Getting Ready

for Residency
XR/EKG Day 0
 Rhythm

Rate

Axis

Ectopy

Conduction

ST Segments

T Waves

Q Waves

Impression
Lines/Tubes

Lungs

Pleura

Heart &
Mediastinum

Bones

Other
 Morning
Report
Getting Ready for
HISTORY
OF 63 year-old female
PRESENT presents with chest pain
ILLNESS and shortness of breath…
Past Medical History

 Polymyalgia rheumatica
MEDications
 Breast mass
 Alendronate 70 mg weekly
 Hiatal hernia
 Ascorbic acid 250 mg daily
 Hypothyroidism  Cholecalciferol vitamin d3 2,000 units
 Osteopenia (right femoral neck per daily
DEXA)  Ibuprofen 200 mg q6h prn
 Levothyroxine 88 mcg daily
 Omeprazole 40 mg daily
 Prednisone 10 mg daily
 Tizanidine 4 mg tid
Past surgical history Social history
 20 pack year smoker
 Appendectomy  Social alcohol use
 Colonoscopy  No illicit drug use
 Oopherectomy
 Salivary gland surgery
 Salpingectomy Allergies
 Sinus surgery  Melon, cucumber, banana
 Penicillins, doxycycline, cefdinir
 PHYSICA
L EXAM

99.7 F 93 154/70 27

92% on RA
 DIAGNOSTICS
CBC BMP
16.9
133 97 18
13.5 247 123
49.5 4.2 25 1.13

HFP Other
Total bilirubin 1.7 Lactate 1.5
Direct bilirubin 0.4 Lipase 21
AST 77 Hs Troponin 61 ->
ALT 107 75 CXR
ALP 114
No acute cardiopulmonary abnormality
Total protein 7.6
Albumin 3.9
EKG
CTPA
 Diagnosi
s?

Bilateral segmental and

subsegmental pulmonary
embolisms
PULMONARY EMBOLISM
I introduction/
pathophysiology
I Diagnosis
I
II treatment
I
I Disposition
V
EPIDEMIOLOGY
VTE is the
third most >90% of PE
common originate
type of from DVTs
cardiovascul
ar disease

If untreated, Highest
acute PE has incidence
mortality rate among
as high as patients 60-80
30%. years of age
 34%

Chest pain

78% 22%

SYMPTOMS Sudden onset

dyspnea
Fainting or syncope

38%

Unilateral painful
swelling of Lower
extremity
 NOMENCLATURE

Temporal Hemodynamic stability Anatomy

Acute Massive (high-risk) saddle
Subacute Submassive lobar
Chronic (intermediate-risk) Segmental
Low risk subsegmental
 pathophysiology
v/q mismatch

Increase in pulmonary vascular

resistance
Backflow to right side of heart

Increase in right ventricular

Dilation of right ventricle pressure

Right heart failure/ISCHEMIA

Decreased RV output, septal shift toward LV

Decreased LV preload  decreased

CO

Decreased systemic arterial pressure

Decreased coronary perfusion

DEATH
 TREATMENT: BLEED VS
BENEFIT
Risk factors
Older age (>65 years; assessed as two risk factors if >75 years) Estimated Risk of Bleeding
Prior bleeding (especially if not correctable) Low Risk Moderate Risk High Risk
Cancer (assessed as two risk factors if metastatic or highly vascular)   (0 Risk Factors) (1 Risk Factor) (≥2 Risk Factors)
Renal insufficiency Anticoagulation 0-3
Liver failure months    
Diabetes mellitus Baseline risk (%) 0.6 1.2 4.8
Thrombocytopenia Increased risk (%) 1 2 8
Prior stroke (especially if hemorrhagic) Total risk (%) 1.6 3.2 12.8
Anemia
Anticoagulation after    
Concomitant antiplatelet or nonsteroidal antiinflammatory therapy first 3 months
Recent surgery Baseline risk per year 0.3 0.6 ≥2.5
Frequent falls (%)
Alcohol abuse Increased risk per year 0.5 1 ≥4.0
Reduced functional capacity (%)
Poor control of WARFARIN therapy Total risk per year (%) 0.8 1.6 ≥6.5

From American College of Chest Physicians

 PROVOKED VS UNPROVOKED
Provoked PE Provoked PE
Unprovoked PE
Transient risk factor Persistent risk factor

Risk of recurrence
Lowe Highest
st
Transient risk factors persistent risk factors
Recent surgery Malignancy
Bedrest in hospital > 3 IBD
days Inheritable
Pregnancy thrombophilias
Estrogen therapy Chronic heart failure
Admission to hospital > 3
days
Reduced mobility > 3
days
 TREATMENT
Provoked PE Provoked PE
Unprovoked PE
Transient risk factor Persistent risk factor

Risk of recurrence
Lowe Highest
st
Duration: Duration: Duration:
3-6 months indefinite Likely indefinite

Options:
DOACs, warfarin, LMW heparin, unfractionated heparin