Question of the Week # 462

462) A 39 year old man is seen in your office for swelling of the abdomen and shortness of breath of several months’ duration. He is an active smoker and smoked about 1 pack per day for 20 years. He drinks alcohol occasionally. He denies any cough or fever. On examination, he is afebrile with a temperature of 98.1F , respiratory rate of 18/min, pulse 88/min and blood pressure at 120/70 mm Hg. Cardiac examination reveals regular heart sounds and no S3 gallop. Chest examination shows decreased breath sounds, increased antero-posterior diameter and hyper-resonance to percussion.  Abdominal exam is significant for fluid wave and shifting dullness. Liver is enlarged. No splenomegaly.

Labs reveal :

Hemoglobin : 14.2gm%

Serum creatinine 1.0mg%

Albumin 3.2gm%

Total bilirubin 1.0 mg%

Alkaline phosphatase 90 U/L

AST ( Aspartate aminotransferase) 160 U/L

ALT (Alanine aminotransferase) 190 U/L

Which of the following is most helpful in establishing the diagnosis

A. Serum Ferritin

B. Serum Ceruloplasmin leve

C. Anti-Actin and Smooth muscle antibodies

D. 2D Echocardiogram

E. Serum Alpha-1 anti-trypsin level.

9 Responses

  1. E!

  2. D, corpolmonal

  3. Answer E

  4. How would 2D Echo help in diagnosing the cause of his condition he is young has emphysema and liver disease so his alpha 1 antitrypsin should be checked his cardiovascular exam is normal no evidence of pulmonary HTN his HB is normal and there is no evidence of involvement of basal ganglia or eye involvement

    • alpha 1 antitrypsin deficiency is highest on the differential diagnosis, 2D echo for cor pulmonale (pulm HTN) due to patient having emphysema, acute pulm HTN and pleural effusion secondary to CCF, wont explain the ascites though and no evidence of pulm HTN as you say, its the patients age and cirrhosis that makes alphs 1 antitrypsin diagnosis most likely.

  5. E- young patient with emphysema and liver problem…red flag for a1 antitrypsin def..

  6. E

  7. E

  8. E

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