A 44-Year-Old Man Comes to the Office for Evaluation of Lower

question 639

Multiple Choice

A 44-year-old man comes to the office for evaluation of lower extremity swelling and exertional dyspnea for 3 months.  The patient has homozygous sickle cell disease and a history of multiple vasoocclusive episodes and acute chest syndrome.  He has required frequent blood transfusions.  Medications include hydroxyurea and folic acid.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 37 C (98.6 F) , blood pressure is 130/80 mm Hg, heart rate is 94/min, and respirations are 22/min.  BMI is 24 kg/m².  Examination shows clear lungs.  The second heart sound is loud.  The point of maximal impulse is at the left fifth intercostal space in the midclavicular line.  The liver is palpable 2 cm below the right costal margin.  There is 2+ pedal edema bilaterally.  Laboratory studies show a hemoglobin of 9.8 g/dL and 2% reticulocytes.  Diffusing capacity for carbon monoxide is normal.  Which of the following is the most likely cause of this patient's symptoms?

• A)Bronchiolitis obliterans
• B)Decreased left ventricular ejection fraction
• C)Pulmonary vascular remodeling
• D)Restrictive lung disease
• E)Right ventricular infarction

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