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Old 02-02-2013
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ObGyn Pregnant Woman with Pulmonary Embolism!

A 27-year-old woman is 7 months pregnant with her first child. Her pregnancy has been uncomplicated to date. She presents to the emergency department 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 notes that her legs began swelling during the sixth month of her pregnancy but the swelling has not worsened. 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.
The D-dimer level is elevated. 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) Doppler ultrasound of the lower extremity
(C) MRI of the lower extremity
(D) Pulmonary angiography
(E) Ventilation/perfusion scan
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(B) Doppler ultrasound of the lower extremity

You start with least invasive/harmful investigation.
In view of s/s of PE a positive Doppler will confirm the diagnosis and enough to start treatment.

The D-dimer level is elevated>>>means nothing since they only have negative predictive value.

(E) Ventilation/perfusion scan >>>only if the B is negative.
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Default (E) Ventilation/perfusion scan

(E) Ventilation/perfusion scan
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This question was discussed here earlier but my answer is still "Doppler ultrasound of the lower extremity" since it is currently the recommended modality & also makes most sense and the explanation given by the QBank is outdated.

Quote:
Originally Posted by USMLE-Syndrome View Post
initial (ABG -cxray -ecg)
if normal cxray the next step to dx is V/Q
if abnormal cxray the next step dx is spiral ct angiography
if spiral ct negtive then do LE doppler or V/Q if they r negtive stop rx
because when u suspect pe u start rx (anticoagulant (warfarin &heparin ) ) dont wait to confirm dx like in DVT (u have to confirm DX 1st then rx given)
if LE doppler is postive no need further IX start anticoagulant (heparin and 6 months warfarin)
if there is C.I to anticoagulant or recurrent emboli or RV dysfunction (RV hypertrophy ) then IVC filter
if unstable or acute RV dysfunction give thrombolytics if they r C.I then emblectomy

Most accurate test is angiography (gold stander )

these all what u need to know to solve q
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Last edited by Novobiocin; 02-02-2013 at 09:31 PM.
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Correct Answer

Ventilation/perfusion lung scanning is currently considered the diagnostic modality of choice in the pregnant population. that was explanation in FA Q&A for CK and also written in MTB 2 the same thing in pregnancy go for ventilation/ perfusion ..
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Old 02-05-2013
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Quote:
Originally Posted by menatallah Elgohary View Post
Ventilation/perfusion lung scanning is currently considered the diagnostic modality of choice in the pregnant population. that was explanation in FA Q&A for CK and also written in MTB 2 the same thing in pregnancy go for ventilation/ perfusion ..
That's the problem with outdated QBanks. It was current when the question was written which was probably more than 5 years ago and the question was specifically written ( "X-ray of the chest appears normal.") to guide towards the V/Q scan as the correct answer.

MTB 2 Page 401 --CT Angio


Also, I have confirmed from multiple reliable sources that CT Angio is currently the investigation of choice in all patients including pregnant patients since radiation dose (with the current technology) is less than a V/Q scan and the yield is higher (it gives more definitive answers than a V/Q Scan).
However, you can do your own research and choose the answer you are comfortable with.
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Last edited by Novobiocin; 02-05-2013 at 08:26 AM.
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(B) The doppler ultrasound

A. an initial step but not appropriately diagnostic
B. Since her leg is swollen, the chances of the Doppler being positive increase and 70% of the time the legs are the source for Emboli to the lungs. The doppler is easy, non-invasive and over here very predictive if that leg is indeed a DVT.
C. MRI. not here. No.
D. Pulmonary Angiography. the most diagnostic but in this case we would go for this invasive study only if the leg wasn't so clearly swollen and the scenario was unclear.
E. V/Q scan is secondary to Pulmonary Angio. Less sensitive. Less specific.
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Last edited by Brainiac; 02-05-2013 at 12:25 PM.
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Check this out http://emedicine.medscape.com/articl...0-workup#a0756
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Quote:
Originally Posted by Brainiac View Post
Exactly the point I was trying to explain.
Quote:
If at initial presentation a patient has concomitant symptoms or signs consistent with DVT and PE, compression ultrasonography may be considered first. If diagnostic for DVT, anticoagulation therapy is recommended, which is appropriate for both DVT and PE, avoiding further unnecessary testing for PE.
I would like to add that it is the compression ultrasound (CUS) showing non-compressible proximal vein (femoral) which is diagnostic of DVT and not the distal leg veins.

Quote:
The current initial test of choice in the evaluation of VTE is compression ultrasound (CUS) of the lower extremity veins. CUS has been shown to be more than 95% sensitive and specific for proximal lower extremity DVT.[
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Quote:
Originally Posted by Novobiocin View Post
That's the problem with outdated QBanks. It was current when the question was written which was probably more than 5 years ago and the question was specifically written ( "X-ray of the chest appears normal.") to guide towards the V/Q scan as the correct answer.

MTB 2 Page 401 --CT Angio


Also, I have confirmed from multiple reliable sources that CT Angio is currently the investigation of choice in all patients including pregnant patients since radiation dose (with the current technology) is less than a V/Q scan and the yield is higher (it gives more definitive answers than a V/Q Scan).
However, you can do your own research and choose the answer you are comfortable with.
plz look at page 161 MTB 2 in blue box written V/Q scan first in pregnancy only ,, i am really confused
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Quote:
Originally Posted by Brainiac View Post
i read what in the link u put it said do u/s if there is evidence (symptoms and signs)of DVT but in this case in problem i put u will find no evidence so as said in the link
Two alternative radiologic modalities exist for diagnosis of PE are spiral CT pulmonary angiography (CT-PA) and ventilation-perfusion (V/Q) scan. In the pregnant patient with no known pulmonary disease and a normal chest radiograph, ventilation-perfusion scan is the recommended study to evaluate for PE.
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I get what you mean. I hope on the USMLE they dont give us such a vague question. confused now.

Quote:
Originally Posted by menatallah Elgohary View Post
i read what in the link u put it said do u/s if there is evidence (symptoms and signs)of DVT but in this case in problem i put u will find no evidence so as said in the link
Two alternative radiologic modalities exist for diagnosis of PE are spiral CT pulmonary angiography (CT-PA) and ventilation-perfusion (V/Q) scan. In the pregnant patient with no known pulmonary disease and a normal chest radiograph, ventilation-perfusion scan is the recommended study to evaluate for PE.
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