A 22 year-old medical student is brought to your office by his friends and his dad who is concerned about his mental status. His dad found him in a very dirty room. There are pizza boxes strewn all over the apartment. There is spoiled food in the refrigerator. He looks disheveled and unkempt as if he did not take a shower for many days. His friends report that for over a year, the patient has lost interest in things he used to take lots of pleasure like going on hiking and playing sports. He is staying in his room by himself staring at a Van Gogh’s the Starry Night painting on his wall. He feels a sense of emptiness and hopelessness in his life. On your questioning, the patient describes he is ‘feeling down’ most of the time. But when his energy levels are normal, he hears voices informing him that an alien race is planning to abduct all doctors from this nation. He affirms that ‘the White House already knew about this but kept the American people in the dark’. When he hears these voices, his friends report, he becomes completely disorganized and loses his focus on his studies and even on personal hygiene and sleep. He voiced a desire to mutilate his ear like Van Gogh, his favorite painter. He was seen urinating in a local public park when lots of other people were around him. He hears these voices for five to six weeks in a row and then for many months he feels just down. His dad informs that for many years, his son looked mostly ‘depressed’ except for these bouts of ‘alien nonsense’ which would come unexpectedly when he was doing just fine. What is the most likely diagnosis in this patient?

A 16 year-old female is brought to your office by her family members because she has been imagining things that are not grounded in reality. The symptoms started rapidly after the spring break holidays. For 5 months she can see the aliens coming on a mission to colonize this planet; she hears ‘satellite signals’ sent from an alien group who are stationed on a UFO; she smells the fumes coming out of the UFO engines. She believes that she and her family would be the first victims of the alien invasion. Her family reports that most of the time, she speaks in a flat voice, she stops in the middle of a sentence, uses words that have no meaning, and even when she expresses very dangerous scenarios, she expresses no emotions on her face. She dresses up oddly, like wearing winter gloves in summer. She takes a shower only once a week when the family members insist. She does not clean up after things get messy. She does not pay attention to the professors in the class and ‘stays in her own world’. Over half of the people first diagnosed with this disorder go on to get diagnosed with which of the following disorders?

A 70 year-old female was admitted to the hospital and had undergone elective cardiac surgery for aortic valve replacement. She was administered heparin for the prevention of thrombosis. On the second day of her admission, she developed a urinary tract infection and was started on trimethoprim-sulfamethoxazole. On the sixth day of her hospital stay, she developed fever, chills, hypertension, tachycardia, chest pain and shortness of breath. On physical examination, you noticed pain, redness, and swelling of her right arm. A severe rash developed in the skin where heparin was given. The attending nurse reports that she is meticulously administering heparin via intravenous route and using heparin flushes before using intravenous lines. Ultrasound of the right arm revealed deep venous thrombosis and a CT angiogram revealed a blood clot in the right lung. Laboratory tests reveal the following: Erythrocyte count (RBC) 4.2 million/mm³ Male: 4.3 – 5.9 million/mm³ Female: 3.5 – 5.5 million/mm³ Erythrocyte sedimentation rate (Westergren) 12 mm/h Male: 0-15 mm/h Female:0-20 mm/h Hematocrit 39% Male:41% – 53% Female: 36% – 46% Hemoglobin, blood 13.4 g/dL Male:13.5-17.5 g/dL Female 12.0 – 16.0 g/dL Leukocyte count (WBC) 7200 /mm³ 4500-11,000/mm³ Neutrophils, segmented 56% 54% – 62% Neutrophils, bands 4% 3% – 5% Eosinophils 1% 1% – 3% Basophils 0.5% 0% – 0.75% Lymphocytes 28% 25% – 33% Monocytes 4% 3% – 7% CD4+ T-lymphocyte count 1100 /mm³ ≥500/mm³ Platelet count 40,000/mm³ (on the day of admission: platelet count was 340,000/mm³ 150,000 – 400,000/mm³ Reticulocyte count 1.0% 0.5% – 1.5% D-Dimer 450 ng/mL ≤250 ng/mL Partial thromboplastin time (aPTT) (activated) 27 seconds 25-40 seconds Prothrombin time (PT) 10 seconds 11-15 seconds Mean corpuscular hemoglobin (MCH) 29 pg/cell 25 – 35 pg/cell Mean corpuscular hemoglobin concentration (MCHC) 34% Hb/cell 31% – 36% Hb/cell Mean corpuscular volume (MCV) 94 μ m³ 80-100 μ m³ PF4 ELISA Test Positive Suspecting heparin-induced thrombocytopenia in this patient, the chief clinician ordered a 4T score for this patient and got a value of 7. Which of the following is true regarding 4T scores?

A 72 year-old female was admitted to the hospital and had undergone elective cardiac surgery for aortic valve replacement. She was administered heparin for the prevention of thrombosis. On the second day of her admission, she developed a urinary tract infection and was started on trimethoprim-sulfamethoxazole. On the sixth day of her hospital stay, she developed fever, chills, hypertension, tachycardia, chest pain and shortness of breath. On physical examination, you noticed pain, redness, and swelling of her right arm. A severe rash developed in the skin where heparin was given. The attending nurse reports that she is meticulously administering heparin via intravenous route and using heparin flushes before using intravenous lines. Ultrasound of the right arm revealed deep venous thrombosis and a CT angiogram revealed a blood clot in the right lung. Laboratory tests reveal the following: Erythrocyte count (RBC) 4.2 million/mm³ Male: 4.3 – 5.9 million/mm³ Female: 3.5 – 5.5 million/mm³ Erythrocyte sedimentation rate (Westergren) 12 mm/h Male: 0-15 mm/h Female:0-20 mm/h Hematocrit 39% Male:41% – 53% Female: 36% – 46% Hemoglobin, blood 13.4 g/dL Male:13.5-17.5 g/dL Female 12.0 – 16.0 g/dL Leukocyte count (WBC) 7200 /mm³ 4500-11,000/mm³ Neutrophils, segmented 56% 54% – 62% Neutrophils, bands 4% 3% – 5% Eosinophils 1% 1% – 3% Basophils 0.5% 0% – 0.75% Lymphocytes 28% 25% – 33% Monocytes 4% 3% – 7% CD4+ T-lymphocyte count 1100 /mm³ ≥500/mm³ Platelet count 40,000/mm³ (on the day of admission: platelet count was 340,000/mm³ 150,000 – 400,000/mm³ Reticulocyte count 1.0% 0.5% – 1.5% D-Dimer 450 ng/mL ≤250 ng/mL Partial thromboplastin time (aPTT) (activated) 27 seconds 25-40 seconds Prothrombin time (PT) 10 seconds 11-15 seconds Mean corpuscular hemoglobin (MCH) 29 pg/cell 25 – 35 pg/cell Mean corpuscular hemoglobin concentration (MCHC) 34% Hb/cell 31% – 36% Hb/cell Mean corpuscular volume (MCV) 94 μ m³ 80-100 μ m³ 4T score 7 PF4 ELISA Test Positive Regarding this complication patient developed in the hospital, which of the following is true about its risk factors?

A 52-year-old man presents to the emergency department with complaints of abdominal pain, progressive abdominal swelling, and fatigue over the past two weeks. He reports increasing difficulty breathing when lying flat and unintentional weight gain due to fluid retention. He denies fever, nausea, or significant alcohol consumption but mentions a history of intermittent headaches and dizziness. On physical examination, he is noted to have hepatomegaly, abdominal distension with shifting dullness, and mild jaundice. His blood pressure and heart rate are normal, but his oxygen saturation is slightly reduced in the supine position. Liver function tests show mild transaminase elevations and hypoalbuminemia, while abdominal ultrasound with Doppler confirms hepatic vein thrombosis, consistent with Budd-Chiari syndrome (BCS). Of the following, which is the most frequent underlying disease associated with Budd-Chiari syndrome?