186) A 65 year old woman is evaluated in your office for lower extremity swelling and weakness. She has difficulty speaking for the past 3 months. Her past medical history is significant for renal insufficiency and hypertension that was diagnosed 6 months ago. A TSH level that was obtained 3 weeks ago was normal. She smokes cigarettes, about 1 pack per day for the past 35 years. Her medications include Lisinopril and Hydrochlorthiazide. On physical examination, her heart rate and rhythm are regular. Lungs are clear to auscultation. She has gross edema of the lower extremities. There is no extremity weakness. Head and neck examination reveals findings as shown below:
Most appropriate next step in management of this patient:
A) Stop Lisinopril
B) Start Levothyroxine
C) Intubation
D) Abdominal fat pad biopsy
E) Serum immunoelectrophoresis
a
Stop lisinopril
dddddddddd,amyloidosis
Well, she has angioedema, Based on studies you must assume meds are involved. Lisinopril is known to do this (ace -) Even if this is not the cause, the correct choice would be top diocontinue the affending meds,
ACEI may cause angioedema but the diagnosis here is not Angioedema. ACEI induced angioedema is acute where as the tongue swelling described in this question is chronic ( 3 months duration). You can not expect a person to have angioedema for 3 months and still be alive.
The most likely etiology is macroglossia due to amyloidosis. Serum immunoelectrophoresis may reveal monoclonal gammopathy and is a supportive evidence for amyloidosis. It is not diagnostic step for Amyloidosis. If Amyloidosis is suspected, an abdominal fat pad biopsy must be obtained to confirm the diagnosis.