Case Study 1

Question 1

A 28 year old woman presents to A&E with a six hour history of sudden onset of severe, right sided, pleuritic chest pain accompanied by shortness of breath and haemoptysis. What is the most likely diagnosis?

Answer 1

Pulmonary embolism

Question 2

Give six risk factors for this condition (diagnosis)

Answer 2

• recent long distance journey or prolonged period of immobility
• recent major surgery
• recent fracture, particularly pelvic or lower limb
• family history of coagulation or thromboembolic disease
• oral contraceptive pill and pregnancy
• coagulaopathy
• malignancy

Question 3

Give four investigations which may be done

Answer 3

• full blood count
• clotting screen
• arterial blood gas
• chest x-ray
• ECG
• V/Q scan

Question 4

What might be found in the FBC of this patient?

Answer 4

• polycythaemia
• thrombocytosis
• abnormal white blood cell count suggestive of haematological malignancy

Question 5

What might be found in the arterial blood gases of this patient?

Answer 5

show type 1 respiratory failure if present, often with hypocapnia

Question 6

What might be found on the CXR of this patient?

Answer 6

• may be normal

- wedge shadow

Question 7

What could be excluded by a CXR of this patient if your diagnosis is correct?

Answer 7

Pneumonias and pneumothoraces

Question 8

What principle abnormality associated with the patient’s condition might be seen on her ECG?

Answer 8

Sinus tachycardia

Question 9

What might be seen on an ECG in larger pulmonary embolisms?

Answer 9

Right ventricular strain pattern with a dominant R wave in V1 and V2

Question 10

Give four treatments/ways you would manage this patient?

Answer 10

• sit the patient upright and give oxygen via a mask
• IV or subcutaneous heparin
• on confirmation of the diagnosis, give 6 months therapy with warfarin, maintaining INR between 2-3
• address and treat any underlying risk factors