Pulmonary Disease Pulmonary Embolus: Review Questions Nuala J. Meyer, MD Dr. Meyer is a pulmonary and critical care fellow, University of Chicago, Chicago, IL. Choose the single best answer for each question.
	Figure 1 1. A 64-year-old man presents to the emergency department complaining of shortness of breath. He has a history of pancreatic cancer. The patient reports a 1-week history of mild pleuritic chest pain and a tender swelling on the medial aspect of his left thigh. On examination, the patient’s heart rate is 112 bpm, blood pressure is 134/72 mm Hg, respiratory rate is 22 breaths/min, and Sao2 is 95% on room air. Cardiovascular examination reveals tachycardia with normal rhythm. Lung examination shows dullness to percussion at the right base with decreased breath sounds. A chest radiograph demonstrates a moderate right-sided pleural effusion, and duplex ultrasonography of the left lower extremity reveals an acute thrombus in the left superficial femoral vein. Thoracentesis is performed and fluid analysis reveals: serous fluid; pH, 7.43; white blood cell count, 566 cells/µL (2% neutrophils, 83% lymphocytes, 7% macrophages, 9% mesothelial cells); red blood cell count, 2040 cells/µL; protein, 1.4 g/dL (serum protein, 5.9 g/dL); l-lactate dehydrogenase (LDH), 58 IU/L (serum LDH, 216 IU/L). No malignant cells are seen on cytopathologic review. What is the likely etiology of this patient’s pleural effusion? Congestive heart failure Hepatic insufficiency due to pancreatic cancer Metastatic pancreatic cancer Pneumonia Pulmonary embolism (PE) Click here to compare your answer. Questions 2 and 3 refer to the following case. A 31-year-old pregnant woman at 29 weeks’ gestation presents to her obstetrician due to dull left-sided chest pain and acute-onset shortness of breath. She denies calf or thigh tenderness. Physical examination is unremarkable except for sinus tachycardia; arterial pulse oximetry is normal (96% on room air). Chest radiograph is also normal. 2. What is the best diagnostic study to evaluate this patient for PE? Computed tomography pulmonary angiography (CTPA) Duplex ultrasonography Invasive pulmonary angiography Perfusion lung scintigraphy Transthoracic echocardiography Click here to compare your answer. 3. PE is determined to be present in this patient. What is the optimal initial and long-term regimen for this patient’s thromboembolic disease? Intravenous (IV) unfractionated heparin to an activated partial thromboplastin time (aPTT) 1.5 to 2 times baseline, followed by warfarin to an international normalized ratio (INR) between 2 and 3 for several months postpartum IV unfractionated heparin to an aPTT 1.5 to 2 times baseline, followed by warfarin to an INR between 1.5 and 2.5 for several months postpartum IV unfractionated heparin to an aPTT 1.5 to 2 times baseline, followed by twice daily subcutaneous unfractionated heparin for several months postpartum Low-molecular-weight heparin (LMWH) subcutaneously throughout pregnancy and for several months postpartum Click here to compare your answer.		Figure 2 Questions 4 and 5 refer to the following case. A 47-year-old man with a history of chronic obstructive pulmonary disease (COPD), diabetes, and hypertension presents to the emergency department complaining of dizziness, weakness, and dyspnea on exertion. He denies chest pain or calf tenderness. Physical examination reveals mild tachycardia (heart rate, 105 bpm), normal blood pressure (132/76 mm Hg), normal respiratory rate, and mild hypoxemia (88% on room air). D-dimer test is positive, and CTPA demonstrates a saddle PE in the main pulmonary arterial trunk (Figure 1 and Figure 2). Transthoracic echocardiography reveals evidence of acute right heart strain, with a poorly contracting right ventricle, tricuspid regurgitation with pulmonary hypertension, and bowing of the interventricular septum towards the left ventricle. Computed tomography of the head is normal and reveals no cause for dizziness. He has no known contraindications to anticoagulation. 4. How should the echocardiographic findings of right ventricular strain alter management of this patient? The patient is at increased risk for shock or death from PE and should receive more intensive monitoring The patient is at increased risk for shock or death from PE and should receive thrombolytic therapy The patient is at increased risk for recurrent PE and should receive LMWH rather than warfarin The patient is at increased risk for ongoing embolization and should receive a vena caval interruption device Click here to compare your answer. 5. The patient is admitted to the intensive care unit and is anticoagulated with heparin. Over the next 24 hours, he develops hypotension and mental status changes. Dobutamine is initiated to support the right ventricle along with norepinephrine to augment mean arterial pressure. Which therapy would be most appropriate at this time? IV alteplase 100 mg over 2 hours IV argatroban 2 µg/kg/min IV dopamine 2.5 µg/kg/min IV tirofiban 0.4 µg/kg/min for 30 min, then 0.1 µg/kg/min Warfarin 7.5 mg by mouth at bedtime Click here to compare your answer.
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