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Old 09-18-2011
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Lungs Pulmonary Embolism, best next step in the management?

26 YO female, on OCP, presented with sudden onset SOB, with chest pain that gets worse with deep inspiration, she is smoker, no significant past medical history. RR 26, P 103. Chest X ray normal, EKG, sinus tachycardia, ABG: 7.50/25/70/92%. What is the best next step in the management?

1. Angiogram.
2. V/Q scan.
3. Spiral CT
4. Echo.
5. MRI
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Old 09-18-2011
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the answer is spiral ct
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3. Spiral CT
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3. Spiral CT

Nice question, but why did you put that it's a pulmonary embolus in the title. Pretty much gave away the answer since half the challenge with the question is figuring out the diagnosis!
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A question, if in the same scenario we have also the option of Chest X-ray then wat should be the next best step?
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Quote:
Originally Posted by step1an View Post
A question, if in the same scenario we have also the option of Chest X-ray then wat should be the next best step?
A chest X-ray, ABG n EKG.... all r the best initial test in case of PE. so a chest x-ray can be the initial test of choice but not the best step because in most cases of PE, chest x'rays appear to be normal.
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Quote:
Originally Posted by step1an View Post
A question, if in the same scenario we have also the option of Chest X-ray then wat should be the next best step?
Should still be spiral CT. Chest X-ray is usually normal in PE (textbook signs of PE such as Hampton's hump of Westermark's sign are rarely seen). In practice, a chest X-ray is usually done to rule out other alternative diagnoses.

Workup for patient with clinically suspected PE:
1) Spiral CT
2) If CT cannot be done or results are inconclusive, do leg ultrasound to look for DVT (if present, treat for PE)
3) If no DVT on leg ultrasound, do V/Q scan or pulmonary arteriogram.

If PE is clinically unlikely but you still want to rule out, measure D-dimer (elevated in PE).
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Quote:
Originally Posted by heights View Post
Workup for patient with clinically suspected PE:
1) Spiral CT
2) If CT cannot be done or results are inconclusive, do leg ultrasound to look for DVT (if present, treat for PE)
3) If no DVT on leg ultrasound, do V/Q scan or pulmonary arteriogram.

If PE is clinically unlikely but you still want to rule out, measure D-dimer (elevated in PE).
Plz correct me if i am wrong;
My understanding is that V/Q scan is indicated if we cannot do the CT scan or its inconclusive.
Examples:
Pregnant Pts & Pts having renal failure (cannot take iv contrast)

So, after CT we should go for V/Q scan instead of Lower limb Doppler.
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Quote:
Originally Posted by step1an View Post
Plz correct me if i am wrong;
My understanding is that V/Q scan is indicated if we cannot do the CT scan or its inconclusive.
Examples:
Pregnant Pts & Pts having renal failure (cannot take iv contrast)

So, after CT we should go for V/Q scan instead of Lower limb Doppler.
I think you're right, according to UW V/Q scan is the test of choice in pts with contrast allergy, renal insufficiency, or pregnant.

According to the algorithm in SUTM, you do the lower extremity doppler prior V/Q scan , but if the no clot found on doppler it doesn't rule out PE, so I guess that's why V/Q scan is the next best treatment of choice after CT.
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The best next step as you all mentioned is spiral CT.
The first (not the best) test is ABG, is of course not diagnostic for PE. Then chest X ray, ECG (these are non specific for PE).
The specific test for PE:
  • Spiral CT: sensitivity >90%, may miss the peripheral small PEs, as we no can’t be done in patients with renal insufficiency or contrast allergy.
  • V/Q scanning: has been replaced by spiral CT as an initial study of choice in many centers. Plays an important role in the diagnosis when there is contraindication to spiral CT. It is cumbersome & does not give exact visualization of the embolus.
  • Angiogram: gold standard test: invasive, not done routinely.
Tests specific for DVT:
  • Compression or duplex ultrasound.
  • Venogram
  • MRI
Tests for both PE & DVT:
D-dimer
What is going in real life like this:
Start with spiral CT (as best initial test):
  • +ve, then 100% PE.
  • –ve , then consider peripheral PEs (look for proximal DVT by compression or duplex U/S, do D-dimer), presence of proximal DVT, means diagnosis of PE.
  • Normal CT + normal D-dimer= no PE.
4. Normal ultrasound + normal D-dimer= no PE
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Please note, in this Q, if there is an option answer for heparin, then go for it (this the best next step in the management), b/c it is high risk patient, you should start heparin & then continue with your diagnostic tests. Because this is high risk patient, if CT is negative, & you couldn't document proximal DVT, you must go for angiogram.
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Old 09-19-2011
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Default still unclear

What is going in real life like this:
Start with spiral CT (as best initial test):
  • +ve, then 100% PE.
  • –ve , then consider peripheral PEs (look for proximal DVT by compression or duplex U/S, do D-dimer), presence of proximal DVT, means diagnosis of PE.
  • Normal CT + normal D-dimer= no PE.
4. Normal ultrasound + normal D-dimer= no PE[/QUOTE]

what is given in uw is that
if v/q scan is inconclusive then go for venous ultrasound or ct angiogram..if both negative then pul angiogram....
so according to the uw ..the order is
v/q-----doppler/ct----d dimer(exclude pul embolism in low setting,in high risk pt --normal level not enough).....angio
so please clarify
BIT is v/q or ct for the exams
even though in real life i know ct is most widely used and few do v/q
???
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You are correct, it is confusing.

If you started with V/Q scan or spiral CT, & you get negative test, then no PE.
As far as we are concerned for the board: in low risk patient: CT is negative, we will do ultrasound for proximal DVT & D-dimer, if both negative, we stop here. If the patient is high risk patient you need to go further, for angiogram (gold standard test).
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sorry but i repeat again..best intial test is ct or v/q....
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Most centers go with CT, most likely in the exam this not a big issue, if you get it go for CT. Please see MTB page 401 & step up to medicine page 100.
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Quote:
Originally Posted by samstar View Post
sorry but i repeat again..best intial test is ct or v/q....
first we check clinical probability....
  • if low....2 approaches
  1. one is to check d-dimers if neg discharge, if positive do spiral ct
  2. other is to do PERC (P.E rule out criteria--its a set of some 8 or 9 clinical features, no labs.. i didnt remember them) if negative, discharge. if positive--- do dimers..if neg discharge, if positive do spiral ct...
  • if high
preffered approach is to do spiral ct---if neg discharge, if positive treat...
if c/i, or not possible, do v/q
if normal----discharge
if intermediate or high probablity scan---treat
problem is with low probability---here we do doppler/ d dimer

i dont remember from where did i get this, i think it was uptodate...ill try to post the link as soon as i can..!!
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when we r given the scenarion in exam, its always high probability...so we just cum to 2nd category n do spiral ct
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Old 09-25-2011
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Quote:
Originally Posted by ag2011n View Post
The best next step as you all mentioned is spiral CT.
The first (not the best) test is ABG, is of course not diagnostic for PE. Then chest X ray, ECG (these are non specific for PE).
The specific test for PE:
  • Spiral CT: sensitivity >90%, may miss the peripheral small PEs, as we no can’t be done in patients with renal insufficiency or contrast allergy.
  • V/Q scanning: has been replaced by spiral CT as an initial study of choice in many centers. Plays an important role in the diagnosis when there is contraindication to spiral CT. It is cumbersome & does not give exact visualization of the embolus.
  • Angiogram: gold standard test: invasive, not done routinely.
Tests specific for DVT:
  • Compression or duplex ultrasound.
  • Venogram
  • MRI
Tests for both PE & DVT:
D-dimer
What is going in real life like this:
Start with spiral CT (as best initial test):
  • +ve, then 100% PE.
  • –ve , then consider peripheral PEs (look for proximal DVT by compression or duplex U/S, do D-dimer), presence of proximal DVT, means diagnosis of PE.
  • Normal CT + normal D-dimer= no PE.
4. Normal ultrasound + normal D-dimer= no PE

from where have you taken these facts......I was really confused and this post again made me confuse....please give me the reference of qbanks or books ....

what I came to conclusion previusly...
BIT--> CXR and ABG
if CXR ,
abnormal --->>spiral CT
normal--->>V/Q
if V/Q not available Spiral CT always(V/Q has been almost replaced because of its complicate procedure )...as because of easier procedure than V/Q..

and further Mx as other and you have mentioned... please correct me...thank you..
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Old 09-25-2011
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My source is Kaplan videos, pulmonary course. Please review step up to medicine second edition Page 97-100.
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in the exam, you wont get both the options of v/q and spiral ct. So no confusion. I dont know if this question was really there or just made up to clear the doubts. we need something that is available in the ER. but if this case scenario does come in the exam, prefer spiral CT over v/q. As per my friends, real exam still uses v/q as the next diagnostic work up after abg, ekg and cxr and ofcos heparin. if v/q is intermed--> do CT and continue treat if + , if low, do d dimer and duplex.
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