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Old 12-15-2012
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Arrow Diagnostic Test of PE during Pregnancy

A 27-year-old woman is 7 months pregnant with her first child. Her pregnancy has been uncomplicated to date. She presents to the ED complaining of sudden-onset, right-sided chest pain that is exacerbated with deep breathing, and shortness of breath, which began 1 hour ago. She denies leg pain, and says the swelling that is apparent has been unchanged since the sixth month of her pregnancy. Her temperature is 37.9°C (100.3°F), blood pressure is 130/87 mm Hg, pulse is 107/min and regular, respiratory rate is 24/min, and oxygen saturation is 90% on room air, increasing to 98% with 4 L oxygen via nasal cannula. Physical examination is significant for crackles at the lower right lung field and a negative Homans’ sign bilaterally. X-ray of the chest appears normal, D-dimer is elevated, and ECG shows sinus tachycardia, right-axis deviation, S wave in lead I, Q wave in lead III, and an inverted T wave in lead III. Which of the following is the most appropriate next step in diagnosis?

(A) Arterial blood gas analysis
(B) Lower extremity Doppler ultrasound
(C) MRI
(D) Pulmonary angiography
(E) Ventilation/perfusion scan
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ventilation perfusion scan to confirm PE.
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(E) Ventilation/perfusion scan

Is it amniotic fluid embolism ??
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(B) Lower extremity Doppler ultrasound
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(E) Ventilation/perfusion scan
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Quote:
Originally Posted by Novobiocin View Post
(B) Lower extremity Doppler ultrasound
a negative Homans’ sign bilaterally,still we will answer lower extremity doppler ?
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Quote:
Originally Posted by aknz View Post
a negative Homans’ sign bilaterally,still we will answer lower extremity doppler ?
I think that's the point of this question.
Negative Homan's sign and positive D-dimer means nothing in the above scenario. Just think about their predictive values.
I may be wrong but think that if her lower extremity doppler is positive then it will be diagnostic for PE especially in the presence of EKG findings, so why expose her to VQ scan which may or may not establish the diagnosis.
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The correct answer is E.
The clinical diagnosis of VTE during pregnancy is insensitive and nonspecific because of normal physiologic changes associated with pregnancy.For example, lower extremity swelling and tachypnea are common in normal pregnancies and in pulmonary embolism (PE). Furthermore, tests for D-dimer are of limited diagnostic utility in pregnancy because of the normal elevation of D-dimer in uncomplicated pregnancy. X-ray of the chest may be normal initially but may later show Westermark sign (dilatation of pulmonary vessels and a sharp cutoff), atelectasis, small pleural effusion, and elevated diaphragm. The ECG findings described here are collectively nicknamed the “S1Q3T3 pattern,” which is a nonspecific finding encountered in any case of acute cor pulmonale (tension pneumothorax, bronchospasm, or PE). An S1Q3T3 pattern alone is not sufficient for diagnosis of PE. A definitive diagnostic strategy is necessary in pregnant patients suspected of VTE. Ventilation/perfusion lung scanning is currently considered the diagnostic modality of choice in the pregnant population.

If the patient is stable and has a nondiagnostic ventilation/perfusion scan, lower extremity Doppler ultrasound is a reasonable test to document deep vein thrombosis (DVT). Because treatments for DVT and submassive PE are the same, identification of DVT is sufficient to terminate the workup of PE.
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Quote:
Originally Posted by heartbeat View Post
The correct answer is E.
The clinical diagnosis of VTE during pregnancy is insensitive and nonspecific because of normal physiologic changes associated with pregnancy.For example, lower extremity swelling and tachypnea are common in normal pregnancies and in pulmonary embolism (PE). Furthermore, tests for D-dimer are of limited diagnostic utility in pregnancy because of the normal elevation of D-dimer in uncomplicated pregnancy. X-ray of the chest may be normal initially but may later show Westermark sign (dilatation of pulmonary vessels and a sharp cutoff), atelectasis, small pleural effusion, and elevated diaphragm. The ECG findings described here are collectively nicknamed the “S1Q3T3 pattern,” which is a nonspecific finding encountered in any case of acute cor pulmonale (tension pneumothorax, bronchospasm, or PE). An S1Q3T3 pattern alone is not sufficient for diagnosis of PE. A definitive diagnostic strategy is necessary in pregnant patients suspected of VTE. Ventilation/perfusion lung scanning is currently considered the diagnostic modality of choice in the pregnant population.

If the patient is stable and has a nondiagnostic ventilation/perfusion scan, lower extremity Doppler ultrasound is a reasonable test to document deep vein thrombosis (DVT). Because treatments for DVT and submassive PE are the same, identification of DVT is sufficient to terminate the workup of PE.
So what will be the order of tests :

Best initial ECG ,X-ray chest and ABGs.

Then V/Q scan without doing lower extremity doppler ??
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Quote:
Originally Posted by aknz View Post
So what will be the order of tests :

Best initial ECG ,X-ray chest and ABGs.

Then V/Q scan without doing lower extremity doppler ??
I am confusing about the best order of test, so try to discuss this with you cuz i think that best initial test is doing compressing Doppler ultrasound but in the bank they mention V/Q scan
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This may be the best order
http://emedicine.medscape.com/article/2056380-workup
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