Pulmonary Embolus

Question 1

What is the best study for DVT

Answer 1

• Venous duplex ultrasonography is currently the diagnostic test of choice in most centers for DVT
• The classic finding on ultrasound for a positive study is the inability to fully compress the vein in the deep venous system of the leg

Question 2

Best study for patients with moderate to high risk of PE?

Answer 2

CT Pulmonary Aniography (CTPA) or V/Q scan.

Question 3

Treatment of PE or DVT

Answer 3

Those with confirmed PE or DVT on imaging should be treated with anticoagulation. Either unfractionated heparin or low-molecular weight heparins (e.g. enoxaparin) may be used in most cases.

Question 4

When can you use thrombolytic therapy?

Answer 4

Thrombolytic therapy in the setting of PE is controversial and indicated in the setting of a massive PE with significant cardiopulmonary compromise or submassive PE with evidence of right heart strain (most commonly echocardiographic diagnosis.)

Question 5

When is a D-dimer useful?

Answer 5

The D-dimer is a useful diagnostic test in patients with a low pre-test probability of the disease

Question 6

Presentation of DVT

Answer 6

General leg pain or a cramping sensation, fullness in the calf, swelling, edema or tenderness on palpation.

Question 7

DVT Physical Exam

Answer 7

Unilateral swelling or edema of the extremity, tenderness to palpation, and a palpable venous “cord.” Homan’s sign is the classic sign of pain in the calf on passive dorsiflexion of the foot with the knee in extension

Question 8

Pre-test probability (Well’s Score) for DVT

Score: 0=low probability, 1-2=moderate, >3=high

Answer 8

Active cancer-treated within previous 6 months (1 point)
Parlaysis, paresis, or recent immobilization (1 point)
Recent bedridden >3 days or major surgery within 12 weeks
requiring general anesthesia (1 point)
Localized tenderness along the distribution of
the deep venous system (1 point)
Entire leg swollen (1 point)
Calf swelling at least 3 cm greater than other side (1 point)
Pitting edema confined to symptomatic leg (1 point)
Collateral superficial veins (non-varicose) (1 point)
Previously documented DVT (1)
Alternative diagnosis at least as likely as DVT (-2 points)

Question 9

PE presentation

Answer 9

shortness of breath or chest pain (pleuritic, worse with deep breaths), general malaise, syncope

Question 10

PE physical exam

Answer 10

Unilateral leg symptoms (DVT symptoms-see above) may be present, as well as signs of right sided heart failure (jugular venous distention, peripheral edema).

Question 11

Most common vital sign abnormality in PE

Answer 11

The most common vital sign abnormality seen is tachycardia in the setting of normal pulse oxygenation.

Question 12

Pre-test probability, modified Wells PE

Clinical Probability: Low probability less than 2, Moderate 2-6, High more than 6

Answer 12

Clinical symptoms of DVT (3 points)
Other diagnosis less likely than pulmonary embolism (3 points)
Heart rate >100 (1.5 points)
Immobilization (3 days) or surgery in the past 4 weeks (1.5 points)
Previous DVT/PE (1.5 points)
Hemoptysis (1.0 points)
Malignancy (1 points)

Question 13

EKG findings in PE

Answer 13

The most common EKG abnormality is sinus tachycardia, although other findings such as right bundle branch block or evidence of right heart strain (an S wave in lead I and Q and inverted T in lead III, the S1Q3T3 pattern)

Question 14

What is a D-dimer and what elevates it?

Answer 14

D-dimer is a protein derived enzymatic breakdown of cross-linked fibrin. Increased levels indicate the presence of clot formation somewhere in the body.

Question 15

Other causes of elevated D-dimer?

Answer 15

malignancy, infection, inflammation, MI, strokes, advanced age, and pregnancy