An elderly man traveled to North America from Australia. After 5 days he develops dyspnea, chest pain, tachycardia and is rushed to the hospital.
What is the most likely diagnosis?
Correct Answer A:
Pulmonary embolism (PE) is the occlusion of one or more pulmonary arteries by thrombi that originate elsewhere, typically in the large veins of the lower extremities or pelvis. Nearly all PEs arise from thrombi in the lower extremity or pelvic veins (deep venous thrombosis (DVT).
'Virchow's triad' of stasis, hypercoagulability and endothelial damage are risk factors for developing DVT.
This man has sat on a very long airplane flight from Australia to North America. Meeting the criteria for stasis. His symptoms are classic for PE which can include: acute dyspnea, pleuritic chest pain, tachycardia and tachypnea. The first symptom in an older patient may be altered mental status.
A 44-year-old man sustained a comminuted fracture of his left tibia and fibula 4 months ago. For the past 3 months he has been in the rehabilitation unit with his leg fully immobilized. Three hours ago he suddenly developed chest pain and shortness of breath, and he has just been brought to the emergency department for further evaluation. On examination he describes an aching discomfort over the right superior anterior chest and the right scapula posteriorly. The family history is strongly positive for heart disease.
The presence of a right pleural friction rub in this patient would suggest which of the following?
Correct Answer D:
Pain and pleural frictional rub is almost diagnostic of infarction of the overlying pleura.
> Pericardial rub due to pericarditis is localized to the lower left side of the heart; there is no evidence for this diagnosis here.
> Pneumonia, which is another complication of immobility, may present with similar signs and symptoms, but should be accompanied with fever and leukocytosis.
> A pneumothorax and a pulmonary embolus without infarction do not typically present with a pleural friction rub.
A 45-year-old female presents to an urgent care center complaining of left-sided chest pain for the past 2 days. The pain is nonradiating and sharp in character, and increases with deep inspiration. She has no associated shortness of breath, cough, nausea, diaphoresis, or dizziness. She has no significant past medical history or recent travel history.
On examination she is afebrile, with a pulse rate of 92 beats/min, a blood pressure of 116/72 mm Hg, and a respiratory rate of 12/min. Her lungs are clear and her heartbeat is regular with no murmurs. Her lower extremities have no edema, tenderness, or varicosities.
Which one of the following is the most appropriate next step in her evaluation?
This patient has a low pretest probability of pulmonary embolism based on the Wells criteria. She would be a good candidate for a high-sensitivity D-dimer test, with a negative test indicating a low probability of venous thromboembolism.
→ In patients with a low pretest probability of venous thromboembolism, an ultrasound or helical CT would not be the recommended initial evaluation.
→ Neither troponin I nor an ANA level would be part of the recommended initial evaluation.
A 60-year-old female presents to the emergency department complaining of shortness of breath. She arrived from Australia yesterday after a long visit at her daughter’s. She has developed swelling of her left leg yesterday evening followed by shortness of breath that began today. Her past medical history is unremarkable. Vital signs are significant for pulse of 120/min and a RR of 24/min. Physical exam is non contributory except for the swollen tender left leg. Chest x-ray is normal.
Which of the following arterial blood gas test findings would suggest pulmonary embolism?
Correct Answer B:
The patient is most likely having pulmonary embolism. The shortness of breath that follows the leg swelling with the associated tachycardia and tachypnea suggests the diagnosis of PE. Arterial blood gas determinations characteristically reveal hypoxemia, hypocapnia(choice B), and respiratory alkalosis.
> The A-a gradient (choice A) is usually increased due to the ventilation/perfusion mismatch.
> PaO2 (choice D) is almost always decreased in PE because of the low perfusion i.e. less oxygenation.
> Respiratory alkalosis and not acidosis (choice E) is usually seen in PE.
A 42-year-old female presents to the emergency department with pleuritic chest pain. Her probability of pulmonary embolism is determined to be low.
Which one of the following should be ordered to further evaluate this patient?
Correct Answer C:
Patients who have a low or moderate pretest probability of pulmonary embolism should have d-dimer testing as the next step in establishing a diagnosis.
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