PE case

Question 1

What are the risk factors for PE

What can cause it

Answer 1

DVT, currently or previously
Immobilisation
Malignancy
Coagulopathy
Oral contraceptives

Venous thrombus
Tumour
Fat
Amniotic fluid
Air
Injected material

Question 2

What are the signs and symptoms for PE

Answer 2

Pleuritic chest pain

-sharp, localized, worse on inspiration

Question 3

What are the differentials for acute pleuritic pain

What are the differentials for slow onset pleuritic pain

Answer 3

Acute

• PT
• PE

Slow onset

• Pneumonia
• Cancer

Question 4

What investigations would you order

What could you find

Answer 4

ECG (acute pulmonary HTN)

• sinus tachycardia
• RBBB
• R ventricular strain (T wave inversion in V1-4)
• Right axis deviation
• Dominant R wave in V1 (RV dilation)
• R atrial enlargement
• S1Q3T3
• tachyarrythmias
• non specific ST changes

CXR

• normal, rule out PT
• can find other features

Question 5

How would you interpret the results of the Wells score

How would you manage from here on

Answer 5

Less than 4

• PE unlikely, D dimer
• if still likely, offer CTPA and interim DOAC (apixaban, rivaroxaban)

More than 4

• PE likely
• Offer CTPA and interim anticoagulation

Fibrinolytic for PE (alteplase)

Question 6

What are the 2 complications of PE

Answer 6

Hypoxia
-VQ mismatch

RV failure
-pulmonary circulation normally has a large reserve => but if it all fills up, puts pressure on RV => CV collapse, cardiac arrest

Question 7

What are the questions that you would ask in the Wells score

How would you score each of the 7 questions

Answer 7

Signs and symptoms of DVT = 3
Alternative diagnosis unlikely = 3
Tachycardia (100+) = 1.5
Immobilized for 3+ days/surgery in past month = 1.5
Past DVT/PE = 1.5
Haemoptysis = 1
Malignancy in the last 6 months = 1

Question 8

How would you manage post discharge

Answer 8

Provoked VTE => 3months on DOAC

Unprovoked VTE => 6months on DOAC