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Situational Analysis
Part I

Rosella L. Montano, MD
Emmanuel R. Dela Fuente, MD
Alejandro E. Arevalo, MD
Situation no. 1 (Case I-A)

FJ, a 36 year old male, a market

vendor, had moderate to high grade
fever, cough productive of yellowish
and occasionally rusty colored
phlegm, and progressive dyspnea of 1
week duration. He is a known diabetic
and takes medications irregularly.
Situation no. 1 (Case 1-A)

On PE, FJ was awake, BP 110/70, PR was

129/min, RR was 29/min, T 38.9 C. She
preferred the upright position. There
were intercostal and subcostal
retractions. There was symmetrical
chest expansion, increase fremiti,
dullness and bronchial breath sounds
on the left lower lung fields. There
were also scattered crackles over both
1. Interpret the CXR.
2. Shown below are 2 gross specimens of the
lungs. Which of the following is more
characteristic for this particular patient?

3. Based on the microscopic section of the
bronchus and bronchiole, explain the
mechanism of productive cough.
4. Which of the following histologic pictures is
more compatible with the physical finding
of crackles / rales ?

5. Based on the microscopic section of the
alveolus, explain the mechanism of
dyspnea, increased fremiti and lung
dullness on percussion.
Situation no. 1 (Case I-B)

His son, mikey, 2 year old, also

developed cough and cold 4 days
ago. This was accompanied by
moderate grade fever temporarily
relieved by Paracetamol. One day
prior to admission, he was noted to
refuse to eat his food, and to have
rapid breathing. Mikey was restless,
and was noted to have alar flaring.
Situation no. 1 (Case I-B)

His CR was 108 beats/min, RR 47/min

and temperature was 39.4 C. PE of
the chest revealed intercostals and
subcostal retractions, equal tactile
and vocal fremiti, resonance on
percussion with scattered fine
crackles over both lung fields.
1. With this particular patient, which of the
following gross pictures of the lungs is
more characteristic?

2. Based on the microscopic section of the
lung parenchyma, explain the mechanism
of dyspnea, equal tactile and vocal fremiti
and resonance on percussion.
3. Give the Pathophysiology of this

Low Power High Power

4. Summarize the main histologic
differences between bacterial
pneumonia and viral pneumonia and
its complications
Situation no. 2

Mina, a 47 year old laundry woman

complained of afternoon rises in
temperature accompanied by cough,
back pains, and “unquantifiable” weight
loss. A consult and a subsequent CXR
showed a “spot” in the LUL.
1. Interpret the CXR
2. With the signs and symptoms, which
of the following pictures is more
compatible with the patient’s history?
3. Interpret the Sputum exam
4. This is a microscopic section from the lung
parenchyma. Discuss the evolution
(formation) of this characteristic lesion, as
well as the predisposing factors that would
favor these lesions to develop.
Two weeks after, she experienced at
least 2-4 episodes of coughing out
blood streaked sputum per day. This
was accompanied by progressive
dyspnea and a sharp pain along the left
subcostal region, which is worsened by
coughing. During the past few days,
she also needed to prop herself up on 3
pillows so as to sleep without feeling
5. Explain the pathophysiology of
6. The 2nd CXR revealed this changes. Explain
the pathoophysiology of dyspnea and
pleuritic chest pain.