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pulmonary embolism

Practice targeted AMC-style multiple-choice questions on pulmonary embolism.

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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 75-year-old male with a history of atrial fibrillation on warfarin presents to the emergency department with acute onset shortness of breath and right-sided chest pain. His vital signs are stable. His INR is found to be 7.2. A chest CT is performed (image attached). Based on the clinical presentation and imaging findings, what is the MOST appropriate immediate management step?

A. Administer Vitamin K and Prothrombinex (PCC) and prepare for chest tube insertion.
B. Administer Fresh Frozen Plasma (FFP) and arrange for surgical consultation.
C. Prescribe analgesia and observe the patient for clinical improvement.
D. Proceed directly to chest tube insertion without reversing anticoagulation.
E. Administer Vitamin K only and monitor the patient closely.
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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 78-year-old male on warfarin for atrial fibrillation presents with sudden onset of severe dyspnoea and right-sided pleuritic chest pain. He denies trauma. On examination, he is tachypnoeic, oxygen saturation is 92% on room air. Blood pressure 110/70 mmHg, heart rate 95 bpm. Chest examination reveals decreased breath sounds on the right. A CT scan of the chest is performed. Considering the patient's clinical presentation, medical history, and the findings demonstrated in the provided image, which of the following pharmacological agents is the most appropriate immediate intervention?

A. Fresh frozen plasma (FFP)
B. Vitamin K
C. Tranexamic acid
D. Prothrombinex (PCC)
E. Recombinant Factor VIIa
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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 78-year-old male on warfarin for atrial fibrillation presents with acute severe dyspnoea and right-sided pleuritic chest pain. Vitals: T 36.8°C, HR 95, BP 110/70, RR 24, SpO2 92% RA. Exam: decreased breath sounds, dullness right hemithorax. A CT scan of the chest is performed. Considering the patient's presentation, history, and the imaging findings, which is the most appropriate immediate management?

A. Arrange for urgent bronchoscopy to rule out airway obstruction
B. Observe the patient closely in the intensive care unit without specific intervention
C. Increase the dose of warfarin and monitor INR
D. Administer broad-spectrum antibiotics and arrange for thoracentesis
E. Administer Vitamin K and Prothrombinex (PCC) and arrange for chest tube insertion
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

A 68-year-old woman recently started on warfarin for a pulmonary embolism presents with a painful, rapidly expanding purpuric lesion on her thigh, which developed two days ago. Her INR is 2.5. She has no history of trauma to the area. Considering the clinical presentation and the appearance of the lesion, what is the most likely underlying pathophysiological process?

A. Allergic vasculitis secondary to warfarin
B. Protein C deficiency leading to paradoxical thrombosis
C. Vitamin K deficiency exacerbating bleeding
D. Direct toxic effect of warfarin on dermal capillaries
E. Heparin-induced thrombocytopenia causing microthrombi
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A 70-80 year old lady being treated for pulmonary embolism with a therapeutic dose of subcutaneous Enoxaparin is found to have multiple new pulmonary emboli. What is the most appropriate next step?

A. Start streptokinase infusion.
B. Switch to intravenous unfractionated heparin.
C. Switch to oral warfarin.
D. Increase the dose of subcutaneous enoxaparin.
E. Insert an IVC filter.
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A 34-year-old man presents to the Emergency Department with acute-onset shortness of breath. A CT pulmonary angiogram (CTPA) is ordered, shown in the photograph, confirming a diagnosis of pulmonary embolism. Which of the following is the most appropriate initial treatment option for this patient?

A. Thrombolytic therapy.
B. Caval filter.
C. Unfractionated heparin or low-molecular weight heparin (LMWH).
D. Dabigatran.
E. Warfarin.
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A 70-80 year old lady, currently managed for pulmonary embolism with Enoxaparin 40 mg daily, is found to have multiple pulmonary emboli. Her vitals are within normal limits. What would be the most appropriate next step?

A. Insert an IVC filter.
B. Switch to apixaban.
C. Switch to oral warfarin.
D. Increase Enoxaparin to therapeutic dose.
E. Start streptokinase infusion.
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A 72-year-old woman presents with sudden onset shortness of breath and pleuritic chest pain. She had knee surgery 10 days ago. She has a history of hypertension. On examination, she is anxious, respiratory rate is 24, heart rate 105, BP 130/80, SpO2 92% on room air. Lungs are clear. ECG shows sinus tachycardia. There is mild swelling in the operated leg. Considering the likely diagnosis, which initial investigation is most appropriate?

A. D-dimer
B. Chest X-ray
C. CT pulmonary angiography
D. Ventilation-perfusion scan
E. Lower limb ultrasound
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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 78-year-old male on warfarin for atrial fibrillation presents to the emergency department with sudden onset of severe dyspnoea and right-sided pleuritic chest pain. He denies trauma. On examination, he is tachypnoeic, oxygen saturation is 92% on room air. Blood pressure 110/70 mmHg, heart rate 95 bpm. Chest examination reveals decreased breath sounds on the right. A CT scan of the chest is performed. Considering the patient's clinical presentation, medical history, and the findings demonstrated in the provided image, which of the following represents the most appropriate immediate management strategy?

A. Arrange for urgent bronchoscopy to investigate airway obstruction.
B. Increase warfarin dose and monitor INR.
C. Observe closely in the emergency department with serial chest X-rays.
D. Administer broad-spectrum antibiotics and arrange for thoracentesis.
E. Administer Vitamin K and Prothrombinex (PCC) and arrange for chest tube insertion.
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