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A 45-year-old Caucasian male comes to the emergency room complaining of shortness of breath that began 3 hours ago. He also has a nonproductive cough, slight fever and right-sided chest pain that worsens with inspiration. He denies coughing up blood, wheezing, palpitations, leg pain or swelling of lower extremities. He recently had a trip to Singapore. Past medical history reveals hypertension for 8 years, and diabetes mellitus for 4 years. His medication includes captopril and glyburide. He is allergic to penicillin. He doesnot smoke. He drinks alcohol occasionally. His vital signs are T: 101 F (38.3C), BP: 115/70 mmHg, PR: 128/min, and RR: 32/min. Physical examination shows slightly obese white man in acute distress. He is alert and cooperative without any cyanosis or jaundice. His physical examination reveals slightly displaced apex beat with loud S 4. Chest-x ray shows mild cardiomegaly. EKG shows sinus tachycardia and left ventricle hypertrophy; no acute ST-T changes seen. His Arterial Blood Gases shows: pH 7.52, pCO2 30, pO2 60, and 86% O2 saturation on room air. He is started on oxygen. What is the next best step in the management of this patient?
A. Ventilation perfusion scan
B. Pulmonary angiogram
C. Doppler of lower legs
D. Spiral CT scan of chest
E. Start heparin
F. Give thrombolytic therapy with t-PA
G. Cardiac enzymes
H. PTCA
I. Echocardiogram
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ventilaton perfusion scan
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Recent trip - DVT - V/Q scan
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well.......hm........
the ans is E.start heparin
Patient with suspected pulmonary embolus should be given supplemental oxygen and placed on bed rest to reduce oxygen consumption. Heparin anticoagulation should be started immediately if the index of suspicion is very high and continued for 7 to 10 days. Heparin is usually started with bolus of 5,000 to 10,000 units followed by constant infusion of 1,000 units/hour to prolong PTT to 1.5 to 2.5 normal.
V/Q scan (Option A) is the most helpful initial evaluation to rule out pulmonary embolus after chest x-ray, ABG and EKG are obtained. But V/Q Scan is not necessarily done prior to the use of heparin, and so are other diagnostic tests. If you suspect a pulmonary embolism clinically, and chest X ray, ABG and EKG results rule out other differential diagnoses then you should begin treatment with heparin without waiting for a V/Q scan to confirm your diagnosis.
have u guys got anythng to say more?
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yes i was pissssed too when i read this q too..i called up my friend and asked him whethr he wud do the same mistake as V/Q scan... he chose A too...lol .its really reckoning that there are no generalisatns and everything is decided in the last sec...i mean we cant assume but only just hv an idea.....of how best we can do to get the answer...
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but sc98 he is vitally stable
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Let give an example of when V/Q scan may be the initial test. Any more examples sc98 for that so we can compare
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I tink since the chap is stable we should do V/Q scan to be sure before starting heparin. Anyway, he is already on O2!!! So i will still go for ans A.
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happifella and sc98 why do you say he is stable? Ihe case they say he has
tachycardia, incr resp rate and is in acute distress??
Are you guys basing "stable" on BP value? Pls explain
