Pulmonary Embolism

(M2.PL.17.4687) A 25-year-old woman with bipolar disorder and schizophrenia presents to the emergency room stating that she is pregnant. She says that she has been pregnant since she was 20 years old and is expecting a baby now that she is breathing much harder and feeling more faint with chest pain caused by deep breaths. Her hospital medical record shows multiple negative pregnancy tests over the past 5 years. The patient has a 20 pack-year smoking history. Her temperature is 98°F (37°C), blood pressure is 100/60 mmHg, pulse is 110/min, respirations are 28/min, and oxygen saturation is 90% on room air. Her fingerstick glucose is 100 mg/dL. She has a large abdominal pannus which is soft and nontender. Her legs are symmetric and non-tender. Oxygen is provided via nasal cannula. Her urine pregnancy test comes back positive and an initial chest radiograph is unremarkable. What is the next best step in diagnosis?

(M3.PL.16.51) A 43-year-old woman presents to her primary care physician with complaints of mild shortness of breath and right-sided chest pain for three days. She reports that lately she has had a nagging nonproductive cough and low-grade fevers. On examination, her vital signs are: temperature 99.1 deg F (37.3 deg C), blood pressure is 115/70 mmHg, pulse is 91/min, respirations are 17/min, and oxygen saturation 97% on room air. She is well-appearing, with normal work of breathing, and no leg swelling. She is otherwise healthy, with no prior medical or surgical history, currently taking no medications. The attending has a low suspicion for the most concerning diagnosis and would like to exclude it with a very sensitive though non-specific test. Which of the following should this physician order?

(M3.PL.15.70) A 64-year-old female with a known diagnosis of metastatic breast cancer presents to the emergency department after decompensating while at the chemotherapy suite. On arrival vitals are: pulse 124 bpm, blood pressure 92/64 mmHg, temperature 98.5 F, respiration 24/min and shallow. The patient is diaphoretic and disoriented, but able to complain about excruciating chest pain. Labs are drawn, and the patient is quickly worked up with an EKG (Figure A) and helical CT (Figure B). The patient is started on a heparin drip. Which of the following results confers a poor prognosis for the patient?

(M2.PL.14.62) A 50-year-old man presents to the emergency department with chest pain. He states that it began earlier today and worsens with inspiration. It is non-exertional, 7/10 in severity, and sharp in nature. He states that he just returned from China yesterday and has not had any similar symptoms prior to today. He noticed that he has coughed up a small amount of blood-tinged sputum several times as well. He is otherwise healthy, other than having his foot splinted 4 days ago for an Achilles tendon injury he sustained while playing volleyball. His temperature is 97.9°F (36.6°C), blood pressure is 112/68 mm Hg, pulse is 120/min, respirations are 23/min, and oxygen saturation is 92% on room air. Physical exam is notable for an uncomfortable man who is mentating appropriately and moving all his extremities. Inspection of his lower extremities reveals a swollen and tender calf on the leg that is splinted. An ECG is seen in Figure A. The patient is started on IV fluids and oxygen. Which of the following is the next best step in management?