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Old 09-18-2011
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Lungs Shortness of breat after a car accident

A 57-year-old man develops acute shortness of breath shortly after a 12-hour automobile ride. The patient is admitted to the hospital for shortness of breath. Findings on physical examination are normal except for tachypnea and tachycardia. He does not have edema or popliteal tenderness. An electrocardiogram reveals sinus tachycardia but is otherwise normal. Which of the following statements is correct?

A) A normal D-dimer level excludes pulmonary embolus.
B) The patient should be admitted to the hospital, and, if there is no contraindication to anticoagulation, full-dose heparin or enoxaparin should be started pending further testing.
C) Normal findings on examination of the lower extremities make pulmonary embolism unlikely.
D) Early treatment has little effect on overall mortality.
E) A normal lower extremity venous Doppler study will rule out a pulmonary embolus.
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Old 09-18-2011
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B...start anti-coagulation its P.E, don't wait for workup
if it was DVT than anti-coagulation could wait
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Old 09-18-2011
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I go for B.
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Old 09-18-2011
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but A also seems correct
an abnormal level can be found in multiple conditions, but normal level usually excludes any type of clot whether dvt or p.e
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Old 09-18-2011
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Correct answer is B.
The clinical situation strongly suggests pulmonary embolism. In greater than 80% of cases, pulmonary emboli arise from thromboses in the deep venous circulation (DVTs) of the lower extremities, but a normal lower extremity Doppler does not exclude the diagnosis.
Pulmonary embolism is associated with a 30% mortality rate. Interestingly, only about 50% of patients with DVT of the lower extremities have clinical findings of swelling, warmth, erythema, pain, or palpable "cord." When a clot does dislodge from the deep venous system and travels into the pulmonary vasculature, the most common clinical findings are tachypnea and tachycardia; chest pain is less likely and is more indicative of concomitant pulmonary infarction.
The ABG is usually abnormal, and a high percentage of patients exhibit low Pco2 with respiratory alkalosis, and a widening of the alveolar-arterial oxygen gradient.
The ECG is frequently abnormal in pulmonary embolic disease. The most common finding is sinus tachycardia, but atrial fibrillation, pseudoinfarction in the inferior leads, and acute right heart strain are also occasionally seen.
Initial treatment for suspected pulmonary embolic disease includes prompt hospitalization and institution of intravenous heparin or therapeutic dose subcutaneous low-molecular-weight heparin.
It is particularly important to make an early diagnosis of pulmonary embolus, as intervention can decrease the mortality rate from 30% down to 5%. A normal D-dimer level helps exclude pulmonary embolus in the low-risk setting. This patient, however, has a high pretest probability of PE; further testing (CT pulmonary angiogram, V/Q lung scan) must be done to exclude this important diagnosis.
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