvement, which of the following is a common extra-articular manifestation of Rheumatoid Arthritis that can lead to restrictive lung disease?
  1. ক
    Pericarditis
  2. খ
    Rheumatoid nodules
  3. গ
    Interstitial lung disease (ILD)
  4. ঘ
    Amyloidosis
ব্যাখ্যা
Interstitial lung disease (ILD) is a significant pulmonary complication of RA, leading to progressive fibrosis and impaired lung function, often presenting as restrictive lung disease. While pericarditis, rheumatoid nodules, and amyloidosis (secondary) are also extra-articular features, ILD directly causes restrictive lung disease.
২১.
Which of the following is the most important principle for initiating treatment in newly diagnosed Rheumatoid Arthritis?
  1. ক
    Initiate disease-modifying anti-rheumatic drugs (DMARDs) as early as possible.
  2. খ
    Wait for clear radiographic evidence of erosions before starting systemic therapy.
  3. গ
    Start with high-dose corticosteroids for rapid symptom control
  4. ঘ
    Begin with NSAIDs and physical therapy alone for several months
ব্যাখ্যা
Current guidelines for RA emphasize early and aggressive treatment with disease-modifying anti-rheumatic drugs (DMARDs), typically methotrexate, within 3 months of diagnosis. This "treat-to-target" strategy aims to achieve remission or low disease activity to prevent irreversible joint damage and improve long-term outcomes. Delaying DMARDs allows progression of structural damage.
২২.
The cornerstone of acute management for the joint symptoms of Reactive Arthritis involves:
  1. ক
    Long-term antibiotics
  2. খ
    Uric acid-lowering therapy
  3. গ
    Non-steroidal anti-inflammatory drugs (NSAIDs)
  4. ঘ
    High-dose systemic corticosteroids for prolonged periods
ব্যাখ্যা
NSAIDs are the first-line treatment for acute joint pain and inflammation in reactive arthritis. While antibiotics are given for the initial infection, they generally do not affect the course of the arthritis itself. Systemic corticosteroids may be used for severe, refractory cases but are not first-line.
২৩.
A 65-year-old woman with chronic knee pain, worse with activity, has X-rays showing joint space narrowing, osteophytes, and subchondral sclerosis. These radiographic findings are characteristic of:
  1. ক
    Gouty arthritis
  2. খ
    rheumatoid arthritis
  3. গ
    Osteoarthritis
  4. ঘ
    Psoriatic arthritis
ব্যাখ্যা
These are the classic radiographic hallmarks of osteoarthritis. Joint space narrowing indicates cartilage loss, osteophytes are bony outgrowths at joint margins, and subchondral sclerosis refers to increased bone density beneath the cartilage.
২৪.
Which of the following non-pharmacological interventions is considered the most effective first-line management strategy for knee Osteoarthritis?
  1. ক
    Complete bed rest and immobilization
  2. খ
    Regular moderate-intensity exercise and weight loss (if overweight/obese)
  3. গ
    Joint bracing and splinting indefinitely
  4. ঘ
    High-impact aerobic activities
ব্যাখ্যা
Regular moderate-intensity exercise (including aerobic and strengthening exercises) and weight loss (for overweight or obese individuals) are the most effective non-pharmacological interventions for managing OA pain and improving function. They reduce joint load, strengthen supporting muscles, and improve joint mobility.
২৫.
A patient reports recurrent, unexpected episodes of intense fear that peak within minutes, accompanied by symptoms such as palpitations, sweating, trembling, shortness of breath, chest pain, and a fear of losing control or dying. This description is characteristic of:
  1. ক
    Generalized Anxiety Disorder
  2. খ
    Social Anxiety Disorder
  3. গ
    Panic Disorder
  4. ঘ
    Obsessive-Compulsive Disorder
ব্যাখ্যা
Panic disorder is defined by recurrent, unexpected panic attacks, which are abrupt surges of intense fear or discomfort that reach a peak within minutes, accompanied by a cluster of physical and cognitive symptoms (as listed). The "unexpected" nature is key for panic disorder diagnosis.
২৬.
A patient develops an intense, irrational fear of heights, leading them to avoid high places at all costs. This fear is specific to this situation and causes significant distress. This is an example of:
  1. ক
    Obsessive-Compulsive Disorder (OCD)
  2. খ
    Specific Phobia (Situational Type)
  3. গ
    Panic Disorder
  4. ঘ
    Illness Anxiety Disorder
ব্যাখ্যা
A Specific Phobia is marked fear or anxiety about a specific object or situation (e.g., heights, animals, injections, flying). The fear is out of proportion to the actual danger, is persistent (typically 6 months or more), and leads to immediate anxiety response and often avoidance.
২৭.
Which of the following is a direct consequence of severe zinc deficiency on the immune system?
  1. ক
    Neutrophilia
  2. খ
    Enhanced B-cell function
  3. গ
    Impaired T-lymphocyte function
  4. ঘ
    Increased phagocytic activity
ব্যাখ্যা
Zinc plays a vital role in the development and function of immune cells, particularly T-lymphocytes. Severe zinc deficiency leads to thymic atrophy and impaired cell-mediated immunity, increasing susceptibility to infections.
২৮.
Which of the following is most suggestive of conversion disorder?
  1. ক
    Positive Babinski reflex
  2. খ
    Symptoms improving with distraction
  3. গ
    MRI lesions
  4. ঘ
    Elevated CK levels
ব্যাখ্যা
Inconsistency in symptoms and improvement with distraction are hallmarks of conversion disorder. There are no objective findings or lab abnormalities.
২৯.
Which neurotransmitter is most implicated in the pathophysiology of major depression?
  1. ক
    Acetylcholine
  2. খ
    Serotonin
  3. গ
    Dopamine
  4. ঘ
    GABA
ব্যাখ্যা
Serotonin (5-HT), along with norepinephrine and dopamine, is strongly implicated in the pathophysiology of depression. Most antidepressants target these systems.
৩০.
A severe form of cardiomyopathy, known as Keshan disease is directly linked to the deficiency of which micronutrient?
  1. ক
    Iodine
  2. খ
    Magnesium
  3. গ
    Selenium
  4. ঘ
    Iron
ব্যাখ্যা
Keshan disease is a severe form of dilated cardiomyopathy that occurs in areas with extremely low soil selenium content, where populations consume predominantly locally grown foods. Selenium deficiency leads to impaired antioxidant defense in the heart, making it vulnerable to oxidative stress and viral infections.
৩১.
Which of the following is a hallmark feature of generalized anxiety disorder (GAD)?
  1. ক
    Sudden-onset palpitations
  2. খ
    Repetitive checking behavior
  3. গ
    Persistent uncontrollable worry about multiple issues
  4. ঘ
    Flashbacks of traumatic events
ব্যাখ্যা
GAD is defined by excessive, persistent worry lasting ≥6 months about various life domains, along with physical symptoms (e.g., fatigue, muscle tension).
৩২.
Which of the following complications is common in patient with RA ?
  1. ক
    Ankylosing spondylitis
  2. খ
    Atlantoaxial subluxation
  3. গ
    Reactive arthritis
  4. ঘ
    Gouty tophi
ব্যাখ্যা
The patient’s symptoms of morning stiffness, symmetrical small joint pain, and positive rheumatoid factor/anti-CCP antibodies are diagnostic of rheumatoid arthritis (RA), a chronic autoimmune connective tissue disorder causing synovial inflammation. RA can lead to joint destruction and systemic complications. Atlantoaxial subluxation is a serious complication due to synovial inflammation in the cervical spine, particularly at the C1-C2 vertebrae, leading to instability and potential spinal cord compression.
৩৩.
A 32-year-old man complains of chronic back pain and stiffness that improves with exercise. HLA-B27 is positive. What is the likely diagnosis?
  1. ক
    Rheumatoid arthritis
  2. খ
    Ankylosing spondylitis
  3. গ
    Osteoarthritis
  4. ঘ
    Spinal stenosis
ব্যাখ্যা
Ankylosing spondylitis is an inflammatory spondyloarthropathy affecting young males, presenting with back pain that improves with activity, and is associated with HLA-B27.
৩৪.
Which of the following organisms is most common in septic arthritis in adults?
  1. ক
    Streptococcus pneumoniae
  2. খ
    Escherichia coli
  3. গ
    Neisseria gonorrhoeae
  4. ঘ
    Staphylococcus aureus
ব্যাখ্যা
Staphylococcus aureus is the most common cause of septic arthritis in all age groups, especially in those with joint prostheses or IV drug use.
৩৫.
A man is convinced his headache is a brain tumor despite normal MRI. He checks his symptoms online daily. What is the most likely diagnosis?
  1. ক
    Illness anxiety disorder (hypochondriasis)
  2. খ
    Somatic symptom disorder
  3. গ
    Conversion disorder
  4. ঘ
    Factitious disorder
ব্যাখ্যা
Illness anxiety disorder = preoccupation with having a serious illness despite reassurance. Somatic symptom disorder involves actual physical symptoms.
04:59
 
 
৩৬.
The most effective treatment approach for Conversion Disorder typically involves:
  1. ক
    Extensive long-term medical hospitalization.
  2. খ
    Pharmacotherapy with high-dose antipsychotics.
  3. গ
    Psychotherapy and physical/occupational therapy.
  4. ঘ
    Invasive neurological surgery.
ব্যাখ্যা
Treatment for Conversion Disorder often involves a multidisciplinary approach. Psychotherapy, particularly trauma-focused therapy or CBT, helps address underlying psychological factors and coping mechanisms. Physical therapy and occupational therapy are crucial for rehabilitating functional deficits and relearning normal movement patterns, often integrated with a psychological approach.
04:51
 
 
৩৭.
A construction worker claims severe back pain after a minor fall but is seen lifting heavy weights at home. What is the most likely diagnosis?
  1. ক
    Malingering
  2. খ
    Factitious disorder
  3. গ
    Somatic symptom disorder
  4. ঘ
    Conversion disorder
ব্যাখ্যা
Malingering = intentional exaggeration for external gain (e.g., workers’ compensation). Factitious disorder lacks obvious external incentives.
৩৮.
Which of the following is the primary role of Vitamin C that explains its importance in maintaining the integrity of connective tissues?
  1. ক
    Its function as an antioxidant.
  2. খ
    Its role in iron absorption.
  3. গ
    Its necessity as a co-factor for collagen synthesis.
  4. ঘ
    Its involvement in red blood cell production.
ব্যাখ্যা
Vitamin C is essential for the hydroxylation of proline and lysine during collagen synthesis. This hydroxylation is critical for forming stable collagen triple helices, which are fundamental to the structural integrity of skin, blood vessels, bones, cartilage, and gums.
৩৯.
The primary underlying pathophysiological mechanism of Heat Stroke is:
  1. ক
    Excessive salt loss from profuse sweating.
  2. খ
    Hypernatremia due to dehydration.
  3. গ
    Failure of thermoregulatory mechanisms to dissipate heat.
  4. ঘ
    Direct viral infection of the hypothalamus.
ব্যাখ্যা
Heat stroke occurs when the body's thermoregulatory mechanisms, primarily involving the hypothalamus and sweat glands, fail to adequately dissipate the heat generated internally or absorbed from the environment, leading to a rapid and uncontrolled rise in core body temperature.
05:13
 
 
৪০.
Medically Unexplained Symptoms (MUS) are best described as:
  1. ক
    Symptoms that are fabricated by the patient for external gain.
  2. খ
    Symptoms that physicians have investigated and found no adequate medical explanation for
  3. গ
    Symptoms that are always purely psychological in origin.
  4. ঘ
    Symptoms that are intentionally caused by the patient.
ব্যাখ্যা
MUS refer to physical symptoms for which a comprehensive medical evaluation has failed to reveal an underlying organic disease process that adequately explains the symptoms. This doesn't mean they are "all in their head" or fabricated, but rather that current medical knowledge or diagnostic tools cannot pinpoint a clear physical cause.