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Old 09-26-2012
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Arrow Gyrus Daily Questions; Internal Medicine #30

0. A 43-year-old man with alcoholic liver disease com-plains of dyspnea upon sitting up. Physical examination is notable for chest spider angiomas and palmar ery-thema. His arterial oxygen saturations fall from 96% to 88% upon transition from lying to sitting. His lung fields are clear and heart sounds are crisp. Abdominal examination is notable for a palpable nodular liver edge but no fluid wave or shifting dullness. He has 1+ lower extremity edema. What is the most likely cause of his dyspnea?


A. Chronic thromboembolic disease
B. Congestive heart failure
C. Pulmonary arteriovenous fistule
D. Portal hypertension
E. Ventricular septal defect
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  #2  
Old 09-26-2012
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correct answer may be (c) Pulmonary arteriovenous fistule
*Chronic thromboembolic disease= may ass with pulmonary hypertension, also dyspnea and decrease saturation occurs in all position
*Congestive heart failure= ass with dyspnea on lying down + basal crepitation + muffled heart sound
*Portal hypertension= not explain dyspnea and decrease saturation with sitting up
*In Ventricular septal defect= there is pansystolic murmur
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Old 09-26-2012
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Answer C

I ruled out all others and reached C as the answer ,but i have not seen this scenario before .Very Nice Question
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Old 09-26-2012
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C?
I really dont know why i just eliminated the others
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Old 09-26-2012
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The answer is C.

Pulmonary arteriovenous fistula.

Cirrhotic patients are at risk of developing pulmonary ar-teriovenous fistulas. These, as well as portopulmonary shunts, cause platypnea and orth-odeoxia (dyspnea and desaturation with sitting up). The fistulas, which are preferentially at the base of the lungs, increase the right-to-left shunting (and therefore hypoxemia) when upright. In the supine position, the apex of the lung is better perfused and the hy-poxemia improves. The oxygen desaturation in the upright position causes the platypnea.
Congenital pulmonary arteriovenous malformations may also cause platypnea and orth-odeoxia. Ventricular septal defects will not cause hypoxemia until they develop right-to-left shunting.
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