Investigations

• What do you look for on a CT pulmonary angiogram?

  Bulging blood vessels

  Artery abnormally connected to a vein

  Identify & treat blood clot

  Identify narrowing of vessel wall

  Check how well blood is flowing to lungs
• What is prothrombin test?

  Measures activity of extrinsic & common pathways

  Evaluated patients suspected of having an inherited or acquired deficiency in these pathways
• How is aPTT useful clinically?

  Test deficiencies in common & intrinsic coagulation pathways

  Screening for coagulation inhibitors

  Useful in monitoring unfractionated heparin therapy
• How does right ventricular strain present on ECG?

  ST depression

  T wave inversion

  
• What is the S2 heart sound?

  2nd heart sound produced by closure of aortic & pulmonic valves
• What is the S1 heart sound?

  1st heart sound produced by closure of mitral & tricuspid valves
• What is the S3 heart sound?

  aka ventricular gallop

  Can be normal at times

  Produced from large amount of blood striking a compliant (distensible) left ventricle
• How would biomarkers of cardiac injury be used for PE?

  Plasma levels of BNP may be elevated -> due to straining of right ventricle

  Troponin may be increased -> due to right ventricular injury - due to strain
• What is bilateral iliofemoral DVT?

  Thrombus in both iliac vein and/or common femoral vein that ibstructs venous outflow from the lower limb -> oedema
• What can prolong prothrombin time?

  Factor VII deficiency

  Warfarin-induced
• What is atelectasis?

  Collapsed lung
• What is an S4 heart sound?

  aka atrial gallop

  Most always pathological

  Produced by blood striking a non-compliant (stiff) left ventricle
• How does S2 heart sound differ between inspiration & expiration?

  Expiration = S2 is a single sound

  Inspiration = S2 made of 2 components (A2 & P2)

  
• What is the ECG presentation of PE?

  Sinus tachycardia

  Right ventricular strain (ST depression, T wave inversions in leads corresponding to right ventricle)

  S1Q3T3 pattern -> Deep S wave in lead I, Q wave in lead III & inverted T wave in lead III

  
• What is a central saddle embolus?

  Large

  Typically straddles the bifurcation of the pulmonary trunk

  Extends into both the left & right pulmonary arteries

  Complete obstruction of both pulmonary arteries causes right heart failure
• When removing central lines, what position should patients be in?

  Placed head down - prevent air entry
• What is a normal prothrombin time?

  10-15 seconds (can vary from lab to lab)
• What is the d-dimer test & what is it looking for?

  Blood test

  D-dimer is a clot breakdown product from stable fibrin

  +ve = clots forming & breaking down in body (not specific for DVT/PE)

  -ve = rule out DVT/PE
• What are the different types of embolus?

  Fat

  Air

  Mycotic

  Thrombotic
• How is Doppler USS used in diagnosis of DVT?

  Assessment of blood flow

  If vein doesn't compress = thrombus within
• Why is a CXR used in PE?

  Cannot prove PE is present/absent

  Used to rule out other causes of symptoms (e.g. pneumonia)
• Why is there a low second heart sound in PE?

  Loud pulmonic component (P2) -> due to high pulmonary pressure (forces valve closed)
• How is CTPA done?

  Contrast dye injected injected into blood vessels (pulmonary artery)

  In PE -> will show blockage
• Fill in the blanks

  A) Respiratory acidosis

  B) Respiratory alkalosis

  C) Respiratory acidosis with metabolic compensation

  D) Respiratory alkalosis with metabolic compensation

  E) Metabolic acidosis

  F) Metabolic alkalosis

  G) Metabolic acidosis with respiratory compensation

  H) Metabolic alkalosis with respiratory compensation

  
• How is a V/Q scan used to diagnose PE?

  Evaluate air flow & blood flow

  If there is good airflow but poor blood flow -> indicates PE

  
• What is the Well's score for DVT?

  Score > 2 = DVT likely

  Active cancer = +1

  Bedridden recently = +1

  Calf swelling > 3cm = +1

  Collateral superficial veins present = +1

  Entire leg swelling = +1

  Localised tenderness along deep veins = +1

  Pitting oedema (symptomatic leg) = +1

  Paralysis, paresis or recent plaster immobilisation of lower extremity = +1

  Previous DVT = +1

  Alternative diagnosis more likely = -2
• What is the Well's score for PE?

  Score > 4 = likely PE

  Clinical signs & symptoms of DVT = +3

  PE is number 1 diagnosis (or equally likely) = +3

  HR > 100 bpm = +1.5

  Immobilisation at least 3 days (or surgery in previous 4 weeks) = +1.5

  Previous PE/DVT = +1.5

  Haemoptysis = +1

  Malignancy w/treatment within 6 months or palliative care = +1