Review Note
Last Update: 07/22/2024 06:03 AM
Current Deck: - ALL SAR 1 ANKI Decks -::Medace Qbank
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Front (Question)
A 32-year-old male presents to your office with concern about progressive fatigue and lower extremity edema. He has experienced decreased exercise tolerance over the past few months, and occasionally awakens coughing at night. Past medical history is significant for sickle cell anemia and diabetes mellitus. He has had multiple admissions to the hospital secondary to vaso-occlusive crises since the age of three. Physical examination reveals a displaced PMI, but is otherwise unremarkable. ECG shows a firstdegree AV block and low voltage. Chest x-ray shows an enlarged cardiac silhouette with clear lung fields. Which of the following would be the best initial diagnostic approach?
- Order serum iron, iron-binding capacity, and ferritin level.
- Order brain-natriuretic peptide (BNP)
- Order CT scan of the chest.
- Arrange for placement of a 24-hour
- ambulatory cardiac monitor.
- Arrange for cardiac catheterization.
Back (Answer)
Order serum iron, iron-binding capacity, and ferritin level.
The patient's history of sickle cell disease should raise the suspicion of iatrogenic iron overload. Multiple transfusions in a patient whose anemia is not attributed to blood loss lead to tissue iron accumulation and end organ damage just like genetic hemochromatosis. Measures to assess body iron status (transferrin saturation, serum ferritin level) are the initial diagnostic studies. This patient's diabetic status may also be related to iron accumulation. Evidence of cardiomegaly (from physical examination and chest x-ray) together with a low voltage on ECG suggests an infiltrative process affecting the heart. Brain-natriuretic peptide (BNP) is released from the cardiac myocytes in response to ventricular stretch and can be a useful tool in determining whether someone is suffering from heart failure. BNP will not, however, help determine the cause of the heart failure. Holter monitoring and cardiac catheterization are not necessary in patients without evidence of intermittent arrhythmias or coronary ischemia respectively. CT of the chest is used to assess lung nodules or parenchymal abnormalities (such as interstitial lung disease) but would not be useful in this patient with clear lung fields on CXR.
The patient's history of sickle cell disease should raise the suspicion of iatrogenic iron overload. Multiple transfusions in a patient whose anemia is not attributed to blood loss lead to tissue iron accumulation and end organ damage just like genetic hemochromatosis. Measures to assess body iron status (transferrin saturation, serum ferritin level) are the initial diagnostic studies. This patient's diabetic status may also be related to iron accumulation. Evidence of cardiomegaly (from physical examination and chest x-ray) together with a low voltage on ECG suggests an infiltrative process affecting the heart. Brain-natriuretic peptide (BNP) is released from the cardiac myocytes in response to ventricular stretch and can be a useful tool in determining whether someone is suffering from heart failure. BNP will not, however, help determine the cause of the heart failure. Holter monitoring and cardiac catheterization are not necessary in patients without evidence of intermittent arrhythmias or coronary ischemia respectively. CT of the chest is used to assess lung nodules or parenchymal abnormalities (such as interstitial lung disease) but would not be useful in this patient with clear lung fields on CXR.
Note (Extra)
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