DrVirgo
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A 45 year old white man comes to the ER complaining of shortness of breath that began 3 hours ago. He has a non productive cough, slight fever and a right sided chest pain that worsens with inspiration. He denies coughing up blood, wheezing, palpitations, leg pain or swelling of the lower extremities. He recently had a trip to Singapore. Past medical history reveals hypertension for 8 years, and diabetes mellitus for 4 years. His medication includes captopril, and glyburide. He is allergic to penicillin. He does not smoke. He drinks alcohol occasionally. His vital sighs are T: 100, BP: 115/70, PR: 128, RR: 32.
Physical exam shows slightly obese white man in acute distress. He is alert and cooperative without any cyanosis or jaundice. His physical exam reveals slightly displaced apex beat with loud S4. CXR shows mild cardiomegaly. EKG shows sinus tachycareia and a left ventricle hypertrophy, no acute ST-T changes seen. His ABG shows pH: 7.52, pCO2: 30, pO2: 60, and 86% O2 saturation on room air. He is started on Oxygen. What is the next best step in the management of this patient?
A. Ventilation perfusion scan
B. Pulmonary angiogram
C. Doppler of the lower legs
D. Spiral CT scan of the chest
E. Start Heparin
F. Give thrombolytic therapy with t-PA
G. Place an IVC filter
H. Embolectomy
I. Cardiac enzymes
J. PTCA
K. Echocardiogram
Please include your EXPLANATION with your answer. Thanks. 
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| hero
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a. we don't have diagnosis, only suspicios, which is not enough to start heparin.
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| anastamosis
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E. The ABG is typical for PE
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| DrVirgo
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anastamosis wrote:
E. The ABG is typical for PE
Yes, thats right! START treatment with Heparin!
We don't have to confirm with a V/Q Scan??
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| multifactorial
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come on guys!thats a clear-cut case for every reason to use tPA.thats what kaplan teaches us.when the patient is unstable,not maintaining BP,give him tPA or if tPA is contraindicated,then do an embolectomy.if the patient has a stable BP,then give him heparin.
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| hero
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DrVirgo wrote:
We don't have to confirm with a V/Q Scan??
1. CXR – R/o Other Lung Problems in the DDx
2. ABG – Hypoxia, Resp Alkalosis leads to Hypocarbia, ↑ A-a Gradient,
Hypoxia w/ Hypocarbia are the Most Consistent Finding on ABG for a PE
AG’s would not be the Next step if the Case gave -> ↑ RR, Hypoxia & O2 Sat (Hypoxia)
3. EKG – To r/o Heart Related Problems as the cause of Chest Pain,
-- Most Common findings in a PE is Sinus Tachycardia, Others are – S1O3T3
4. V/Q – Non-Invasive Test to Dx PE
If Suspicion is High and 1-3 are given in the case and the Answer Choices included Rxment then choose Rx over V/Q Scan
--If Negative R/o PE
or
Spiral CT – Done Instead of V/Q if Baseline CXR was Abn (i.e. Destroyed Lung)
5. Doppler US – Would be the Next Step if V/Q was Inconclusive or Indeterminate V/Q
(V/Q Matched, i.e. Vent & Perfusion Defect, instead of V/Q Mismatch, i.e. Ventilation w/o Perfusion D.)
or
CT Angiogram -- Can Dx Large Emboli, but may Miss Small Emboli
6. Pulmonary Angiogram – Invasive, used if All Test were Non-Dx
* Labs = D Dimer – The Presence of A D-Dimer is Sensitive enough to Dx ANY CLOT but not Specific enough to Confirm PE
-- If negative PE is Unlikely
Edited by hero on 01/08/08 - 08:35 PM
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| hero
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http://www.youtube.com/watch?v=NnhK_FK4WDQ
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| drduck
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pO2 and pCO2 both are lowered.
high suspition towards PE,
a very nice history...supporting diagnosis.
so go for the best initial investigation always will be V/Q study.
what else??
so what is answer.
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| DrVirgo
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drduck wrote:
pO2 and pCO2 both are lowered.
high suspition towards PE,
a very nice history...supporting diagnosis.
so go for the best initial investigation always will be V/Q study.
what else??
so what is answer.
I posted answer above:
E. Start Heparin
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| drduck
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are u sure just on the basis of suspision, we start of with heparin...
and once u start with heparin will ur tests for PE come positive??
anyways thank you for the Q and yes for the answer...
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| DrVirgo
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multifactorial wrote:
come on guys!thats a clear-cut case for every reason to use tPA.thats what kaplan teaches us.when the patient is unstable,not maintaining BP,give him tPA or if tPA is contraindicated,then do an embolectomy.if the patient has a stable BP,then give him heparin.
This guy's BP is 115/70. He is NOT Unstable.
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| multifactorial
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he is unstable.he is tachycardiac and low on his BP.plus the question says that he is in acute distress.
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| DrVirgo
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drduck wrote:are u sure just on the basis of suspision, we start of with heparin... and once u start with heparin will ur tests for PE come positive?? anyways thank you for the Q and yes for the answer...
Well I was not sure of this answer, but UW says the right answer is E, so I guess they are sure. 
Anyway, here is the given explanation:
Right answer E- Start heparin
The most likely diagnosis in this case is PE. Sudden onset SOB with clear lung sounds should always raise the suspicion of PE. Note that the patient had a recent long trip to Singapore, which is a resk factor for developing PE.
Patient iwth suspected PE should be given supplemental oxygen and placed on bed rest to reduce oxygen consumption. Heparin anticoagulation should be started immediately if the index of suspicion is very high and continued for 7-10 days. Heparin is usually started with bolus of 5,000 to 10,000 units followed by constant infusion of 1,000 units/hour to prolong PTT to 1.5 to 2.5 normal.
Choice A -V/Q Scan
V/Q Scan is the most helpful initial evaluation to rule out pulmonary embolus after chest x-ray, ABG and EKD are obtained. But V/Q scan is not necessarily done prior to the use of heparin, and so are other diagnostic tests. If you suspect a pulmonary embolism clinically, and chest x ray, ABG, and EKG results rule out other differential diagnoses then you should begin treatment with heparin without waiting for a V/Q scan to confirm your diagnosis.
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| DrVirgo
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multifactorial wrote:
he is unstable.he is tachycardiac and low on his BP.plus the question says that he is in acute distress.
Yes, i agree he is tachycardic, but do you consider 115/70 a LOW BP?
And acute distress doesn't mean unstable.
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| neurom
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just did this UW question and got it right , but i agree it is a little tricky.
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