Case-based MCQ

⏳ Case-based MCQ | #Case_460 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 27-year-old woman was brought to the hospital after collapsing an hour ago while she was lining up in a coffee shop. The patient stated that she was fine while she was standing in the long queue until she felt dizzy, and within seconds she became unaware of what happened next. Her medical, family and social histories are unremarkable. You strongly suspected this patient suffered a syncopal attack. On physical examination, the patient was anxious but oriented to time, place, and person. She was not pale, jaundiced or cyanosed. Supine heart rate was 82 bpm, respiratory rate 15 bpm and blood pressure 132/84 mm Hg. Pulse and blood pressure were also evaluated 3 minutes after the patient stood upright. Compared to supine blood pressure, standing systolic and diastolic blood pressures were 10 and 5 mm Hg lower, respectively. Simultaneously, the heart rate increased from 82 to 92 bpm. The pulse was regular. The apex beat was located to the 5th intercostal space in the mid-clavicular line. The rest of the examination was normal.

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✔ CCCCC Hemoptysis can range from blood-tinged sputum to coughing up large amounts of pure blood. Massive hemoptysis is defined as coughing up 100 to 600 ml of blood over 24 hours. It is important to differentiate hemoptysis from blood coming from the gastrointestinal tract and nasopharynx. In true hemoptysis, blood could come from tracheobronchial, pulmonary parenchymal, primary vascular or other miscellaneous sources. Causes of hemoptysis due to primary pulmonary vascular diseases include arteriovenous malformations, pulmonary embolism, pulmonary artery catheterization, and elevated pulmonary vascular pressure. The most important cause of the latter is mitral stenosis. The two most common causes of hemoptysis are bronchitis and bronchogenic carcinoma. However, in this patient, the symptoms favour a cardiac cause. Specifically, breathlessness that is aggravated by adopting the supine position (orthopnea) and paroxysmal nocturnal dyspnea (PND) point towards a cardiac cause. Of the cardiac lesions, mitral stenosis (choice C) is a well-known cause of hemoptysis because it leads to marked elevation of pulmonary venous pressure and venous rupture. ⚠ Although the immigration history of the patient increases the possibility of tuberculosis (choice A), the symptoms are not typical for this disease. The absence of fever, chills, and night sweats is against this diagnosis. ⚠ The typical symptom of bronchiectasis (choice B) is a cough with mucopurulent sputum lasting months to years. Although dyspnea might develop in generalized severe bronchiectasis, orthopnea and PND are not typical of bronchiectasis. ⚠ Chronic productive cough with sputum that might be streaked with blood is a known symptom of bronchitis (choice D). However, in adults with bronchitis, dyspnea is not observed unless the patient has underlying chronic obstructive lung disease. Further, orthopnea and PND are not typical of bronchitis. ⚠ Arteriovenous malformations (choice E) rarely cause hemoptysis. The symptoms of these disorders are rather insidious and develop gradually over the years due to the slow enlargement of the malformation. Dyspnea requires many years to develop. 🔖 Key point: Mitral stenosis is a well-known cause of hemoptysis because it leads to marked elevation of pulmonary venous pressure and venous rupture

⏳ Case-based MCQ | #Case_460 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 21-year-old nonsmoker came to you complaining of shortness of breath and coughing up blood-tinged sputum. The cough, which accompanied the shortness of breath, started about five months ago, and it occurred only when he would lie down. During the last two weeks, both breathlessness and cough became more aggressive. He noticed increasing amounts of sputum, and even on several occasions some blood in his sputum. He denied any fever, chills or night sweats. He immigrated to Canada with his family eight years ago from a sub-Saharan African country. His past medical and family history were unremarkable.

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