Amboss MCQs PDF

ICM Final MCQs including: Amboss questions With explanations. + questions bank It contains all the files that Dr. Shoeb attached in the Drive. Done by: Nawaf Alhagbani A...

ICM Final MCQs including: Amboss questions With explanations. + questions bank It contains all the files that Dr. Shoeb attached in the Drive. Done by: Nawaf Alhagbani Amboss questions bank Dermatology – Skin and skin appendage Q1/ A 3400-g (7-|b 8-02) newborn is delivered at 40 weeks' gestation. Physical examination shows pale skin, blond hair, and blue irides. Her parents are from Haiti and express concern, as the newborn's appearance contrasts greatly with their own. The most likely cause of this newborn's condition is a defect in which of the following processes? A) Intracellular transport of melanosomes. B) Oxidation of dihydroxyphenylalanine. C) Glycosylation of procollagen. D) Transfer of melanosomes to keratinocytes. E) Migration of neural crest cell derivates. Q2/ A 32-year-old man comes to the physician because of a 1-week history of fever, nausea, headache, and confusion. Three weeks ago, he had an episode of a sore throat, diarrhea, and generalized lymphadenopathy. He is sexually active with a new partner that he met 2 months ago and they use condoms inconsistently. He appears ill. Physical examination shows nuchal rigidity. Further evaluation shows infection with an enveloped, single-stranded, positive-sense RNA virus. The cells most likely a ected in this patient's current condition are analogous to which of the following cell types? A) Ependymal cells B) Osteoblasts C) Plasma cells D) Mast cells E) Schwann cells F) Langerhans cells Q3/ A 74-year-old man comes to the physician for evaluation of a skin lesion on his right arm. The lesion first appeared 3 months ago and has since been slowly enlarging. Physical examination shows a 1.5-centimeter, faintly erythematous, raised lesion with irregular borders on the dorsum of the right forearm. A biopsy specimen is obtained. If present, which of the following histopathological features would be most consistent with carcinoma in situ? A) Pleomorphism of cells in the stratum corneum B) Irreversible nuclear changes in the stratum basale C) Full-thickness basal to apical cell polarity D) Increased nuclear to cytoplasmic ratio in the stratum spinosum E) High mitotic activity in the stratum granulosum Q4/ A 19-year-old woman comes to the physician because of increased sweating for the past 6 months. She experiences severe sweating that is triggered by stressful situations and speaking in public. She is failing one of her university classes because of her avoidance of public speaking. She has not had any fevers, chills, weight loss, or night sweats. Her temperature is 36.6°C (98°F). Physical examination shows moist skin in the axillae and on the palms, soles, and face. Which of the following drugs is most likely to be e ective for this patient's condition? A) Pilocarpine B) Oxytocin C) Physostigmine D) Phenylephrine E) Glycopyrrolate Q5/ A 19-year-old woman comes to the physician because of a 2-week history of blue staining of her clothes when she exercises. She noticed that the stains are most prominent on her underwear and under her arms. She works as a professional ballet dancer and trains at least 15 hours per week. Her menstrual cycles occur at regular 28-day intervals. Physical examination shows black-blue discoloration of the skin in the axillae, areolae, and perineum. The remainder of the examination shows no abnormalities. A biopsy of the skin obtained from the axilla shows lipofuscin granules within coiled secretory glands in the lower dermis; the secretory ducts of these glands empty into the infundibulum of hair follicles. Which of the following terms best describes the glands seen on this patient’s biopsy? A) Autocrine B) Holocrine C) Endocrine D) Paracrine E) Eccrine F) Apocrine Q6/ A 28-year-old African American woman delivers her first child at 39 weeks' gestation. On examination, the newborn's skin and hair have a milky white color, and his eyes are light blue with a slight reddish hue. A skin biopsy shows a normal number of epidermal and follicular melanocytes. The physician advises the parents that the child will need a comprehensive eye examination and genetic testing to establish the suspected diagnosis. A defect in which of the following enzymes is the most likely cause of this patient's condition? A) Phenylalanine hydroxylase B) DOPA decarboxylase C) Tyrosine kinase D) Tyrosinase E) Homogentisate oxidase F) Phenylethanolamine-N-methyltransferase Family Medicine – Osteoarthritis Q1/ A 52-year-old woman comes to the physician because of a 3-week history of pain in her right knee. The pain is worse at the end of the day and when she walks. She says that it has become difficult for her to walk up the flight of stairs to reach her apartment. She has hypertension. Her sister has rheumatoid arthri s. She drinks two to three beers daily. Current medica ons include hydrochlorothiazide and a mul vitamin. She appears anxious. She is 160 cm (5 3 in) tall and weighs 92 kg (202 lb); BMI is 36 kg/m2. Her temperature is 37.0°C (98.6°F), pulse is 87/min, and blood pressure is 135/83 mm Hg. Cardiopulmonary examina on shows no abnormali es. The right knee is not tender or erythematous; range of mo on is limited. Crepitus is heard on flexion and extension of the knee. Her hemoglobin concentra on is 12.6 g/dL, leukocyte count is 9,000/mm3, and erythrocyte sedimenta on rate is 16 mm/h. An x-ray of the right knee is shown. Which of the following is the most appropriate next step in the management of this pa ent? A) Intraarticular glucocorticoid injections B) Weight Loss program C) Arthrocentesis of the right knee joint D) MRI of the right knee Q2/ A 67-year-old woman comes to the physician for the evalua on of bilateral knee painfor the past year. She reports that the pain is worse with movement and is relieved with rest. She has type 2 diabetes mellitus. The pa ent says her mother takes leflunomide for a “joint condi on.” The pa ent's medica ons include me ormin and a mul vitamin. She is 165 cm (5 5 in) tall and weighs 85 kg (187 lb); BMI is 31 kg/m2. Vital signs are within normal limits. Physical examina on shows pain both in complete flexion and extension, crepitus on joint movement, and joint s ffness and restricted range of mo on of both knees. X-ray of the knee joints shows irregular joint space narrowing, subchondral sclerosis, osteophytes, and several subchondral cysts. There is no reddening or swelling. Which of the following is the most appropriate pharmacotherapy? A) Intraarticular glucocorticoid injections B) Administration of ibuprofen C) Administration of infliximab D) Administration of celecoxib Q3/ A 58-year-old woman comes to the physician because of a 3-month history of le knee pain as well as s ffness upon waking for about 10–15 minutes. The pain is worse a er standing a lot at work and when she climbs stairs. There is no history of trauma. She has hypercholesterolemia and hypertension. Her mother died of metasta c breast cancer at the age of 65 years. She does not smoke or drink alcohol. Current medica ons include atorvasta n, labetalol, and aspirin. Over the past 2 months, she has been taking over-the-counter ibuprofen as needed for the joint pain. She is 163 cm (5 4 in) tall and weighs 84 kg (185 lb); BMI is 32 kg/m2. Her temperature is 37.0°C (98.6°F), pulse is 88/min, and blood pressure is 114/68 mm Hg. Examina on of the le knee shows tenderness on palpa on of the anteromedial joint line; there is crepitus and pain with full flexion and extension. Serum uric acid concentra on is 8.0 mg/dL, and erythrocyte  sedimenta on rate is 15 mm/h. Which of the following is the most likely finding on imaging of the le knee? A) Osteophytes with joint space narrowing on x-ray B) Calcification of synovia and cartilage on ultrasound C) Di use lytic-sclerotic bone lesions on x-ray D) Joint effusion and pannus on ultrasound Q4/ A 52-year-old woman comes to the physician because of a 4-month history of progressive pain and s ffness of the fingers of her right hand that is worse at the end of the day. She works as a hairdresser and has to take frequent breaks to rest her hand. Over the past 2 weeks, she has been taking ibuprofen as needed for the joint pain. Two weeks ago, she completed a course of oral an bio cs for a urinary tract infec on. She has hypertension for which she takes hydrochlorothiazide. Her sister has systemic lupus erythematosus. She drinks one to two beers daily and occasionally more on weekends. Her vital signs are within normal limits. Physical examina on shows swelling, joint-line tenderness, and decreased range of mo on of the right first carpometacarpal joint as well as the second and fourth distal interphalangeal joints of the right hand. Discrete, hard, mildly tender swellings are palpated over the second and fourth distal interphalangeal joints of the right hand. Which of the following is the most likely underlying mechanism for these findings? A) Monosodium urate crystal precipita on in the joints B) Bacterial infec on of the joint space C) Autoimmune-mediated car lage erosion D) Degenera ve disease of the joints Q5/ A 58-year-old woman comes to the physician because of a 2-year history of progressively worsening pain in her knees and fingers. The knee pain is worse when she walks for longer than 30 minutes. When she wakes up in the morning, her fingers and knees are s ff for about 15 minutes. She cannot recall any trauma to the joints. She was treated with amoxicillin following a ck bite 2 years ago. She is otherwise healthy and only takes a mul vitamin and occasionally acetaminophen for the pain. She drinks one to two glasses of wine daily. She is 160 cm (5 3 in) tall and weighs 79 kg (174 lb); BMI is 31 kg/m2. Her temperature is 36.9°C (98.4°F), pulse is 70/min, and blood pressure is 133/78 mm Hg. Examina on of the lower extremi es shows mild genu varum. Range of mo on of both knees is limited; there is palpable crepitus. Complete flexion and extension elicit pain. Tender nodules are present on the proximal and distal interphalangeal joints of the index, ring, and li le fingers bilaterally. Which of the following is the most likely diagnosis? A) Gout B) Lyme arthri s C) Rheumatoid arthri s D) Osteoarthri s Q6/ A 59-year-old woman comes to the physician because of a 1-year history of pain and s ffness in her fingers and knees. The s ffness lasts for about 10 minutes a er she wakes up in the morning. She also reports that her knee pain is worse in the evening. She drinks one glass of wine daily. Her only medica on is acetaminophen. She is 175 cm (5 9 in)tall and weighs 102 kg (225 lb); BMI is 33 kg/m2. Physical examina on shows firm nodules on the distal interphalangeal joints of the index, ring, and li le fingers of both hands. Which of the following is the most likely diagnosis? A) pseudogout B) Rheumatoid arthri s C) Gout D) Sep c arthri s E) Osteoarthri s Q7/ A 62-year-old woman comes to the physician because of a 6-month history of progressive pain and s ffness of the fingers of her right hand. The s ffness is worse at the end of the day. She recently re red a er working for 28 years as a typist at a data entry firm. Physical examina on shows swelling, joint-line tenderness, and decreased range of mo on of the first metacarpophalangeal joint and the distal interphalangeal joints of the right hand. Discrete, hard, mildly tender nodules are palpated over the 2nd and 4th distal interphalangeal joints of the right hand. An x-ray of her right hand shows narrowing of the interphalangeal joint spaces with subchondral sclerosis and osteophytes. Which of the following is the most likely underlying mechanism of this pa ent's condi on? A) Monosodium urate crystal precipita on in the joints B) Bacterial infec on of the joint space C) Autoimmune-mediated car lage erosion D) Degenera ve disease of the joints Q8/ A previously healthy 61-year-old man comes to the physician because of bilateral knee pain for the past year. The pain is worse with movement and is relieved with rest. Physical examina on shows crepitus, pain, and decreased range of mo on with flexion and extension of both knees. There is no warmth, redness, or swelling. X-rays of both knees show irregular joint space narrowing, osteophytes, and subchondral cysts. Which of the following is the most appropriate pharmacotherapy? A) prednisone B) Methotrexate C) Naproxen D) Allopurinol Q9/ A 71-year-old man with type 2 diabetes mellitus comes to the physician because of a 9-month history of pain and s ffness in the right knee. He reports that the s ffness lasts approximately 10 minutes a er waking up and that the pain is worse in the evening. There is no history of trauma. He is 175 cm (5 9 in) tall and weighs 102 kg (225 lb); BMI is 33 kg/m2. Examina on of the right knee shows tenderness in the anteromedial joint line and crepitus during knee movement. Laboratory studies show an erythrocyte sedimenta on rate of 15 mm/h and a serum uric acid concentra on of 6.9 mg/dL. Which of the following is the most likely finding on imaging of the right knee? A) Osteophytes and narrowing of the joint space B) Marginal bony erosions and opacification of periarticular soft tissue C) Periarticular osteopenia and pannus formation D) Loculated epiphyseal cyst with thinning of the overlying cortex Q10/ A 66-year-old man comes to the physician because of a 6-month history of gradually worsening pain in his right groin. The pain increases during and a er physical exercise, especially when climbing stairs. A er waking up in the morning, the right hip feels s ff for up to 20 minutes. He has not sustained any recent trauma. His father died of lung cancer at the age of 78 years. He has hypertension and benign prostate hyperplasia. He drinks one 12-oz beer daily. Current medica ons are valsartan and tamsulosin. He is 180 cm(5 11 in) tall and weighs 100 kg (220 lb); BMI is 31 kg/m2. His temperature is 36.8°C (98.2°F), pulse is 73/min, and blood pressure is 129/80 mm Hg. Examina on of the right hip shows a limited internal rota on; there is crepitus, and pain with full flexion and extension. The right inguinal area is so without any palpable masses. Muscle strength is 5/5 bilaterally. Leukocyte count is 4,500/mm 3, erythrocyte sedimenta on rate is 16 mm/h, and serum uric acid concentra on is 7.3 mg/dL. An x- ray of this pa ent's right hip is most likely to show which of the following findings? A) Marginal bone erosions and opaque periarticular soft tissue B) Car lage calcifica on C) Joint-space narrowing and subchondral sclerosis D) Car lage erosions and bone demineraliza on Q11/ A 61-year-old man with progressive le hip pain comes to the physician for a follow-up examina on. One year ago, he was diagnosed with osteoarthri s of the le hip. Since then, he has had an 8-kg (18-lb) weight loss a er changing to a vegetarian diet, regular swimming, and physical therapy. The pain worsens when he climbs stairs, which makes it increasingly difficult for him to reach his apartment located on the second floor. Over the last few weeks, he gradually increased the frequency of diclofenac intake but says that even a daily intake does not provide complete pain relief. He asks for a treatment that will lead to a long-term improvement of his symptoms. He has no history of major medical illness. His only other medica on is pantoprazole. He does not smoke or drink alcohol. He is 179 cm (5 10 in) tall and weighs 80 kg (176 lb); BMI is 25 kg/m2. Physical examina on of the le hip shows crepitus, a limited internal rota on, and pain with full flexion and extension. An x-ray of the le hip shows joint space narrowing, osteophytes, and subchondral sclerosis and cysts. Which of the following is the most appropriate recommenda on for this pa ent? A) Arthroscopic hip debridement B) Intraarticular glucocorticoid injections C) Walking aids D) Fentanyl patches E) Total hip arthroplasty Family Medicine – Back pain Q1/ A 24-year-old man comes to the physician because of severe lower back pain for the past 2 days. The pain is constant and nonradia ng, and he describes it as 7 out of 10 in intensity. The pain began a er he helped a friend move into a new apartment. He has a history of intravenous heroin use. He takes no medica ons. His temperature is 37°C (98.6°F), pulse is 98/min, and blood pressure is 128/90 mm Hg. Examina on shows old track marks on the cubital fossae bilaterally. His lumbar paraspinal muscles are firm and tense on palpa on. There is no midline spinal tenderness. Flexing the hip and extending the knee while raising the leg to 70° does not cause any pain. Sensa on is not impaired. Which of the following is the most appropriate next step in management? A) Epidural glucocor coid injec on B) Bed rest only C) Analgesia and regular ac vity Q2/ A 47-year-old man comes to the emergency department because of urinary and fecal incon nence for 6 hours. Earlier in the day, he fell off a ladder at a construc on site and sustained injuries to his back and thighs but did not seek medical a en on. He took ibuprofen for lower back pain. His temperature is 36.9°C (98.4°F), pulse is 80/min, and blood pressure is 132/84 mm Hg. Examina on shows tenderness over the lumbar spine and bilateral symmetric lower extremity weakness. Deep tendon reflexes are 3+ in the ankles and 2+ in the knees. Rectal tone is decreased. Abdominal ultrasound shows a distended bladder. Which of the following is the most likely diagnosis? A) Spinal epidural abscess B) Cerebellar stroke C) Cauda equina syndrome D) conus medullaris syndrome Q3/ A 47-year-old woman comes to the emergency department because of increasing back pain for the past 2 weeks. She is unable to perform her daily chores. One month ago, she fell and hurt her back while working outside in the garden. The pain subsided with over-the-counter acetaminophen. She underwent a le mastectomy 1 year ago for breast cancer. She has type 2 diabetes mellitus. Current medica ons include me ormin, sitaglip n, and a mul vitamin. She appears uncomfortable. Her temperature is 38.9°C (102.0°F), pulse is 101/min, and blood pressure is 110/80 mm Hg. Examina on of the back shows thoracic vertebral tenderness. She has mild s ffness on neck flexion. Muscle strength is decreased in the lower extremi es. Deep tendon reflexes are 2+ bilaterally. Sensa on to pain, fine touch, temperature, and propriocep on is intact. Her hemoglobin concentra on is 13.1 g/dL and leukocyte count is 19,300/mm3. Which of the following is the most appropriate next step in management? A) Ibuprofen therapy and bed rest  B) X-ray of the spine C) Methylprednisone therapy D) Vancomycin and nafcillin therapy E) MRI of the spine Q4/ A 65-year-old woman comes to the physician because of a 3-week history of sharp, stabbing pain in her lower back. The pain radiates to the back of her right leg and is worse at night. She reports decreased sensa on around her bu ocks and inner thighs. During the last several days, she has had trouble urina ng. Three years ago, she was diagnosed with breast cancer and was treated with lumpectomy and radia on. Her only medica on is anastrozole. Her temperature is 37.0°C (98.6°F), pulse is 80/min, respira ons are 12/min, and blood pressure is 130/70 mm Hg. Neurologic examina on shows 4/5 strength in the le lower extremity and 2/5 strength in the right lower extremity. Knee and ankle reflexes are 1+ on the right. Res ng anal sphincter tone is normal, but the squeeze tone is reduced. Which of the following is the most likely diagnosis? A) conus medullaris syndrome B) Cauda equine syndrome C) Central cord syndrome D) Brown-Sequard syndrome Q5/ One day a er undergoing a right hemicolectomy for colon cancer, a 55-year- old woman is evaluated for a 5-hour history of progressively worsening back pain and difficulty moving her legs. Her ini al postopera ve course was uncomplicated. Current medica ons include prophylac c subcutaneous heparin. Her temperature is 37.2°C (98.9°F), pulse is 100/min, respira ons are 18/min, and blood pressure is 130/90 mm Hg. Examina on shows a well-posi oned epidural catheter site without redness or swelling. There is weakness of the lower extremi es and decreased anal tone. Deep tendon reflexes are absent in both legs. Sensa on to pinprick is decreased from below the umbilicus. Her hemoglobin concentra on is 11.2 g/dL, leukocyte count is 6000/m3, and platelet count is 215,000/mm3. Her erythrocyte sedimenta on rate is 19 mm/h. A T2-weighted MRI of the spine is shown. Which of the following is the most appropriate next step in management? A) Observa on only B) Perform surgical decompression C) Administer vancomycin and cedepime  D) Perform CT guided aspira on Q6/ A 76-year-old man is brought to the physician by his wife because of low back pain and weakness for the past 4 weeks. He says that the pain is sharp, radiates to his le side, and has a burning quality. He has had a cough occasionally produc ve of blood- streakedsputum for the past 2 months. He has had 3.2-kg (7.0-lb) weight loss in that me. He is now unable to walk without assistance and has had cons pa on and difficulty urina ngfor the past 2 weeks. He has hypertension treated with enalapril. He has smoked 1 packof cigare es daily for 60 years. His temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 150/80 mm Hg. He is oriented to person, place, and me. Neurologic examina on shows 3/5 strength of the lower extremi es. Deep tendon reflexes are hyperreflexive. Babinski sign is present bilaterally. Sensory examina on shows decreased sensa on to pinprick below the T4 dermatome. He is unable to lie recumbent due to severe pain. An x-ray of the chest shows mul ple round opaci es of varying sizes in both lungs. Which of the following is the most appropriate next step in the management of this pa ent? A) Surgical decompression B) Surgical stabiliza on of the spine C) Radia on therapy D) Intravenous dexamethasone therapy Q7/ A 45-year-old man comes to the physician because of intermi ent lower back pain for 1 week. His symptoms began shortly a er li ing heavy boxes at work. He has not had any fever, chills, or weight loss. He has a history of recurrent pep c ulcer disease. He does not smoke or drink alcohol. His vital signs are within normal limits. Examina on shows mild paraspinal lumbar tenderness. Neurologic examina on shows no focal findings. An x-rayof the spine shows no abnormali es. The pharmacotherapy for this pa ent's condi on should include which of the following agents? A) Aspirin B) Cyclobenzaprine C) Oxycodone D) Acetaminophen Q8/ A 75-year-old man comes to the physician because of a 2-week history of sharp, stabbing pain in the lower back that radiates to the back of his le leg. He also has had a loss of sensi vity around his bu ocks and inner thighs as well as increased trouble urina ng the last week. Two years ago, he was diagnosed with prostate cancer and was treated with radia on therapy. Neurologic examina on shows reduced strength and reflexes in the le lower extremity; the right side is normal. The res ng anal sphincter tone is normal but the squeeze tone is reduced. Which of the following is the most likely diagnosis? A) Brown sequard syndrome B) Anterior spinal cord syndrome C) Central cord syndrome D) Conus medullaris syndrome E) Cauda equina syndrome Q9/ A 67-year-old man comes to the physician because of worsening lower back pain for 6 weeks. He reports that the pain is most intense with movement and that it some mes occurs at night. Over the past 3 months, he has no ced a weakened urinary stream. He has not seen any blood in his urine. His only daily medica on is ibuprofen, which does not provide adequate pain relief. Examina on shows no spinal deformi es. Palpa on of the lumbar spinal process elicits localized tenderness. Muscle strength is normal. Sensa on is intact bilaterally. Which of the following is the most likely cause of this pa ent’s back pain? A) Malignancy B) Lumbar spinal cord C) Osteoporosis D) Spinal epidural abscess Family Medicine – Rheumatoid Arthri s Q1/ A 39-year-old woman comes to the physician because of progressive pain and swelling of her wrists and hands for the past 2 months. Her hands are stiff in the morning; the stiffness decreases as she starts her chores. She also reports early-morning neck pain at rest for the past 3 weeks. She has no history of serious illness and takes no medications. Her sister has systemic lupus erythematosus. Vital signs are within normal limits. Examination shows bilateral swelling and tenderness of the wrists, second, third, and fourth metacarpophalangeal joints; range of motion is limited by pain. There is no vertebral tenderness. Cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. Laboratory studies show: Hemoglobin 12.8 g/dL Leukocyte count 9800/mm3 Erythrocyte sedimentation rate 44 mm/h Serum Glucose 77 mg/dL Creatinine 1.1 mg/dL Total bilirubin 0.7 mg/dL Alkaline phosphatase 33 U/L AST 24 U/L ALT 21 U/L Rheumatoid factor positive Which of the following is the most appropriate next step in management? A) Arthrocentesis B) Adalimumab C) X-ray of the cervical spine D) CT scan of the chest Q2/ A 42-year-old woman comes to the physician because of an 8-month history of intermi ent pain and s ffness in her hands and feet. She reports that these episodes occur about three mes a month a er she wakes up and last for approximately one hour. The episodes are some mes accompanied by fever and myalgia. She takes ibuprofen during the episodes, which provides sufficient pain relief. She had her last a ack 5 daysago. She is otherwise healthy and takes no  medica ons. Her sister has systemic lupus erythematosus. Vital signs are within normal limits. Examina on shows mild swelling and tenderness of the wrists and the proximal interphalangeal joints of both hands. The remainder of the examina on shows no abnormali es. An x-ray of her hands is shown. Which of the following is the most appropriate pharmacotherapy? A) Methotrexate B) Ceftriaxone C) Hydroxychloroquine D) Adalimumab Q3/ A 46-year-old woman comes to the physician with a 4-month history of lethargy. She has had joint pain for the past 15 years and does not have a primary care physician. Her temperature is 37.4°C (99.3°F), pulse is 97/min, and blood pressure is 132/86 mm Hg. Physical examination shows pallor of the oral mucosa and nontender subcutaneous nodules on both elbows. The distal interphalangeal joints of both hands are flexed and the proximal interphalangeal joints appear hyperextended. Range of motion in the fingers is restricted. The liver span is 6 cm and the spleen tip is palpated 4 cm below the left costal margin. Laboratory studies show: Hematocrit 33% Leukocyte count 1,800/mm3 Segmented neutrophils 35% Lymphocytes 60% Platelet count 130,000/mm3 Increased serum titers of which of the following is most specific for this patient's condition? A) Anti-cyclical citrullinated peptide antibody B) Anti-Smith antibody C) Antinuclear antibody D) Rheumatoid factor Q4/ A 45-year-old woman comes to the emergency department because of severe pain in both of her wrist joints and her fingers for the past 24 hours. She has a 6- month history of similar episodes, which are o en associated with s ffness for about 90 minutes when she wakes up in the morning. She has hyperlipidemia and hypertension. Two years ago, she was diagnosed with pep c ulcer disease, for which she underwent treatment. Current medica ons include fenofibrate and amlodipine. Vital signs are within normal limits. She is 175 cm (5 9 in) tall and weighs 102 kg (225 lb); BMI is 33 kg/m2. Examina on shows swelling and tenderness of the wrists and metacarpophalangeal joints bilaterally. Range of mo on is decreased due to pain. There are subcutaneous, nontender, firm, mobile noduleson the extensor surface of the forearm, with the overlying skin appearing normal. Which of the following is the most appropriate acute treatment for this pa ent's symptoms? A) Indomethacin B) Methotrexate C) Prednisolone D) Adalimumab Q5/ A 48-year-old woman comes to the physician because of an increasingly painful swelling behind her right knee for the past 2 months. During this me, she has also had intermi ent low-grade fevers and has been more fa gued than usual. She has not had any trauma to the knee. Over the past year, she has had occasional pain in her hands and wrists bilaterally. She has hypertension and type 2 diabetes mellitus. She drinks one to two glasses of wine daily and occasionally more on weekends. Current medica ons include enalapril, me ormin, and glimepiride. Her mother and older brother have osteoarthri s. She is 165 cm (5 5 in) tall and weighs 68 kg (150 lb); BMI is 25 kg/m2. Vital signs are within normal limits. Examina on shows a 3-cm nontender mass in the right popliteal fossa that becomes prominent when the knee is extended. There is mild swelling and redness of her right knee joint. Which of the following is the most likely diagnosis? A) Osteoarthri s B) Psoria c arthri s C) Popliteal artery aneurysm D) Rheumatoid arthri s Q6/ A 66-year-old man comes to the physician because of fatigue and swelling of his legs and feet for 6 weeks. During this time, he has felt like his eyes have been unusually puffy in the mornings and his urine has been frothy. He has hypertension and rheumatoid factor-positive rheumatoid arthritis. Current medications include amlodipine, methotrexate, and ibuprofen. He does not smoke. He has a history of chronic alcohol use. His temperature is 36.7°C (98°F), pulse is 80/min, and blood pressure is 148/86 mm Hg. Physical examination shows pallor, periorbital edema, 2+ pedal edema, and ascites. He has swan-neck deformities and nodules on multiple fingers and swelling and restricted range of motion of bilateral knee joints. Laboratory studies show: Hemoglobin 8.2 mg/dL Prothrombin time 12 sec Serum Albumin 2.8 g/dL Total bilirubin 1.0 mg/dL Alkaline phosphatase 80 U/L AST 20 U/L ALT 19 U/L Urea 18 mg/dL Creatinine 1.2 mg/dL Urine Protein 3+ WBCs 5–10/hpf RBCs negative  Bacteria negative Ultrasound of the liver and kidneys shows no abnormalities. Which of the following is the most likely cause of this patient's findings? A) Decreased hepatic albumin production B) adverse effect of amlodipine C) Renal AL amyloid deposi on D) Increased serum amyloid A produc on Q7/ A 50-year-old woman comes to the physician because of worsening pain and swelling of her le knee. For the past year, she has had pain in her knees and hands bilaterally, but never this severe. During this period, she has also had difficul es moving around for about an hour in the mornings and has been swea ng more than usual, especially at night. She has been sexually ac ve with a new partner for the past 4 weeks, and they use condoms inconsistently. She occasionally drinks alcohol. The day before she drank 6 beers because she was celebra ng a friend's birthday. Her temperature is 38.5°C (101.3°F), pulse is 92/min, and blood pressure is 110/70 mm Hg. The le knee is erythematous, swollen, and tender; movement is restricted due to pain. There is swelling of the metacarpophalangeal joints and proximal interphalangeal joints bilaterally. Arthrocentesis of the knee with synovial fluid analysis shows a greenish, turbid fluid, a cell count of 68,000 WBC/μL, and Gram-nega ve diplococci. An x-ray of the affected knee is most likely to show which of the following findings? A) Calcifica on and osteolysis with moth-eaten appearance B) Sunburst appearance of lytic bone lesions and codman triangle C) irregularity or fragmentation of the tibial tuberosity D) Punched-out ly c bone lesions with spiky periosteal apposi ons E) Joint space narrowing and bone erosions Q8/ A 32-year-old woman comes to the physician because of pain and s ffness in both of her hands for the past 3 weeks. The pain is most severe early in the day and does not respond to ibuprofen. She has no history of serious illness and takes no medica ons. Vital signs are within normal limits. Examina on shows swelling and tenderness of the wrists and metacarpophalangeal joints bilaterally. Range of mo on is decreased due to pain. There are subcutaneous, nontender, firm, mobile nodules on the extensor surface of the forearm. Which of the following is the most appropriate pharmacotherapy for this pa ent's current symptoms? A) Methotrexate B) Adalimumab C) Colchicine D) Sulfasalazine E) Prednisone Q9/ A 56-year-old woman with rheumatoid arthri s comes to the physician for a follow- up examina on. She has no other history of serious illness. Menopause occurred 1 year ago. Current medica ons include an rheuma c drugs and hormone replacement therapy. She exercises regularly. A DEXA scan shows a T-score of -1.80, indica ng decreased bone density. Which of the following drugs is most likely involved in the pathogenesis of this finding? A) Sulfasalazine B) Medroxyprogesterone acetate C) Naproxen D) Prednisone Q10/ A 31-year-old woman comes to the physician because of a 2-day history of low- grade intermi ent fever, dyspnea, and chest pain that worsens on deep inspira on. Over the past 4 weeks, she has had pain in her wrists and the fingers of both hands. During this period, she has also had difficul es working on her computer due to limited range of mo on in her fingers, which tends to be more severe in the morning. Her temperature is 37.7°C (99.8°F). Physical examina on shows a high-pitched scratching sound over the le sternal border. Further evalua on of this pa ent is most likely to reveal which of the following findings? A) Muta on of the HFE gene B) Blood urea nitrogen level > 60 mg/dL C) Decreased C3 complement levels D) Increased ter of an -citrullinated pep de an bodies Q11/ A 47-year-old woman comes to the physician because of progressive pain and s ffness in her hands and wrists for the past several months. Her hands are s ff in the morning; the s ffness improves as she starts her chores. Physical examina on shows bilateral swelling and tenderness of the wrists, metacarpophalangeal joints, and proximal interphalangeal joints. Her range of mo on is limited by pain. Laboratory studies show an increased erythrocyte sedimenta on rate. This pa ent's condi on is most likely associated with which of the following findings? A) IgG an bodies with a TNF-a binding domain on the Fc region B) HLA-DQ2 proteins on WBCs C) Membrane proteins that bind to the Fc region of IgG D) HLA-B27 protein on WBCs E) IgM an bodies against the Fc region of IgG Q12/Case scenario: Patient Information: Age: 42 years, Gender: F, self-identified, Race/Ethnicity: unspecified, Site of Care: office History Reason for Visit/Chief Concern: “I am tired and my joints hurt.” History of Present Illness:  fatigue, myalgia, and joint pain over several years  joint pain rated 5/10 at worst  neck pain at rest most mornings, lasting more than an hour  occasionally wakes up at night with tingling in the right volar hand and thumb Past Medical History:  no recent medical care in over a decade due to limited health care coverage  generalized anxiety disorder Medications:  citalopram Allergies:   no known drug allergies Family History:  mother and father alive with no chronic conditions Psychosocial History:  has smoked one-half pack of cigarettes daily for 10 years  does not drink alcoholic beverages  not sexually active Physical Examination Temp Pulse Resp BP Ht Wt BMI 36.8°C 164 cm 90 kg 87/min 14/min 142/85 mm Hg 33 kg/m2 (98.2°F) (5 ft 5 in) (198 lb)  Appearance: no acute distress  HEENT: conjunctival pallor; thyroid gland is normal in size with no mass or tenderness  Cardiac: regular rhythm; no murmurs  Musculoskeletal: flexion of proximal interphalangeal joints of bilateral index fingers with hyperextension of distal interphalangeal joints; tenderness and swelling in metacarpophalangeal and proximal interphalangeal joints of both hands and metatarsophalangeal joint of right 1st and 2nd toes  Neurologic: shooting pain along the right upper neck and shoulder with tilt and rotation of the neck toward the right side while applying downward pressure to the head Diagnostic Studies Blood  Hemoglobin 10.1 g/dL WBC 4,200/mm3 Platelet count 345,000/mm3 ESR 42 mm/h Testing for which of the following serum parameters is most likely to yield a positive result? A) Anticentromere antibody B) An -double-stranded DNA C) Antinuclear antibody (ANA) D) Rheumatoid factor Q13/ A 42-year-old woman comes to the physician because of a 10-month history of joint pain and s ffness in her wrists and fingers. The symptoms are worse in the morning and improve with ac vity. Physical examina on shows swelling and warmth over the MCP and wrist joints in both hands. An x-ray of the hands is shown. Synovial biopsy from an affected joint would most likely show which of the following? A) Noninflammatory superficial fibrin deposits B) Monosodium urate crystals C) calcium pyrophosphate crystals D) Proliferation of granulation tissue Surgery – Cirrhosis Q1/ A 44-year-old man comes to the physician because of increasing fatigue for the past year. He says that his trousers do not fit him anymore as his waist has increased in size during this time. He had not seen his primary care physician for 7 years. He takes no medications. His temperature is 37.1°C (98.7°F), pulse is 65/min, respiratory rate is 15/min, and blood pressure is 120/70 mm Hg. Physical examination shows erythema on both of his palms. The abdomen is nontender but difficult to assess due to severe distension. Laboratory studies show: Hemoglobin 11 g/dL Hematocrit 33% Leukocyte count 7000/mm3 Platelet count 90,000/mm3 Serum Urea nitrogen 35 mg/dL Creatinine 1.3 mg/dL Total bilirubin 3.0 mg/dL Carbohydrate-deficient transferrin 3.4% (N < 1.5%) Test results for hepatitis B and C are negative. Which of the following is the most likely explanation for this patient's thrombocytopenia? A) Bone marrow infiltration B) Uremia C) Thrombotic microangiopathies D) Hypersplenism Q2/ A 59-year-old man with a history of alcoholic cirrhosis is brought to the physician by his wife for a 1-week history of progressive abdominal distension and yellowing of the eyes. For the past month, he has been irritable, had difficulty falling asleep, become clumsy, and fallen frequently. Two months ago he underwent banding for esophageal varices a er an episode of vomi ng blood. His vital signs are within normal limits. Physical examina on shows jaundice, mul ple bruises, pedal edema, gynecomas a, loss of pubic hair, and small, firm testes. There are mul ple small vascular lesions on his chest and neck that blanch with pressure. His hands are erythematous and warm; there is a flexion contracture of his le 4th finger. A flapping tremor is seen when extending the forearms and wrist. Abdominal examina on shows dilated veins over the anterior abdominal wall, the spleen p is palpated 4 cm below the le costal margin, and there is shi ing dullness on percussion. Which of the following pairs of physical examina on findings are caused by the same underlying pathophysiology? A) Splenomegaly and Dupuytren contracture B) Jaundice and flapping tremor C) Palmar erythema and gynecomastia D) Esophageal varices and pedal edema Q3/ A 52-year-old man comes to the physician because his skin has been progressively yellowing for the past 4 weeks. He also reports low appe te and difficulty fi ng into his pants because of his swollen legs over the past several months. There is no personal or family history of serious illness. He does not smoke and drinks one to two beers on special occasions. He used to be sexually ac ve with mul ple female partners but has lost interest in sexual intercourse recently. He is 178 cm (5 10 in) tall and weighs 68 kg(150 lb); his BMI is 22 kg/m2. Vital signs are within normal limits. Physical examina on shows yellowing of the skin and sclera as well as erythema of the palms. There is bilateral enlargement of breast ssue. Cardiopulmonary examina ons show no abnormali es. The abdomen is distended. The liver is palpated 2 to 3 cm below the right costal margin. On percussion of the le abdomen, a thrill can be felt on the right side. Hepatojugular reflux is absent. There is bilateral edema below the knees. Which of the following is the most likely underlying cause of this pa ent's condi on? A) Chronic viral hepatitis B) Congestive hepatopathy C) Primary biliary cholangitis D) Primary sclerosing cholangitis Q4/ A 55-year-old man comes to the physician for a follow-up examination. During the past month, he has had mild itching. He has alcoholic cirrhosis, hypertension, and gastroesophageal reflux disease. He used to drink a pint of vodka and multiple beers daily but quit 4 months ago. Current medications include ramipril, esomeprazole, and vitamin Bsupplements. He appears thin. His temperature is 36.8°C (98.2°F), pulse is 68/min, and blood pressure is 115/72 mm Hg. Examination shows reddening of the palms bilaterally and several telangiectasias over the chest, abdomen, and back. There is symmetrical enlargement of the breast tissue bilaterally. His testes are small and firm on palpation. The remainder of the examination shows no abnormalities. Laboratory studies show: Hemoglobin 10.1 g/dL Leukocyte count 4300/mm3 Platelet count 89,000/mm3 Prothrombin time 11 sec (INR = 1) Serum Albumin 3 g/dL Bilirubin Total 2.0 mg/dL Direct 0.2 mg/dL Alkaline phosphatase 43 U/L AST 65 U/L ALT 50 U/L α-Fetoprotein 8 ng/mL (N < 10)  Anti-HAV IgG antibody positive Anti-HBs antibody negative Abdominal ultrasonography shows a nodular liver surface with atrophy of the right lobe of the liver. An upper endoscopy shows no abnormalities. Which of the following is the most appropriate next step in management? A) Measure serum α-fetoprotein levels in 3 months B) Repeat upper endoscopy in 3 months C) Administer hepatitis A vaccine now D) Obtain CT scan of the abdomen now E) Repeat abdominal ultrasound in 6 months Q5/ A 47-year-old man with alcoholic cirrhosis comes to the physician for a follow- upexamina on. Examina on of the skin shows erythema over the thenar and hypothenar eminences of both hands. He also has numerous blanching lesions over the trunk and upper extremi es that have a central red vessel with thin extensions radia ng outwards. Which of the following is the most likely underlying cause of these findings? A) Increased circulating ammonia B) Decreased circulating albumin C) Decreased circulating thrombopoietin D) Decreased circulating testosterone E) Increased circulating cortisol F) Increased circulating estrogen Q6/ A 59-year-old man comes to the emergency department because of progressive abdominal swelling and shortness of breath for 1 week. He drinks 12 to 13 alcoholicbeverages daily. He appears emaciated. Examina on shows pallor, jaundice, hepatomegaly, gynecomas a, and a protuberant abdomen with a fluid wave and shi ing dullness. Periodic monitoring of which of the following markers is most appropriate for this pa ent?  A) Chromogranin A B) Calcitonin C) Desmin D) S-100 protein E) Alpha fetoprotein Q7/ A 65-year-old man is brought to the emergency department because of a 1- day history of fever and disorienta on. His wife reports that he had abdominal pain and diarrhea the previous day. He drinks 60 oz of alcohol weekly. His pulse is 110/min and blood pressure is 96/58 mm Hg. Examina on shows jaundice, palmar erythema, spider nevi on his chest, dilated veins on the anterior abdominal wall, and 2+ edema of the lower extremi es. The abdomen is so and diffusely tender; there is shi ing dullness to percussion. His albumin is 1.4 g/dL, bilirubin is 5 mg/dL, and prothrombin me is 31 seconds (INR = 3.3). Hepa s serology is nega ve. A CT scan of the abdomen is shown. Which of the following processes is the most likely explana on for these findings? A) Accumula on of iron in hepatocytes B) Hepatocyte swelling and necrosis with neutrophilic infiltration C) Ground-glass hepatocytes with cytotoxic T cells D) Fibrous bands surrounding regenerating hepatocytes Q8/ A 55-year-old woman comes to the physician for a follow-up examina on 2 months a er being diagnosed with alcoholic liver cirrhosis. She feels well. She has no ced a slowly progressive increase in her abdominal circumference for the past month. She has a history of major depressive disorder. Her father passed away from a heart a ack at the age of 52 years. She does not smoke. She has a 10-year history of drinking 1–3 bo les of wine daily, but recently par cipated in an alcohol rehabilita on program and has not drunk alcohol for the past 6 weeks. She takes no medica ons. The pa ent is 165 cm (5 5 in) tall and weighs 50 kg (110 lb); BMI is 18 kg/m2. She is alert and fully oriented. Temperature is 37.0°C (98.6°F), pulse is 89/min, and blood pressure is 124/76 mm Hg. Physical examina on shows palmar erythema, scleral icterus, and a distended abdomen with shi ing dullness. The liver edge is palpated 5 cm below the right costal margin. There are prominent telangiectasias on the pa ent's nose. The remainder of the examina on, including neurological examina on, is unremarkable. Abdominal paracentesis yields clear, yellow fluid. Which of the following is the most appropriate next step in the evalua on of this pa ent? A) Abdominal CT scan B) Mini-Mental state Examina on C) Echocardiography D) Peritoneal fluid culture E) Upper endoscopy Q9/ A previously healthy 44-year-old man comes to his physician because of frequent urina on and increased thirst for several weeks. Physical examina on shows darkened skin and a firm mass in the right upper quadrant. His blood glucose is 220 mg/dL. A photomicrograph of a specimen obtained on liver biopsy is shown. Which of the following best describes the pathogenesis of the disease process in this pa ent? A) Upregula on of erythropoie n produc on B) Absence of B-globin synthesis C) Absence of a serine protease inhibitor D) Defec ve transferrin receptor binding Surgery – Portal hypertension Q1/ A 45-year-old man comes to the physician because of bright red blood in his stool for 5 days. He has had no pain during defeca on and no abdominal pain. One year ago, he was diagnosed with cirrhosis a er being admi ed to the emergency department for upper gastrointes nal bleeding. He has since cut down on his drinking and consumes around 5 bo les of beer daily. Examina on shows scleral icterus and mild ankle swelling. Palpa on of the abdomen shows a fluid wave and shi ing dullness. Anoscopy shows enlarged bluish vessels above the dentate line. Which of the following is the most likely source of bleeding in this pa ent? A) Superior rectal vein B) Internal pudendal vien C) Inferior mesenteric artery D) Inferior rectal Q2/ A 45-year-old man is brought to the physician for a follow-up examina on. Three weeks ago, he was hospitalized and treated for spontaneous bacterial peritoni s. He has alcoholic liver cirrhosis and hypothyroidism. His current medica ons include spironolactone, lactulose, levothyroxine, trimethoprim-sulfamethoxazole, and furosemide. He appears ill. His temperature is 36.8°C (98.2°F), pulse is 77/min, and blood pressure is 106/68 mm Hg. He is oriented to place and person only. Examina on shows scleral icterus and jaundice. There is 3+ pedal edema and reddening of the palms bilaterally. Breast ssue appears enlarged, and several telangiectasias are visible over the chest and back. Abdominal examina on shows dilated tortuous veins. On percussion of the abdomen, the fluid-air level shi s when the pa ent moves from lying supine to right lateral decubitus. Breath sounds are decreased over both lung bases. Cardiac examina on shows no abnormali es. Bilateral tremor is seen when the wrists are extended. Genital examina on shows reduced tes cular volume of both testes. Digital rectal examina on and proctoscopy show hemorrhoids. Which of the following complica ons, if seen in this pa ent, would be the strongest indica on for the placement of a transjugular intrahepa c portosystemic shunt (TIPS)? A) Hepa c veno-occlusive disease B) Recurrent variceal haemorrhage C) Portal hypertensive gastropathy D) Hepa c encephalopathy Q3/ A 49-year-old man with alcoholic cirrhosis is brought to the emergency department by his wife because of 2 episodes of vomi ng bright red blood over the past 2 hours. His wife reports that he drank 1 bo le of vodka over the past 24 hours. During this me, he has had nausea but no bloody or tarry stool, and no abdominal pain. There is no history of similar episodes. The pa ent takes no medica ons. On arrival, he is awake but confused. His temperature is 36°C (96.8°F), pulse is 92/min, and blood pressure is 110/82 mm Hg. Physical examina on shows ascites. On mental status examina on, he is not oriented to person, place, or me. During the examina on, the pa ent has another episode of vomi ng blood. His hemoglobin concentra on is 9.5 g/dL. Two large intravenous catheters are placed. Administra on of intravenous fluids, octreo de, and ce riaxone is begun. When vital signs are measured again, his pulse is 94/min and blood pressure is 109/80 mm Hg. Which of the following is the most appropriate next step in management? A) Place nasogastric tube B) Administer packed RBC C) Perform endotracheal intuba on  D) Administer oral omeprazole Q4/ A 65-year-old man comes to the physician because of progressive abdominal distension and swelling of his legs for 4 months. He has a history of ulcera ve coli s. Physical examina on shows jaundice. Abdominal examina on shows shi ing dullness and dilated veins in the periumbilical region. This pa ent's abdominal findings are most likely caused by increased blood flow in which of the following vessels? A) Le gastric vein B) Hepa c vein C) Splenic D) Superior epigastric vein Medicine – Myocardial infarc on Q1/ A 76-year-old woman is brought to the emergency department by her son because of a 1-day history of upper abdominal pain, nausea, and dyspnea. She was diagnosed with an inferior wall myocardial infarc on 3 days ago and was successfully treated with coronary stent placement. She lives alone since her husband died 2 years ago. Her medical history is significant for type 2 diabetes mellitus and recently diagnosed Alzheimer disease. Her medica ons include aspirin, clopidogrel, atorvasta n, metoprolol, lisinopril, and me ormin. The son reports that she has trouble remembering to take medica ons regularly. She drinks two to three glasses of wine daily. She is alert and oriented to person and place but not to me. Her temperature is 36.9°C (98.4°F), pulse is 59/min, respira ons are 17/min, and blood pressure is 145/77 mm Hg. Physical examina on shows no other abnormali es. Which of the following is most likely to establish the diagnosis? A) Measurement of serum lipase ac vity B) Serial measurement of serum troponin concentra on C) CT angiography of the abdomen D) Echocardiography Q2/ A 55-year-old man comes to the emergency department because of a dry cough and severe chest pain beginning that morning. Two months ago, he was diagnosed with inferior wall myocardial infarc on and was treated with stent implanta on of the right coronary artery. He has a history of hypertension and hypercholesterolemia. His medica ons include aspirin, clopidogrel, atorvasta n, and enalapril. His temperature is 38.5°C (101.3°F), pulse is 92/min, respira ons are 22/min, and blood pressure is 130/80 mm Hg. Cardiac examina on shows a high-pitched scratching sound best heard while si ng upright and during expira on. The remainder of the examina on shows no abnormali es. An ECG shows diffuse ST eleva ons. Serum studies show a troponin I of 0.2 ng/mL. Which of the following is the most likely cause of this pa ent's symptoms? A) Cardiac tamponade B) Constrictive pericarditis C) Aortic dissection D) Reinfarction E) Early infarct-associated pericarditis F) Dresser syndrome Q3/ Three days after undergoing cardiac catheterization and coronary angioplasty for acute myocardial infarction, a 70-year-old man develops shortness of breath at rest. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. His current medications include aspirin, clopidogrel, atorvastatin, sublingual nitroglycerin, metoprolol, and insulin. He appears diaphoretic. His temperature is 37.0°C (98.6°F), pulse is 120/min, respirations are 22/min, and blood pressure is 100/55 mm Hg. Crackles are heard at both lung bases. Cardiac examination shows a new grade 3/6 holosystolic murmur heard best at the cardiac apex. An ECG shows sinus rhythm with T wave inversion in leads II, III, and aVF. Which of the following is the most likely explanation for this patient's symptoms? A) Left ventricular aneurysm B) Early infarct-associated pericarditis C) Ventricular septal rupture D) Postmyocardial infarction syndrome E) Coronary artery dissection F) Ventricular free wall rupture G) Papillary muscle rupture Q4/ A 55-year-old man is brought to the emergency department because of sharp chest painfor the past 3 hours. He reports that he can only take shallow breaths because deep inspiration worsens the pain. He also says that the pain increases with coughing. Two weeks ago, he underwent cardiac catheterization for an acute myocardial infarction. Current medications include aspirin, ticagrelor, atorvastatin, metoprolol, and lisinopril. His temperature is 38.5°C (101.1°F), pulse is 55/min, respirations are 23/min, and blood pressure is 125/75 mm Hg. Cardiac examination shows a high-pitched scratching soundheard best when the patient is sitting upright and during expiration. An ECG shows diffuse ST elevations and ST depression in aVR and V1. Echocardiography shows no abnormalities. Which of the following is the most appropriate treatment? A) Start heparin infusion B) Administer vancomycin and ceftriaxone C) Administer prednisone D) Administer nitroglycerin E) Increase aspirin dose Q5/ A 57-year-old man is brought to the emergency department for crushing substernal chest pain at rest for the past 2 hours. The pain began gradually while he was having an argument with his wife and is now severe. He does not take any medications. He has smoked one pack of cigarettes daily for 35 years. He is diaphoretic. His temperature is 37.1°C (98.8°F), pulse is 110/min, respirations are 21/min, and blood pressure is 115/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Cardiac examination shows an S4 gallop. The lungs are clear to auscultation. An ECG is shown. Which of the following is the most likely underlying cause of this patient's condition? a) Occlusion of the right coronary artery b) Inflammation of the pericardium c) Occlusion of the left anterior descending artery d) Thromboembolism to the right interlobar pulmonary artery e) Diffuse coronary vasospasm f) Occlusion of the left circumflex artery g) Tear in the intimal lining of the aorta Q6/ Serum studies show a troponin T concentration of 6.73 ng/mL, and fingerstick blood glucose concentration of 145 mg/dL. The cardiac catheterization team is activated. Treatment with unfractionated heparin, aspirin, ticagrelor, and sublingual nitroglycerin is begun, and the patient's pain subsides. His temperature is 37.3°C (99.1°F), pulse is 59/min, respirations are 23/min, and blood pressure is 89/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Which of the following is the most appropriate additional pharmacotherapy? a) Oral metoprolol b) Intravenous morphine c) Oral atorvastatin d) Intravenous furosemide Q7/ A 47-year-old man comes to the physician because of severe retrosternal chest pain and shortness of breath for 45 minutes. He has dyslipidemia, hypertension, and type 2diabetes mellitus. Current medications include hydrochlorothiazide, lisinopril, metformin, and atorvastatin. He has smoked one pack of cigarettes daily for 20 years. He appears pale and diaphoretic. His temperature is 37.0°C (98.6°F), pulse is 115/min, and blood pressure is 140/70 mm Hg. Breath sounds are normal. The remainder of the examination shows no abnormalities. An ECG shows left ventricular hypertrophy with ST-segmentelevation in leads I, aVL, and V1–V6. High-dose aspirin, clopidogrel, metoprolol, sublingual nitroglycerin, and unfractionated heparin are administered. As the patient awaits transport to the nearest emergency room, he collapses and becomes unresponsive. His pulse and blood pressure cannot be detected. Despite resuscitative efforts, the patient dies. Which of the following is the most likely cause of death in this patient? a) Papillary muscle rupture b) Left ventricular failure c) Ventricular fibrillation d) Pericarditis Q8/ A 54-year-old man is brought to the emergency department 1 hour after the sudden onset of shortness of breath, epigastric pain, and sweating. He has no history of similar symptoms. He has hypertension and type 2 diabetes mellitus. Current medications include amlodipine and metformin. He has smoked one pack of cigarettes daily for 20 years. He appears weak and pale. His pulse is 59/min, respirations are 18/min, and blood pressure is 85/56 mm Hg. Cardiac examination shows normal heart sounds. The lungs are clear to auscultation. The skin is cold to the touch. An ECG is shown. Bedside transthoracic echocardiography shows normal left ventricular function. High-dose aspirin is administered. Administration of which of the following is the most appropriate next step in management? a) Intravenous atropine b) Oral metoprolol c) Intravenous morphine d) Sublingual nitroglycerin e) Phenylephrine infusion f) Normal saline bolus Q9/ Four days after being admitted to the intensive care unit for acute substernal chest pain and dyspnea, an 80-year-old man is evaluated for hypotension. Coronary angiography on admission showed an occlusion in the left anterior descending artery, and a drug-eluting stent was placed successfully. The patient has a history of hypertension and type 2diabetes mellitus. Current medications include aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin. His temperature is 37.2°C (99°F), pulse is 112/min, respirations are 21/min, and blood pressure is 72/50 mm Hg. Cardiac examination shows a normal S1 and S2 and a new harsh, holosystolic murmur heard best at the left sternal border. There is jugular venous distention and a right parasternal heave. The lungs are clear to auscultation. Pitting edema extends up to the knees bilaterally. An ECG shows Q waves in the anterior leads. Which of the following is the most likely cause of this patient’s hypotension? a) Ascending aortic dissection rupture b) Post-infarction fibrinous pericarditis c) Left ventricular free wall rupture d) Left ventricular aneurysm rupture e) Papillary muscle rupture f) Interventricular septum rupture Q10/ A 65-year-old man is brought to the emergency department 30 minutes after the onset of acute chest pain. He has hypertension and asthma. Current medications include atorvastatin, lisinopril, and an albuterol inhaler. He appears pale and diaphoretic. His pulse is 114/min and blood pressure is 130/88 mm Hg. An ECG shows ST- segment depressions in leads II, III, and aVF. Laboratory studies show an increased serum troponin Tconcentration. The patient is treated for acute coronary syndrome and undergoes percutaneous transluminal coronary angioplasty with stent placement. At the time of discharge, echocardiography shows a left ventricular ejection fraction of 58%. In addition to aspirin, which of the following drugs should be added to this patient's medication regimen? a) Valsartan b) Nifedipine c) Enoxaparin d) Clopidogrel Q11/ A 69-year-old man is brought to the emergency department because of severe epigastric pain and vomiting that started 30 minutes ago while gardening. His pulse is 55/min, respirations are 30/min, and blood pressure is 90/50 mm Hg. Physical examination shows diaphoresis and jugular venous distention. An ECG shows P waves independent of QRS complexes and ST segment elevation in leads II, III, and aVF. Coronary angiography is most likely to show narrowing of which of the following vessels? a) Left coronary artery b) Proximal right coronary artery c) Left circumflex artery d) Left anterior descending artery Q12/ Two days after being admitted for acute myocardial infarction, a 61-year-old man has sharp, substernal chest pain that worsens with inspiration and improves when leaning forward. Cardiac examination shows a scratchy sound best heard over the left sternal border. Histopathological examination of the affected tissue is most likely to show which of the following findings? a) Neutrophilic infiltration b) Normal myocardium c) Hypercontracted myofibrils d) Collagenous scar tissue Q13/ A 61-year-old man is brought to the emergency department by ambulance because of severe retrosternal chest pain and shortness of breath for 30 minutes. Paramedics report that an ECG recorded en route to the hospital showed ST-segment elevation in I, aVL, and the precordial leads. On arrival, the patient is unresponsive to painful stimuli. Examination shows neither respiration nor pulse. Despite appropriate lifesaving measures, he dies10 minutes later. Which of the following is the most likely cause of death in this patient? a) Cardiac septal rupture b) Left ventricular failure c) Ventricular aneurysm d) Hemorrhagic stroke e) Cardiac free wall rupture f) Ventricular fibrillation Q14/ Seventy-two hours after admission for an acute myocardial infarction, a 48-year- old man develops dyspnea and a productive cough with frothy sputum. Physical examination shows coarse crackles in both lungs and a blowing, holosystolic murmur heard best at the apex. ECG shows Q waves in the anteroseptal leads. Pulmonary capillary wedge pressure is 23 mm Hg. Which of the following is the most likely cause of this patient’s current condition? a) Postmyocardial infarction syndrome b) Aortic root dilation c) Rupture of the chordae tendinae d) Rupture of the ventricular free wall Q15/ A 76-year-old man is admitted to the hospital for evaluation of sudden-onset chest pain. Three days after admission, he develops severe shortness of breath. Despite appropriate care, the patient dies. The left ventricle of the heart at autopsy is shown. Which of the following most likely contributed to this patient's cause of death? a) Occlusion of the posterior descending artery b) Exudative inflammation of the pericardium c) Pseudoaneurysmatic dilation of the left ventricle d) Rupture of the interventricular septum Q16/ A 55-year-old man comes to the emergency department because of left- sided chest pain and difficulty breathing for the past 30 minutes. His pulse is 88/min. He is pale and anxious. Serum studies show increased cardiac enzymes. An ECG shows ST- elevations in leads I, aVL, and V5-V6. A percutaneous coronary intervention is performed. In order to localize the site of the lesion, the catheter must pass through which of the following structures? a) Posterior coronary sinus -> left circumflex artery b) Left coronary artery -> left circumflex artery c) Right coronary artery -> right marginal artery d) Left coronary artery - posterior descending artery Q17/ An 80-year-old man is admitted to the hospital after the sudden onset of sub- sternalchest pain and shortness of breath while sitting in a chair. He has hypertension and type 2diabetes mellitus. He has smoked 1 pack of cigarettes daily for 42 years. Four days after admission, he becomes tachycardic and then loses consciousness; the cardiac monitor shows irregular electrical activity. Cardiac examination shows a new systolic murmur at the apex. Despite appropriate measures, he dies. Microscopic evaluation of the myocardium is most likely to show which of the following? a) Coagulative necrosis with dense neutrophilic infiltrate b) Wavy myocardial fibers without inflammatory cells c) Low cellularity with dense, non-contractile scar tissue d) Dense granulation tissue with collagenous scar formation e) Hyperemic granulation tissue with abundance of macrophages Q18/ A 56-year-old man comes to the emergency department because of nausea and shortness of breath that started while he was at work 1 hour ago. He also reports lightheadednessthat started earlier in the day. He has type 2 diabetes mellitus, for which he takes metformin and sitagliptin. He has smoked 1 pack of cigarettes daily for 20 years. He appears pale and diaphoretic. A 12-lead ECG is shown. Which of the following is the most likely underlying cause of this patient's symptoms? a) Acute posterior myocardial infarction b) Viral myocarditis c) Ventricular fibrillation d) Acute pericarditis e) Acute inferior myocardial infarction Q19/ A 54-year-old woman is brought to the emergency department because of a 2- hourhistory of nausea and retrosternal chest pain. She has a 15-year history of type 2 diabetes mellitus. Her current medications include atorvastatin, metformin, and lisinopril. She is diaphoretic. Her serum troponin level is 3.0 ng/mL (N: < 0.04). She undergoes cardiac catheterization. A photograph of coronary angiography performed prior to percutaneous coronary intervention is shown. An acute myocardial infarction associated with the finding on angiography is most likely to manifest with ST elevations in which of the following leads on ECG? a) I,VR b) V3R – V6R c) VI-V6 d) lI, Ill, and aVF e) V7-V9 Q20/ A 67-year-old man comes to the emergency department because of retrosternal chest pressure and shortness of breath for 4 hours. The symptoms started while he was walking to work and have only minimally improved with rest. He has a history of type 2 diabetesmellitus. He has smoked one pack of cigarettes daily for 35 years. He appears uncomfortable. His pulse is 95/min. Serum studies show a normal troponin concentration. An ECG shows no abnormalities. Which of the following is the most likely underlying cause of this patient's symptoms? a) Aortic valve thickening and calcification b) Coronary artery occlusion due to transient increase in vascular tone c) Stable atherosclerotic plaque with 85% coronary artery occlusion d) Infarction and rupture of a papillary muscle e) Disruption of an atherosclerotic plaque with a nonocclusive coronary artery thrombus Q21/ A 62-year-old man is evaluated for sudden left arm pain 7 days after being admitted to the hospital for anterior ST-elevation myocardial infarction, which was treated with percutaneous coronary angioplasty and stenting of the distal left anterior descending artery. The sharp pain woke him up and he now is also complaining of numbness in the fingers and difficulty moving his arm. He has a history of hypertension and hyperlipidemia. Current medications include atorvastatin, aspirin, lisinopril, metoprolol, and clopidogrel. His temperature is 37.5°C (99.5°F), pulse is 102/min, respirations are 14/min, and blood pressure is 115/75 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. His left arm is cool to touch and pale, and the left radial pulse is not palpable. Muscle strength is 1/5 in the left upper extremity and 5/5 in all other extremities. Which of the following is the most likely underlying diagnosis? a) Papillary muscle rupture  b) Postmyocardial infarction syndrome c) latrogenic brachial arterial injury d) Ventricular pseudoaneurysm Q22/ A 63-year-old man comes to the physician because of a 1-month history of worsening shortness of breath on exertion and increased urinary frequency at night. During this time, he has used 2 pillows at night to avoid waking up from a dry cough and dyspnea. Three months ago, he had a myocardial infarction that was treated with placement of a stent in the left anterior descending artery. He has hypertension and type 2 diabetes mellitus. He smoked one pack of cigarettes daily for 40 years but quit 5 years ago. He does not drink alcohol. Current medications include aspirin, clopidogrel, enalapril, and insulin. His temperature is 37.0°C (98.6°F), pulse is 75/min, and blood pressure is 130/80 mm Hg. On cardiac examination, a grade 4/6 holosystolic murmur is heard best at the left sternal border. There is an S3 gallop. On pulmonary examination, crackles are heard over the lung base bilaterally. ECG shows persistent ST elevations and deep Q waves in leads V1 through V4. Which of the following is the most likely explanation for this patient's clinical findings? a) Ventricular aneurysm b) Papillary muscle rupture c) Ventricular septal rupture d) Right coronary artery occlusion Q23/ A 60-year-old man comes to the emergency department because of a 2-day history of sharp chest pain and a nonproductive cough. The pain worsens with deep inspiration and improves when he leans forward. Three weeks ago, the patient was diagnosed with an ST-elevation myocardial infarction and underwent stent implantation of the right coronary artery. His temperature is 38.4°C (101.1°F) and blood pressure is 132/85 mm Hg. Cardiac auscultation shows a high-pitched scratching sound during expiration. An x-ray of the chest shows enlargement of the cardiac silhouette and a left- sided pleural effusion. Which of the following is the most likely underlying cause of this patient's current condition? a) Outpouching of ventricular wall b) Occlusion of coronary artery stent c) Pericardial infiltration with neutrophils d) Embolism to left pulmonary artery e) Immune response to cardiac antigens Psychiatry – Approach to psychosis Q1/ A 23-year-old man is brought to the emergency department by his girlfriend because of a 12-hour history of agitation and bizarre behavior. The girlfriend reports that, over the past 3 months, the patient has become withdrawn and stopped pursuing hobbies that he used to enjoy. One month ago, he lost his job because he stopped going to work. During this time, he has barely left his apartment because he believes that the FBI is spying on him and controlling his mind. He used to smoke cannabis occasionally in high school but quit 5 years ago. Physical and neurologic examinations show no abnormalities. On mental status examination, he is confused and suspicious with marked psychomotor agitation. His speech is disorganized and his affect is labile. Which of the following is the most likely diagnosis? a) Schizoaffective disorder b) Brief psychotic disorder c) Schizoid personality disorder d) Substance-induced psychotic disorder e) Paranoid personality disorder f) Schizophrenia g) Schizophreniform disorder Q2/ A 23-year-old man is brought to the emergency department by his mother because of a change in his personality. The mother reports that over the past 7 months her son has become increasingly withdrawn; he has not answered any phone calls or visited his family and friends. He had always been a quiet boy, who needed some time on his own, but he used to meet with friends at least once a week. The patient says that he cannot leave the house because aliens are watching him and are “stealing his thoughts”. He does not drink alcohol. He used to smoke cannabis occasionally but quit 1 year ago. His vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, it is impossible to follow the patient's sequence of thoughts. He is anxious and has a flat affect. Which of the following is the most likely diagnosis? a) Brief psychotic disorder b) Schizotypal personality disorder c) Delusional disorder d) Mood disorder with psychotic features e) Schizoaffective disorder f) Paranoid personality disorder g) Substance-induced psychosis h) Schizophreniform disorder i) Schizoid personality disorder j) Schizophrenia Q3/ A 24-year-old male graduate student comes to the physician for a 2-month history of repetitive thoughts and anxiety that he is going to be harmed by a stranger on the street. The anxiety worsened after witnessing a pedestrian getting hit by a car 2 weeks ago. He says, “That was a warning sign.” On his way to school, he often leaves an hour early to take a detour and hide from people who he believes might hurt him. He says his friends are concerned about him but that they do not understand because they were not present at the accident. He reports no decline in academic performance. The patient has no known history of psychiatric illness. On mental status examination, he is alert and oriented, and shows full range of affect. Thought processes and speech are organized. His memory and attention are intact. He denies auditory, visual, or tactile hallucinations. Urine toxicology screening is negative. Which of the following is the most likely diagnosis in this patient? a) Avoidant personality disorder b) Schizotypal personality disorder c) Delusional disorder d) Schizophreniform disorder Q4/ A 23-year-old woman is brought to the physician by her father because of strange behavior for the past 6 months. The father reports that his daughter has increasingly isolated herself in college and received poor grades. She has told her father that aliens are trying to infiltrate her mind and that she has to continuously listen to the radio to monitor these activities. She appears anxious. Her vital signs are within normal limits. Physical examination shows no abnormalities. Neurologic examination shows no focal findings. Mental status examination shows psychomotor agitation. She says: “I can describe how the aliens chase me except for my car which is parked in the garage. You know, the sky is beautiful today. Why does my mother have a cat?” Which of the following best describes this patient's thought process? a) Circumstantial speech b) Thought-blocking c) Loose associations d) Flight of ideas Q5/ Two days after undergoing hemicolectomy for colon cancer, a 78-year-old man is found agitated and confused in his room. He says that a burglar broke in. The patient points at one corner of the room and says “There he is, doctor!” Closer inspection reveals that the patient is pointing to his bathrobe, which is hanging on the wall. The patient has type 2diabetes mellitus and hypertension. Current medications include insulin and hydrochlorothiazide. His temperature is 36.9°C (98.4°F), pulse is 89/min, respirations are 15/min, and blood pressure is 145/98 mm Hg. Physical examination shows a nontender, nonerythematous midline abdominal wound. On mental status examination, the patient is agitated and oriented only to person. Which of the following best describes this patient's perception? a) External attribution b) Illusion  c) Labile affect d) Delusion Q6/ A 61-year-old woman is brought to the emergency department by the police after she was found yelling at a bookshelf in a public library 30 minutes ago. The patient appears unkempt and restless. Her vital signs are within normal limits. Pulse oximetry on room air shows an oxygen saturation of 98%. On mental status examination, she talks very fast with occasional abrupt interruptions and frequent changes of topic. She is cooperative but requires continuous redirection. She is disoriented to time and repeatedly tells the physician, “I hear the sun telling me that I was chosen to save the universe.” The remainder of the examination, including cardiopulmonary and neurological examination, shows no abnormalities. The results of routine serum studies show no abnormalities and urine toxicology screening is negative. Which of the following is the most appropriate pharmacotherapy? a) Intravenous haloperidol b) Oral lorazepam c) Intravenous ketamine d) Oral valproic acid e) Oral risperidone Q7/ A 45-year-old woman comes to the emergency department with her 17-year- old son because she believes she has been poisoned by her ex-husband. She reports that her coffee tasted “strange” this morning. After breakfast, she then saw a black car drive by the house, which she concludes must have been her ex-husband, who also drives a black car. She says that since the divorce 3 years ago, her ex-husband has been seeking revenge and thinks that he has installed cameras in her apartment to spy on her and their son. She has never seen any of these cameras but when she is alone in the apartment, she can sometimes hear them beeping and feel them recording her. The son also reports his mother's coffee mug smelled of bitter almonds, which he suspects was cyanide. He agrees with the mother's distrust towards his father and reports that he has also occasionally heard a camera beeping but has not been able to find any cameras yet. The mother's vital signs are within normal limits. Physical examination shows no abnormalities. Arterial blood gas analysis on room air shows a pH of 7.4. Toxicology screening is negative. Which of the following is the most appropriate initial step in management? a) Ziprasidone therapy b) Fluphenazine treatment c) Examine mother and son separately d) Family therapy Q8/ A 29-year-old woman is brought to the physician by her father because of a change in her behavior over the past 8 months. The father says that his daughter has become increasingly withdrawn; she has not answered any phone calls or visited her family and friends. The patient says that she has to stay at home because a foreign intelligence service is monitoring her. She thinks that they are using a magnetic field to read her mind. Mental status exam shows disjointed and perseverative thinking. She is anxious and has a flat affect. Which of the following is the most likely diagnosis? a) Schizophrenia b) Delusional disorder c) Paranoid personality disorder d) Schizoid personality disorder e) Schizophreniform disorder Q9/ A 23-year-old woman is brought to the emergency department by her boyfriend because of a 4-month history of feeling sad. Her boyfriend says that, during this period, she has slept and eaten very li le and has been unable to focus at work. She says that she feels “empty inside” and has been hearing voices telling her that she is worthless. She first heard these voices 7 months ago when they started to make fun of her. She does not drink alcohol or use illicit drugs. Physical and neurological examina ons show no abnormali es. On mental status examina on, her speech is slow and monotonous; she abruptly stops talking in the middle of sentences and does not finish them. She occasionally directs her a en on to the ceiling as if she were listening to someone. Which of the following is the most likely diagnosis? a) Schizophrenia b) Schizophreniform disorder c) Brief psychotic disorder d) Schizoaffective disorder Q10/ A 38-year-old woman comes to the physician for a 6-week history of sleeping difficul es because she thinks that someone is watching her through security cameras. Her anxiety started 6 weeks ago when a security camera was installed outside her house by the police. Ever since, she has felt that she is being monitored by security cameras throughout the city. She avoids going outside whenever possible and refuses to take the subway. Whenever she needs to leave the house she wears large hats or hooded sweaters so that she cannot be recognized by the cameras. As soon as she arrives at her office or at home she feels safer. She was recently promoted to the team manager of a small adver sing agency. She takes no medica ons. On mental status examina on, she is alert, oriented, and shows a normal range of affect. Urine toxicology screening is nega ve. The pa ent's symptoms are best described as which of the following? a) Delirium b) Agoraphobia c) Delusions d) Derealization Q11/ An 18-year-old previously healthy woman is brought to the physician by her father because she has been ac ng strangely for the past week. The pa ent's only brother died of leukemia 10 days ago. The father says that since the funeral a week ago, the pa ent has stayed in her brother's room most of the me and only joined the parents for breakfast and dinner. She has not gone to school since her brother's death. She eats very li le and stays awake most of the night. The father reports that he has heard her talking in her brother's room even though she was alone and her phone was on the kitchen table. At the dinner table, she asked if she could have two extra plates for her friends, “Anna and Joseph,” although nobody had ever heard these names before. The pa ent says that she misses her brother a lot and that she feels red and sad all the me. She does not have nightmares or flashbacks and remembers details of her brother's last days and the funeral. She denies suicidal idea ons or feelings of guilt. She does not smoke cigare es, drink alcohol, or use drugs recrea onally. Her only medica on is a daily mul vitamin. She appears calm and is a en ve. Her speech is clear and organized. Her vital signs are within normal limits. During the examina on, she suddenly turns to the side and says: “Yes, Joseph, this is a very good ques on, but wait un l a er the examina on.” She then turns back to the physician and apologizes for the interrup on. Physical examina on shows no other abnormali es. Which of the following is the most likely diagnosis? a) Adiustment disorder b) Acute stress disorder c) Major depressive disorder with psychotic features d) Normal bereavement e) Pathological grief f) Schizoaffective disorder g) Schizophreniform disorder h) Brief psychotic disorder Q12/ A 30-year-old man is brought to the emergency department by his sister a er she stopped him from jumping off the balcony of his high-rise apartment building. The pa ent says, “I had to listen to the voices. They finally told me to fly away.” During the past 5 months, he has had a 10-kg (22-lb) weight loss due to decreased appe te and lack of energy. Two months ago, he was fired from his job because he was frequently absent without no ce and has since spent most of his me sleeping in his apartment. He says he doesn't care that he lost his job because, according to the pa ent, he felt “inadequate and stupid” anyway. He used to be an avid chess player but stopped because he could no longer concentrate when he played. He reports that he first started hearing voices 7 months ago and that they started giving him instruc ons about 3 weeks ago. He appears thin and disheveled. On mental status examina on, he has a depressed mood and flat affect. Physical examina on shows no other abnormali es. Toxicology screening of the urine is nega ve. Which of the following is the most likely diagnosis? a) Mood disorder with psychotic features b) Schizotypal personality disorder c) Schizoaffective disorder d) Brief psychotic disorder Q13/ A 26-year-old man is brought to the emergency department by his wife because of bizarre and agitated behavior for the last 6 weeks. He thinks that the Na onal Security Agency is spying on him and controlling his mind. His wife reports that the pa ent has become withdrawn and at mes depressed for the past 3 months. He lost his job because he stopped going to work 4 weeks ago. Since then, he has been working on an inven on that will block people from being able to control his mind. Physical and neurologic examina ons show no abnormali es. On mental status examina on, he is confused and suspicious with marked psychomotor agita on. His speech is disorganized and his affect is labile. Which of the following is the most likely diagnosis? a) Paranoid personality disorder b) Delusional disorder c) Schizophreniform disorder d) Schizophrenia