Review Question - QID 103521

This patient is presenting with chest pain, recent travel/stasis, recent surgery, and calf swelling suggesting a diagnosis of a pulmonary embolism (PE). Hemoptysis would make this patient high risk warranting work up with a CT angiogram regardless of clinical suspicion.

Pulmonary embolism (PE) typically presents with pleuritic chest pain, tachypnea, and dyspnea, while some also have evidence of concomitant deep venous thromboembolism. Patients can be risk stratified using Wells criteria:

1. Findings of a DVT (3 points)
2. PE is most likely diagnosis (3 points)
3. Heart rate > 100/min (1.5 points)
4. Immobilization for 3 days or surgery in past 4 weeks (1.5 points)
5. Previous PE or DVT (1.5 points)
6. Hemoptysis (1 point)
7. Malignancy within 6 months or palliative care (1 point)

The management of a PE is based on the Wells score:

1. < 2 points (low risk): D-dimer
2. 2-6 points (intermediate risk): D-dimer or CT angiogram
3. > 6 points (high risk): CT angiogram (a D-dimer should not be used)

A patient who is high risk by Wells criteria must receive a CT angiogram to rule out a PE since a D-dimer if positive or negative would still be followed by a CT angiogram.

Incorrect Answers:
Answer 1: Bilateral wheezing would be suggestive of asthma or COPD which can be diagnosed clinically and treated with albuterol, ipratropium, and steroids.

Answer 2: Decreased breath sounds over area of the lung describes a pleural effusion which would not require more workup than a chest radiograph initially.

Answer 4: Increased breath sounds over area of the lung could be seen in a bacterial pneumonia which could be worked up with a chest radiograph and treated empirically with ceftriaxone and azithromycin which covers for community acquired pneumonia.

Answer 5: Green sputum is not a sensitive or specific finding for an infectious process and a pneumonia would not require a CT angiogram.

Bullet Summary:
Hemoptysis is a finding concerning for a pulmonary embolism.