Monday, June 6, 2011

Intern Report Case Presentation 4.0

Case Presentation by Dr. Stephanie Wise

A 42-year-old man presents to the Emergency Department with a 2-day history of coughing up blood. His symptoms started about 5 days after he returned from a week-long business trip in South Africa. He has not had any fevers or weight loss. He does have chest pain, however, on the left antero-lateral side. He describes this pain as sharp, worse with a deep breath. He denies any shortness of breath. No nausea or vomiting or diarrhea. Appetite has been normal.

PMH: Asthma
Medications: albuterol HFA PRN
Allergies: None
Surgeries: Appendectomy, age 19
FH: HTN, "blood problem" in two uncles
SH: Smokes 1/2 pack daily for 12 years; occasional alcohol, denies ilicit drugs

Physical exam:

BP 134/85, HR 108, RR 21, Temp 37.1
General: Well-developed overweight male, sitting up on stretcher, mild distress
HEENT: PERRL, EOMI; trachea midline, no LAD
CV: Regular rhythm, tachycardic, no murmurs
Resp: Breath sounds decreased at the left base with mild crackles; otherwise clear to auscultation, no wheezing
ABD: soft, non-tender, non-distended; normal active bowel sounds
Extremities: pulses equal, no deformities seen
Neuro: AOx3, normal strength and sensation in all extremities; no facial droop or other focal deficits; gait normal; reflexes 2+ in all extremities

143 105 12
4.1 21 0.9 Glucose 88
WBC 9.9
Hb 14.2
Platelets 248
EKG shows sinus tachycardia, rate of 112, no ST elevations or depressions


1. What is the most common inherited hypercoagulable state?
a. Factor V Leiden
b. Protein C deficiency
c. Anti-thrombin III deficiency
d. von Willebrand disease
e. Sticky platelet syndrome

2. In the presence of acute pulmonary embolism, what is true of ECG findings:
a. "S1Q3T3" is the most sensitive finding
b. Anterior T wave inversions are the most specific finding
c. Typically no abnormality is seen on ECG
d. Sinus tachycardia is an uncommon finding

3. Which statement is correct about the diagnosis of pulmonary embolism?
a. Lower extremity Doppler studies that are positive for DVT are present in 70% of PE patients
b. The chest x-ray is typically normal
c. Pulmonary angiography is the gold standard
d. A D-dimer's value is in its positive predictive value

4. What percentage of ambulatory patients who present with PE have no identifiable clinical risk factors?
a. 10%
b. 30%
c. 50%

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