A 24-year-old male with no major medical history has been receiving treatment for a lower respiratory tract disease for the past 5 days. He had a large bout of hemoptysis this evening, which prompted his visit to the emergency room. His BP is 120/70 mm Hg, HR 120/min, and RR is 30/min. Physical examination reveals bilateral rales and a diastolic murmur.
Patients with which of the following valvular disorders are MOST likely to present with hemoptysis?
Correct Answer: B
Massive hemoptysis is most commonly defined as a volume over 500 mL in 24 hours or over 100 mL per hour. Hemoptysis could be the presenting symptom in a patient with mitral stenosis, although uncommon in patients with a known diagnosis. Several pathophysiological mechanisms have been postulated for this presentation. In patients with severe MS, shunts occur between the pulmonary and bronchial venous vasculature. Rupture of these vessels could result in hemoptysis which could occasionally be massive resulting in pulmonary apoplexy. Other causes of hemoptysis in patients with mitral stenosis include pulmonary edema and infarction.
Which of the following statements regarding the signs and symptoms of venous air embolism (VAE) is INCORRECT?
Correct Answer: A
The clinical effects of VAE depend on the volume and rate of entrainment of air. Spontaneous respiration with negative intrathoracic pressure could facilitate further entrainment of air. Venous air embolism can present with arrhythmias. Tachyarrhythmias are common but bradyarrhythmias can occur, as well. Associated substernal chest pain could be a presenting symptom. Right heart failure and cardiovascular collapse are more often seen with large volumes of entrainment—around 2 mL/kg. Changes in levels of monitored gases like nitrogen and carbon dioxide can occur with smaller volumes of air entrainment. Fundoscopy is typically normal. Rarely, air bubbles can be seen within the retinal vessels. Paradoxical embolism could happen either through a patent foramen ovale or by overwhelming the capacity of the lungs to filter the air emboli.
A 34-year-old male undergoing an emergent open reduction and internal fixation of his left femur suddenly develops tachycardia, hypotension and hypoxemia. Fat embolism syndrome (FES) is suspected. All of the following are considered a part of the major clinical criteria for the diagnosis of FES proposed by Gurd EXCEPT:
Fat embolism syndrome (FES) is most often seen in orthopedic patients with long bone fractures. Although rare, liposuction, bone marrow harvest, and sickle cell crisis could also be complicated by FES. The clinical manifestations of FES are considered to occur as a result of the proinflammatory and prothrombotic effects of fat cells, resulting in either mechanical obstruction or biochemical injury. Gurd criteria are the most commonly used or cited diagnostic criteria for FES. Gurd criteria typically require the presence of one major and four minor criteria to make a clinical diagnosis of FES. The major criteria include respiratory insufficiency, cerebral involvement, and petechial rash. The minor criteria include tachycardia, fever, jaundice, retinal changes, and renal changes. The treatment of FES is largely supportive with some studies advocating the use of heparin and corticosteroids.
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