Pulmonology (thromboembolic disease)

Question 1

Gold standard for diagnosing PE

Answer 1

pulmonary angiogram
however, this is rarely done b/c it is invasive and expensive
use when other tests are non conclusive and no other plausible alternative diagnosis

Question 2

D-dimer to diagnose PE is most helpful when it is (positive/ negative) and has high (sensitivity/ specificity)

Answer 2

negative, high sensitivity

-can rule OUT PE

Question 3

Diagnostic test for DVT/ PE that has high sensitivity for 1st episode in outpatients

Answer 3

LE doppler ultrasound

-if positive, can stop and treat for PE

Question 4

If you have a high Well’s score >4 (pre test probability for PE), what’s the first line test?

Answer 4

CT angiogram
(unless you suspect DVT, then do doppler LE)
(or if dye allergy –> V/Q scan)
(last resort = plum angio or MR angio)

Question 5

Which is FALSE regarding the treatment of pulmonary embolisms?

a. If episode is unprovoked, treat for 3-6 months
b. If recurrent episodes, treat for 1 year of indefinitely
c. Treatment for acute PE is warfarin
d. If HIT with heparin, use direct thrombin inhibitors (rivaroxaban, apixaban)
e. If hemodynamically unstable (systolic P >90), treat with tPA

Answer 5

c. is false. Acute PE is treated with heparin (low molecular weight or unfractioned). Then transitioned to Warfarin for long term therapy.

Question 6

If high risk of bleeding in a hospitalized patient, what should be used to decreased the risk of thromboemoblism?

Answer 6

pneumatic stockings

Question 7

Which of the following is most helpful in the diagnosis of PE?

a. presence of reproducible chest pain
b. abnormal pulse oximetry
c. clinical findings of dyspnea, tachypnea, tachycardia
d. chest x ray
e. patient history

Answer 7

e - patient history will help you to assess the risk for PE (such as immobilization, recent surgery, history of VTE, or malignancy)

Really, none of these things are very reliable or specific for pulmonary embolism.

Question 8

When is a V/Q scan helpful in the diagnosis of PE?

Answer 8

When a high probability scan is paired with high pretest probability, or a low probability scan with low pretest probability.
But, most patients fall in the middle –> 40% chance of PE.
This test has mostly been replaced by CT angio.

Question 9

What is heparin induced thrombocytopenia?

Answer 9

5% of people taking heparin get venous and arterial clots

-give direct thrombin inhibitors instead