55-year-old male presents with face and arm swelling

55-year-old male presents with face and arm swelling that he says is worst when he wakes in the morning. He
also notes a 10 pound unintentional weight loss over the past three months, plus new-onset exertional dyspnea.His past medical history is significant for hypertension, for which he takes hydrochlorothiazide. He has smoked cigarettes for the past 40 years and drinks alcohol occasionally. On physical examination, he is afebrile and his vital signs are within normal limits. His face is plethoric and dark-appearing. The veins on the anterior chest wall appear engorged. His abdomen is soft, non-tender, and non-distended, and there is no organomegaly. The lower extremities are non-edematous. What is the most appropriate next step in the management of this patient?

  • Q A. Echocardiogram
  • Q B. Doppler ultrasound of the upper extremities
  • Q C. Chest x-ray
  • Q D. Urine for 24-hour protein excretion
  • Q E. Serum albumin level

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32-year-cid woman comes to the clinic due to progressively worsening dyspnea a month after returning from a vacation in Texas The symptoms started with shortness of breath on exertion and have progressed to the point that she now wakes during the night with a choking sensation that improves only with sitting up The patient has had a very active lifestyle for years, but currently she is markedly limited in her activities. She has no associated chest pain, skin rash, or joint pain The patient has no significant medical history. Family historyis significant for thyroid cancer in her aunt and lungcancer in her father. There is nofamily historyof coronary artery disease, heart failure, or sudden cardiac death. She does not use illicit drugs The patient currently lives in New York City Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 96/min, and respirations are 14/min. Bilateral pitting ankle edema is preserit. The liver is erilarged2cmbelow the right costal margin Lurig auscultation reveals decreasedbreath sounds at the bases bilaterally Cardiac examination reveals the presence of a third heart sound. Chest x-ray reveals an enlarged cardiac silhouette and small bilateral pleural effusions ECG shows nonspecific ST segment changes Which of the fcilowing is the most likely cause of this patient’s symptoms?

  • QA Atherosclerosis
  • QB Coccidioidomycosis
  • QC Connective tissue disease
  • Q D Hypothyroidism
  • Q E Lyme disease
  • QF. Viral infection

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