Mortality rates in the first 3 months following a PE dx are:
1.5%
5%
15%
30%
50%
Emboli begin as thrombi which may consist of:
fat
air
tumor
Only A & B
All of the above
Venous thromboembolism may originate from:
DVTs
catheters
infections
A & C only
Which of the following are physiologic anticoagulants that oppose thrombosis?
AT-III
Fibrin
Protein C
Which of the following are the most common sources for clinically important pulmonary emboli? (select all that apply)
Subclavian veins
Right Atrium/Ventricle
Femoral vein
Iliac vein
Pelvic vein
Which of the following compose Virchow's Triad:
Factors in the vessel wall (e.g. tissue damage)
Abnormal blood flow (e.g. venous stasis)
Abnormal/Hypercoagulable states
Abnormal/Hypocoagulable states
Abnormal branching of vessels
Which of the following may cause venous stasis?
Surgery
Congestive Heart Failure
Pregnancy
Which of the following may cause hypercoagubility? (select all that apply)
Oral contraceptives
Hormone Replacement Therapy
Malignancy
Excesses of Proteins C or S
Over 95% of pulmonary emboli are thromboemboli.
Which of the following are NOT true regarding the natural history of a venous thomboembolism?
Non-extended distal DVTs rarely cause PE
80% of symptomatic DVTs have extended into the distal veins
60% of pts w/ symptomatic DVTs w/ will have a PE
70% of pts with symptomatic PE will have asymptomatic DVTs
DVTs most often start in the calf (distal) veins
Of the following sxs, which are all associated w/ PE, which is the least common? (choose one)
Dyspnea
Cough
Leg Pain/Swelling
Pleuritic chest pain
Hemoptysis
Wheezing
Orthopnea
Which of the following is the most common sign associated with PE? (found in approximately 54% of PE presentations)
Tachypnea
Calf swelling/tenderness
Tachycardia
Decreased breath sounds
Crackles
Which of the following is NOT part of the PERC clinical decision tool (i.e. HADCLOTS) used for diagnosing PE?
Surgery/trauma w/in past 28 days
Coughing blood
Lower extremity swelling unilaterally
O2 Saturation <95%
All of the above are associated with PERC
Which of the following pairs would have the HIGHEST Wells score?
1) PE most likely dx (on ddx), 2) Hemoptysis
1) Clinical signs and sxs of DVT, 2) Immobilization for > 3 consecutive days or surgery in previous 4 weeks
1) Previous Dx of PE or DVT, 2) Cancer (tx w/in past 6 mo)
1) Tachycardia (>100bpm), 2) Immobilization for > 3 consecutive days or surgery in previous 4 weeks
1) PE most likely dx (on ddx), 2) Cancer (tx w/in past 6 mo)
An EKG & Chest X-ray can be helpful tools in diagnosing a PE.
Which of the following may be found on a chest x-ray of a pt w/ PE? (note: these are neither sensitive nor specific findings)
Decreased vascular markings in an area of lung (i.e. Westermark’s sign)
Wedge-shaped infiltrate extending to the pleural surface (i.e. Hampton’s hump)
Normal (no abnormal findings)
Which of the following may be found on an EKG of a pt w/ PE? (note: these are neither sensitive nor specific findings)
Ventricular arrhythmias
Left bundle branch block
S1 Q3 T3 pattern
Only A & C
Which of the following clinical signs of PE is shown on this x-ray?
Westermark's sign
Hampton's hump
Which of the following is NOT true regarding use of CT angiography in dx of PE? (select any that apply)
Bolus radiocontrast injection given intravenously.
High speed, multi-slice CT scanner takes thin section images.
Excellent definition of main and lobar.
May detect central and peripheral emboli.
May provide bonus information about the lungs and mediastinal structures.
CT scanning has excellent (~90%) positive predictive values.
Pulmonary angiography is considered the "gold standard" for dx of PE.
Which of the following statements is/are NOT accurate regarding pulmonary angiography.
Considered the "gold standard" in dx PE
Allows measurement of pulmonary artery pressures
It is both invasive and expensive
Frequently used to confirm dx of PE
Requires administration of intravenous radiocontrast
Which of the following is/are NOT true in regards to V/Q scanning in dx of PE: (select any that apply)
perfusion scanning uses venous injection with radiolabeled- macroaggregated albumin (technetium 99)
ventilation scanning requires Iinhalation of a gas mixture containing a radiotracer (xenon 133)
it is sensitive for decreased flow to areas of the pulmonary vascular bed, but not specific
a normal perfusion scan excludes the diagnosis of PE.
in PE cases, areas of vascular obstruction should show decreased ventilation but preserved perfusion
A "high probability" V/Q scan result, coupled with high clinical suspicion, gives a > 95% likelihood of PE.
A negative (i.e. normal) D-Dimer result may be used to rule-out DVT and PE, regardless of clinical presentation and probability scores.
Which of the following labs is LEAST helpful in the dx of PE?
CBC
ABG
BNP
Troponin
INR, PTT
Which of the following labs/results are NOT properly matched, in regards to dx PE.
ABG: hypoxemia, widened alveolar-arterial gradient, and respiratory alkalosis
BNP: may be elevated due to right heart strain
Troponin: may be decreased in 30-50% of cases
PTT: needed for baseline when considering tx options
A D-Dimer test could be positive in which of the following cases?
Infection
Post-Op
Trauma
According to the diagnostic algorithm for pulmonary embolism, if the pt's Wells score exceeds 4, what is the next step?
D-Dimer
CT angiography
Pulmonary Angiography
Ultrasound (serial venous doppler)
V/Q scan
According to the diagnostic algorithm for pulmonary embolism, if the pt's Wells score is below 4, what is the next step?
No treatment (PE dx excluded)
D-Dimer to confirm
Chest X-ray to confirm
Serial Venous Doppler (US) to rule-out DVT
Labs to confirm (BNP, LFT, CBC, etc.)
Small emboli discovered in the course of dx are relatively benign and do not require tx.
Which three signs/sxs are most indicative of an acute PE?
Hemodynamic instability (hypotension)
AMS
Shock
Prompt use of heparin in pt's w/ a DVT helps to lyse the clot and reduce mortality.
Mortality of PE after the initiation of heparin decreases to <5%
Which of the following anticoagulants is the treatment of choice in pt's w/ a bleeding risk?
Low molecular weight heparin
Unfractionated heparin
High molecular weight heparin
Fractionated heparin
None of the above (Anticoagulants are contraindicated in pt's w/ bleeding risk)
Which of the following statement is NOT accurate?
Unfractionated Heparin requires frequent lab monitoring
Unfractioned Heparin requires continuous infusion due to a short half-life
Unfractionated Heparin is reversible
LMW Heparin is administered via intramuscular injections
LMW Heparin does not require frequent monitoring and may be managed at home
Which of the following is NOT true regarding Rivaroxaban & Dabigatran?
they are oral medications approved by the FDA for the tx of PE
their risk of causing bleeding events is comparable or less than that of coumadin
they are both reversible
neither require close monitoring
they are both thrombin inhibitors
Thrombolytics are only indicated in hemodynamically stable patients.
Thromolytic tx may cause an intracranial hemorrhage.
Thrombolyics are typically administered by a vascular surgeon and/or radiologist.
Which of the following might necessitate the use of an IVC ?
Pt. w/ bleeding problems
Pt. allergic/intolerant to anticoagulants
Pt. in need of acute stabilization
A & B only
Which of the following are predictors of poor outcomes for pt's w/ hx of PE? (choose all that apply)
Hypotension
Hypoxemia
Coexisting DVT
Decreased lactate
Decreased WBC
A resting pulmonary artery pressure of ________ is considered pulmonary hypertension.
more than 25mmHg
more than 35mmHg
more than 45mmHg
more than 55mmHg
Pulmonary hypertension may be:
familial
arise from areas affected by PE
related to drug toxicity
secondary to pulmonary venous congestion (e.g. left ventricular failure)
Pulm. HTN is due to hypoxia and hypoxemia and may be seen in diseases such as COPD.
An increase in blood flow, such as one experiences while exercising, will cause a proportional increase across the pulmonary vascular bed.
Which of the following may cause pulm HTN (via chronic hypoxemia): (select all that apply)
Chronic high altitude
COPD
Pulmonary fibrosis
Obstructive sleep apnea
Chronic Asthma
Which of the following may also cause pulm HTN: (select all that apply)
Parasitic infections
Recurrent/unresolved PE
Cocaine use
HIV
Syphilis
Liver disease
Allergies
Idiopathic pulm HTN is most common in women, ages 20-45 years old, and is due to medial hypertrophy and intimal proliferation and fibrosis.
Common symptoms of Pulm HTN may include: (choose all that apply)
Dysphagia
Peripheral edema
Syncope
Chest pain
Possible signs of pulm HTN may include:
Carvahlo's sign (tricuspid murmur, regurg. w/ inspir.)
Prominent pulmonic component of second heart sound
Right ventricular (S3) gallop
JVD
Transient periods of tachycardia
Distended spleen
Left ventricular hypertrophy
Corrigan's pulse (alternates weak and bounding)
All of the following are possible lab/diagnostic findings in Pulm HTN, EXCEPT:
Polycythemia
Decreased PaO2
Stenosis of main pulmonary (CXR)
Cardiomegaly (CXR)
Elevated Pulm Pressures (ECG & Echo)
Which of the following are potential treatments for Pulm HTN: (select all that apply)
Long-term anticoagulation (even when not due to chronic PE)
Vasodilators (especially for Primary Pulm HTN)
Lung Transplantation
Supplemental O2
Cardiopulmonary bypass
Of the vasodilators used to tx pulm HTN, which is the most controversial?
Calcium channel blockers
Prostacyclin
Endothelin receptor blockers
All vasodilators are controversial in tx of Pulm HTN
Which of the following statements is NOT accurate regarding Cor Pulmonale?
Right ventricular failure due to pulmonary disease
Usually accompanied by hypercapnia
Most commonly caused by pulm HTN, COPD, or pulm fibrosis
Chronic and progressive
Which are NOT common sxs associated with Cor Pulmonale:
Swelling of face/neck
Cyanosis
Gallop S3 heart rhythm
Common lab findings in Cor Pulmonale include:
Westermark sign on CXR
RAD, RVH on EKG
Polycythemia on CBC
B & C only
All of the following are used to tx Cor Pulmonale EXCEPT:
ACE Inhibitors/Angiotensin Receptor Blockers
Dopamine/dobutamine
Anticoagulants
Beta-2 Agonists
This is a rare autoimmune disease that affects the kidneys and lungs, causing necrosis of alveoli and loss of gas exchange.
Goodpasture's Syndrome
Wegener's Granulomatosis
While Goodpasture's may affect persons of all ages, it is found to be more common in younger males and older females.
Signs/Sxs that might differentiate Goodpasture's from diseases such as PE and Pulmonary HTN, include: (select all that apply)
Hematuria
Pallor
Weight Loss
Myalgia
Proteinuria
Which of the following diagnostics are indicated in a work-up for Goodpasture's syndrome? (Select all that apply)
Anti-glomerular basement membrane test
BUN
CXR
LFT
Lung & Kidney Biopsy
MRI
Goodpasture's Syndrome is treated with:
Plasma exchange to remove antibodies
Immunosuppressants
Steroids
This rare disease causes "geograpahic" necrosis and granulomatous inflammation of the airways.
Goodpasture's
Wegener's
Wegener's granulomatous is believed to be caused by cellular immune processes and may present w/ respiratory and renal involvement.
Which of the following statements concerning Wegener's granulomatous is FALSE ?
It is a rare disease
Equally prevalent in men and women
Typically occurs in the 4th-5th decade of life
Is fatal within one year if not treated
All of the above statements are TRUE
This rare disease can cause recurrent sinusitis, chronic ear infections, and a variety of flu-like sxs.
The work-up for this disease includes a blood test for anti-neutrophil cytoplasmic antibodies.
While many survivors may be dependent on dialysis, the 5-year survival rate for Wegener's granulomatous is about 70%
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