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Somatic symptom disorder involves excessive preoccupation with physical symptoms that cause distress and impairment, despite medical reassurance. Symptoms are real to the patient, even if unexplained medically. Illness anxiety disorder focuses on fear of having a serious illness with minimal or no symptoms. Factitious disorder involves deliberate falsification of symptoms for the primary purpose of assuming the sick role. Malingering involves intentional symptom exaggeration for secondary gain (money, drugs, avoiding responsibility). Patients with somatic symptom disorder require supportive care, regular follow-ups, and limited unnecessary investigations to avoid reinforcing illness behavior. Psychotherapy (CBT) is the mainstay of management.

Vitamin B12 (cobalamin) deficiency causes megaloblastic anemia with macrocytosis and hypersegmented neutrophils. Neurologic manifestations include paresthesias, ataxia, and impaired proprioception due to subacute combined degeneration (dorsal columns and lateral corticospinal tracts). Causes include pernicious anemia (autoantibody against intrinsic factor), gastrectomy, malabsorption (Crohn disease, ileal resection), or vegan diet. Folate deficiency also causes macrocytic anemia but without neurologic deficits. Vitamin B1 deficiency causes beriberi and Wernicke–Korsakoff. B6 deficiency causes peripheral neuropathy and sideroblastic anemia. Vitamin C deficiency causes scurvy. Diagnosis of B12 deficiency involves low serum B12 and elevated methylmalonic acid and homocysteine. Treatment is B12 replacement. Untreated, neurologic deficits can be irreversible.

This patient has Bell’s palsy, caused by dysfunction of the facial nerve (cranial nerve VII). Clinical features include sudden unilateral facial weakness affecting both upper and lower face, loss of forehead wrinkling, inability to close the eye, drooping mouth, and impaired taste on the anterior two-thirds of the tongue. In contrast, central (UMN) lesions such as stroke spare forehead movement due to bilateral cortical innervation of upper facial muscles. The trigeminal nerve provides facial sensation and mastication, not motor facial expression. The glossopharyngeal nerve controls taste and sensation of the posterior tongue. The hypoglossal nerve controls tongue movements. Bell’s palsy is often idiopathic but linked to HSV reactivation. Treatment includes corticosteroids and eye protection. Most patients recover fully within weeks to months.

This patient has features of Cushing syndrome. The diagnostic algorithm begins with confirming hypercortisolism (via late-night salivary cortisol, 24-hour urinary cortisol, or overnight low-dose dexamethasone suppression test). If hypercortisolism is confirmed, the next step is to determine the cause. Plasma ACTH helps distinguish ACTH-dependent (pituitary adenoma, ectopic ACTH) from ACTH-independent (adrenal adenoma/carcinoma) causes, but only after hypercortisolism is confirmed. The high-dose dexamethasone suppression test further distinguishes pituitary vs ectopic ACTH once ACTH dependency is established. Adrenal imaging is done only after biochemical localization. Thus, the low-dose dexamethasone suppression test is the correct initial confirmatory test. Management depends on etiology, with surgery as definitive treatment for pituitary or adrenal tumors.

Autonomy is the ethical principle that patients have the right to make decisions regarding their medical care, including the refusal of life-prolonging treatment. This patient’s request for comfort care reflects an informed, voluntary choice that should be respected. Beneficence refers to acting in the patient’s best interest, while nonmaleficence means avoiding harm. Justice involves fairness in resource allocation. Palliative care honors patient autonomy by aligning treatment with values and goals. Physicians must ensure that the patient understands prognosis, available interventions, and expected outcomes. Respecting autonomy fosters trust and preserves dignity in end-of-life care.