Thromboembolic Disease Board Exam Review Questions, CME
This week's Med-Challenger free CME quiz - Thromboembolic Disease - the quick quiz covers which types of anticoagulants are effective in preventing post-surgical thromboembolism in high risk post-operative patient, the appropriate use of imaging and other diagnostic tests in a patient with suspected venous thromboembolic disease, when it is appropriate to apply cardioversion for atrial fibrillation, and best practice for the discontinuation of anticoagulants before major surgery and restarting during convalescence.
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Here's this week's sample CME board review question on thromboembolic disease:
A 62-year-old woman follows up for a recent hospitalization for a severe urinary tract infection.
Since returning home 100 days ago, she has developed swelling and pain in her left calf and, over the past 24 hours, she has become winded on minimal activity.
She has a history of hypertension for which she takes levofloxacin. She has no history of peptic ulcer disease or malignancy.
She reports that she refused low-molecular weight heparin prophylaxis while an inpatient because she dislikes needles.
Physical examination findings include a pulse of 95 beats/minute, blood pressure of 100/60 mmHg, and oxygen saturation of 92%. The lungs are clear.
There are no cardiac abnormalities, Chest x-ray and EKG are normal.
The most appropriate next step is:
Computed tomography angiography (CTA) scan
Doppler ultrasonography of left leg for deep venous thrombosis (DVT)
See the Answer:
The correct answer is:
Computed tomography angiography (CTA) scan
Know the appropriate use of imaging and other diagnostic tests in a patient with suspected venous thromboembolic disease.
Wells criteria guide the diagnostic workup of patients with suspected venous thromboembolism.
A common scoring system to assess the likelihood of pulmonary embolism (PE) is the Wells Clinical Prediction Rule. Three points are awarded for the presence of calf swelling or tenderness, and 3 points for absence of an alternative diagnosis. In addition, 1.5 points are awarded for tachycardia, recent history of immobilization, or history of DVT/PE. One point is awarded for hemoptysis or evidence of malignancy.
This patient has a Wells score of 4.5 (evidence of DVT =3) and a predisposing factor (recent hospitalization =1.5). In addition, she has modest tachycardia (95/min) and below-normal oxygen saturation, not otherwise explained.
Based on these findings, and the history of exertional dyspnea, it is likely she has suffered a pulmonary embolism.
The key question, here, is... which test is likely to be more informative, computed tomography angiography (CTA) or doppler ultrasound of the left leg?
The selection of ultrasound would give no information about a pulmonary embolus or its hemodynamic burden. The CTA would confirm both an embolism and, by inference, a clot in the left leg. Where CTA is not available, one would confirm a thrombus by doppler and infer an embolic event from the clot.
Given the clinical findings, a D-dimer test would be superfluous. One would not conclude that she has not had a pulmonary embolus if the test was negative.
Due to its low rates of sensitivity and specificity, a ventilation-perfusion scan is not a cost-effective test for the evaluation of possible PE.
Weitz JI, Ginsburg JS. Venous Thrombosis and Embolism, Goldman-Cecil Medicine, 2020; 74: 476-487
Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. London: National Institute for Health and Care Excellence (NICE); 2020 Mar 26. (NICE Guideline, No. 158.)
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