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CR2 > Tutorial #24: Pulmonary Embolism > Flashcards

Tutorial #24: Pulmonary Embolism Flashcards

1
Q

What three major risk factors for thrombosis? (Virchows Triad)

A
  1. Disruption in blood flow (stasis)
  2. Hypercoagulability
  3. Endothelial cell damage
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2
Q

What is the most common symptom of a pulmonary embolism?

A

Dyspnea (breathlessness)

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3
Q

For a patient with a low clinical likelihood of DVT and PE (through Wells and YEARS respectively), what test should be ordered?

A

D-dimer

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4
Q

For a patient with a high clinical likelihood of DVT and PE (through Wells and YEARS respectively), what test should be ordered?

A

imaging test (ex. CT chest angiogram)

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5
Q

What is the most common symptom of DVT?

A

Swelling (present 97% of the time) and pain (present 86% of the time).

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6
Q

Is the d-dimer test for PE a rule-in, or rule-out test, and why?

A

Rule out test.

This is because the d-dimer lacks specificity. A positive d-dimer can be due to a variety of reasons (MI, pneumonia, sepsis, malignancy, etc) (remember SpIn - SPECIFICITY for RULE IN), and has a high chance of false positive. It’s sensitivity (SnOUT - SENsitivity for RULE OUT) is 90% regardless of risk, but its sensitvity drops significantly the higher risk the patient. Remember, we use d-dimer in patients that have low pre-test probability of having PE.

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7
Q

What is the most common abnormalities found on EKG for a pt. with a Pulmonary Embolism?

A

sinus tachycardia + T wave inversion in leads V1-V4

Note: The clasically taught “S1Q3T3 sign” is neither sensitive nor specific.

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8
Q

What is Wells Criteria for Pulmonary Embolism? (x7 criteria)

A
  1. Clinical signs and symptoms of DVT = 3
  2. PE is #1 diagnosis OR equally likely = 3
  3. Heart rate > 100 = 1.5
  4. Immobilization at least 3 days OR surgery in the previous 4 weeks = 1.5
  5. Previous, objectivey diagnosied PE or DVT = 1.5
  6. Hemoptysis = 1
  7. Malignancy w/ treatment within 6 months or palliative = 1
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9
Q

Pt. has a WELLs score of ≤ 4 , in the two tier model of Wells what is the best investigation at this point in time?

A

consider D-dimer. If negative, stop work-up for PE, if positive -> CTA

PE unlikely (0-4 points). Remember we use the d-dimer only in patients where the pre-test probability is low.

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10
Q

Pt. has a WELLs score of > 4 , in the two tier model of Wellswhat is the best investigation at this point in time?

A

Consider CT angiogram

Pt. has a high pre-test probabilty of PE, so d-dimer is not useful at this time.

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11
Q

What is the PERC rule for Pulmonary embolism (definition not criteria)

A

It is a clinical decision tool that is used to rule out PE.

PE is ruled out if NO criteria are present, and the pre-test probabilily is < 15%

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12
Q

What are the criteria for the PERC rule for PE?

A
  1. Age > 50 = 1
  2. HR > 100 = 1
  3. SaO2 on room air < 95% = 1
  4. Unilateral leg swelling = 1
  5. Hemoptysis = 1
  6. Recent surgery or trauma = 1
  7. Prior PE or DVT = 1
  8. Hormone use = 1

If any of these features are present, you cannot rule out PE.

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13
Q

What are the limitations to clinical decision tools such as Wells, and PERC? (x4)

A
  1. Validity (does it actually measure what it says it does)
  2. Reliability (i.e does it produce consistent results)
  3. Practicality (it is easy to use)
  4. Applicability/generalizability (can it be used on your patient population)
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14
Q

What are the top 4 most common symptoms of PE?

A
  1. Dyspnea
  2. Chest pain (pleuritic)
  3. Calf or thigh pain and/or swelling
  4. Tachypnea

Tip from A and C - we’ve had a lot of questions where hemoptysis was also a presenting complaint, and although low prevalence in the list above, think about PE if it comes up in a question!

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15
Q

What are the positive predictors of Cardiac chest pain/ACS? (x3)

A
  1. Exertional chest pain
  2. Pain improved with resting
  3. Pain that radiates to arms or neck.
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16
Q

What are the two MOST IMPORTANT test you would order when suspecting ACS? (x2)

A

EKG
Troponin

17
Q

What are positive predictors of Pericarditis on history?

A

Pleuritic chest pain, that improves with leaning forward, worse when laying flat.

18
Q

What is a positive predictor for pericarditis on physical exam?

A

Pericardial friction rub during chest auscultation.

19
Q

What are the typical findings of pericarditis on ECG?

A

Diffuse ST elevation and PR depression.

Pericarditis is classically associated with ECG changes that evolve through four stages.
Stage 1 – widespread STE and PR depression with reciprocal changes in aVR (occurs during the first two weeks)
Stage 2 – normalisation of ST changes; generalised T wave flattening (1 to 3 weeks)
Stage 3 – flattened T waves become inverted (3 to several weeks)
Stage 4 – ECG returns to normal (several weeks onwards)

20
Q

What are the positive predictors of a Spontaneous Pneumothorax? (x4)

A
  1. Sudden onset dyspnea
  2. Pleuritic chest pain on the side of collapse
  3. Hyper-resonance on percussion on side of collapse
  4. decreased breath sounds.
21
Q

What test would you organize when suspecting pneumothorax on a stable patient?

A

Chest x-ray as initial test - it has reasonable sensitivity and give you measurements for “small vs large”.

Ultra-sound is even more sensitive, but it does not reliably tell you size.

22
Q

What are the positive predictors of Pneumonia?

A
  1. Pleuritic chest pain
  2. Fever
  3. productive cough
23
Q

What are the positive predictors of CHF/pulmonary edema? (x3)

A
  1. SOB, orthopnea, PND
  2. Peripheral edema and elevated JVP (may be present)
  3. usually not painful.
24
Q

What are the positive predictors of COPD exacerbation (x3)

A
  1. Positive COPD history
  2. Wheezing and dyspnea (either development of or worsening)
  3. change in sputum volume or color
25
Q

What would spirometry or PFT show in a COPD exacerbation?

A

PFT showing an obstructive pattern, that has lack of response to bronchodilators.

26
Q

What are the positive predictors of Asthma? (x3)

A
  1. Has other atopy (allergies, chronic rhinitis)
  2. Response to irritants (smoking, smoke, exercise)
  3. Wheezing on auscultation
27
Q

What would you see on PFT for a patient that has Asthma?

A

PFT showing obstructive pattern that is responsive to brhonchodilators.

CR2 (20 decks)

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