PE

Question 0

Well’s Score Interpretation?

Answer 0

Low chance if 4

Low chance it =4

Question 1

Wells score criteria?

Answer 1

Clinical signs of DVT– 3 points
PE most likely – 3 points

Surgery in past 4 weeks – 1.5 points
Tachycardia– 1.5 points
Demobilization for the past three days – 1.5 points
Previous PE/DVT – 1.5 points

Hemoptysis – 1 point
Malignancy – 1 point

Question 2

Wells score for DVT’s?

Answer 2

Alternate diagnoses at least as likely: -2 points

Active cancer
Previous DVT
Calf Swelling >= 3 cm
Entire leg swelling
Unilateral Swollen superficial veins
Unilateral pitting edema
Paralysis or cast mobilization
Bedridden >3 days
Major surgery in past 12 weeks

Tenderness:

Question 3

Wells score for DVT’s interpretation?

Answer 3

High risk if >2
Moderate risk if 1 – 2
Low risk if <1

Question 6

Use Inferior Vena cava filter if?

Answer 6

1. Active bleeding or other contraindication for anticoagulation
2. Recurrent DVT/PE despite therapeutic anticoagulation

Question 9

PE – most common symptom, most frequently observed sign?

Answer 9

Dyspnea, tachypnea

Question 11

Most appropriate diagnostic step for patient with suspected PE?

Answer 11

CT with contrast (In patient with severe renal disease or contrast allergy use V/Q scan)

Question 13

The most common inherited hypercoagulable disorders?

Answer 13

Factor V Leiden and prothrombin gene mutations

Question 14

Why is malignancy a predisposing condition for DVT’s?

Answer 14

Thought to generate thrombin or secrete procoagulants

Question 15

Most common site of Clot formation?

Answer 15

The deep, proximal lower extremity veins

Question 16

Obstruction to the pulmonary arteries cause?

Answer 16

1. Platelets release serotonin – elevating pulmonary vascular resistance (RV Dilation)
2. V/Q mismatch
3. Reflex bronchoconstriction increases airway resistance
4. Edema/hemorrhage/loss of surfactant further decreases lung compliance

Question 17

Signs of massive PE versus smaller PE?

Answer 17

Syncope, hypertension, cyanosis

versus

pleuritic pain, cough, hemoptysis

Question 18

Classical physical exam findings of PE?

Answer 18

1. Tachycardia
2. Right ventricular dysfunction – Tachypnea, left parasternal lift, accentuated pulmonic component of second heart sound, systolic murmur increases that with inspiration

Question 19

Course to initiate warfarin therapy?

Answer 19

Use unfractionated heparin, Lovenox, or fondaparinux for five days while overlapping with warfarin until INR is 2.5 for two days

Question 20

Treatment length for warfarin?

Answer 20

Provoked DVT of calf or upper extremity: 3 months

PE or provoked DVT of the proximal leg: 6 months

unprovoked DVT/PE with ongoing risk factors (cancer, antiphospholipid): indefinite

Question 21

D-dimer value in patients with PE?

Answer 21

> 500

Question 22

Most common ECG findings in PE?

Other findings?

Answer 22

Sinus tachycardia

#New Onset AFIB 
#T-wave conversions in anterior leads (V1 – V4)
#S1 Q3 T3

Question 23

Most common CXR abnormality in PE?

Others?

Answer 23

Usually normal but If abnormality - atelectasis

2. Westermark sign – prominence of central pulmonary artery with decreased pulmonary vascularity
3. Hampton hump – a peripheral wedge shaped density above diaphragm
4. Palla sign - Enlargement of right descending pulmonary artery

Question 24

Primary therapy for PE?

Answer 24

Patients with right heart failure or hypotension (high risk): Thrombolysis or surgical embolectomy

Otherwise: anticoagulation With unfractionated heparin or Lovenox or Fondaparinux

Question 25

Usual cause of death from PE?

Answer 25

Right heart failure

Question 39

Virchow’s Triad?

Answer 39

Trauma, hypercoagulability, venostasis

Question 40

Prerequisite for a V/Q scan?

Answer 40

Normal CXR (if abnormal, get CT)

Question 41

When to use direct thrombin inhibitor for anticoagulation instead of heparin?

Answer 41

Heparin-induced thrombocytopenia