A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 82-year-old man who is currently being managed by the internal medicine service agrees to be examined by medical students as part of their training in physical examination. He is visited by a small group of medical students under the instruction of a preceptor and allows the students to make observations. They find that he has bibasilar crackles that are most prominent during inspiration as well as some wheezing. Furthermore, he coughs up some sputum during the exam, and this sputum is found to have a rust color. He does not report any pain and no skin findings are seen. Which of the following is most closely associated with the cause of this patient's physical exam findings?
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A
Left heart failureCorrect. left heart failure produces chronic pulmonary venous hypertension, alveolar edema with hemosiderin-laden macrophages ('heart failure cells'), and rust-colored sputum; bibasilar crackles and cardiac wheezing complete the picture.
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B
Long bone fracturesIncorrect. Long bone fractures cause fat embolism syndrome with petechiae, hypoxia, and neurologic changes 24–72 hours after injury; this elderly patient has chronic findings, not acute fat embolism.
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C
Protein C/S deficiencyIncorrect. Protein C/S deficiency predisposes to venous thromboembolism (DVT, PE); pulmonary embolism causes acute dyspnea/pleuritic pain, not chronic bibasilar crackles with rust sputum.
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D
Tall, thin malesIncorrect. Tall, thin males are at risk for spontaneous primary pneumothorax with sudden unilateral chest pain and absent breath sounds — not chronic bilateral crackles with rust sputum.
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E
Mycobacterium tuberculosis infectionIncorrect. Reactivation tuberculosis classically produces apical (upper-lobe) cavitary disease with hemoptysis, night sweats, and weight loss — not the bibasilar crackles and rust-colored sputum of pulmonary venous congestion.
↑ Tap an answer to reveal the reasoning
Answer: A. Bibasilar inspiratory crackles, wheezing, and RUST-COLORED sputum in an 82-year-old man are the classic findings of LEFT HEART FAILURE with chronic pulmonary congestion. When left ventricular failure raises pulmonary venous pressure, fluid extravasates into alveoli and pulmonary capillaries leak red blood cells; alveolar macrophages phagocytose extravasated erythrocytes and accumulate hemosiderin, becoming 'heart failure cells' (siderophages). The breakdown products give expectorated sputum its characteristic rust-brown color.
The crackles are velcro-like inspiratory rales most prominent at the lung bases (where gravity-dependent edema accumulates), and cardiac asthma can produce wheezing from bronchial wall edema and reactive bronchoconstriction. Other causes of rust-colored sputum to consider include Klebsiella pneumonia ('currant jelly' sputum) and lobar pneumococcal pneumonia, but these are acute febrile illnesses, not chronic findings with bibasilar crackles in an elderly stable patient.
**Why each option:**
**A.** Correct: left heart failure produces chronic pulmonary venous hypertension, alveolar edema with hemosiderin-laden macrophages ('heart failure cells'), and rust-colored sputum; bibasilar crackles and cardiac wheezing complete the picture.
**B.** Long bone fractures cause fat embolism syndrome with petechiae, hypoxia, and neurologic changes 24–72 hours after injury; this elderly patient has chronic findings, not acute fat embolism.
**C.** Protein C/S deficiency predisposes to venous thromboembolism (DVT, PE); pulmonary embolism causes acute dyspnea/pleuritic pain, not chronic bibasilar crackles with rust sputum.
**D.** Tall, thin males are at risk for spontaneous primary pneumothorax with sudden unilateral chest pain and absent breath sounds — not chronic bilateral crackles with rust sputum.