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Diagnosis of venous thromboembolism using clinical pretest probability rules, D-dimer assays, and imaging techniques

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doi: 10.1097/01.NPR.0000751656.46507.49
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INSTRUCTIONS Diagnosis of venous thromboembolism using clinical pretest probability rules, D-dimer assays, and imaging techniques


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Diagnosis of venous thromboembolism using clinical pretest probability rules, D-dimer assays, and imaging techniques

Learning Outcomes: By completing this activity and taking the posttest, participants will achieve a minimum score of 70%.

Learning Objectives: After reading the article and completing the posttest, the participant will be able to: 1. Summarize the risk factors, pathogenesis, and clinical presentation related to VTE. 2. Describe the use of CPPRs and D-dimer assays in diagnosis of VTE. 3. Apply algorithms related to imaging to appropriately diagnose VTE in a case scenario.

Case-Based Assessment: Placing yourself in the role of the healthcare provider, use the scenario below to apply knowledge and skills learned in the attached article.

Questions #1 - #10 will be based on the following Case Scenario:

MR is a 52-year-old woman who arrives in the ED with complaints of shortness of breath along with left arm pain and swelling for the last 24 hours. She is halfway through an outpatient course of I.V. chemotherapy for breast cancer via a central venous catheter (CVC) following a recent double mastectomy. She states that she had first called her oncologist, who recommended that she go to the ED immediately for assessment.

  1. MR's risk factors for VTE, based on Virchow's triad, include
    1. venous stasis, endothelial injury, and acquired hypercoagulability.
    2. inherited coagulability, prior thrombotic event, and immobilization.
    3. endothelial injury, excess procoagulant activity, and central catheter.
  2. MR's additional signs and symptoms on exam include chest pain, dyspnea at rest, tachypnea, tachycardia, and oxygen saturation of 91% on room air. Which CPPR would help in differentiating her diagnosis for these additional signs and symptoms?
    1. Hamilton clinical decision rule for DVT
    2. Wells clinical decision rule for PE
    3. Constans clinical decision score for UE DVT
  3. MR has localized pain in her left upper arm, and her CVC is located in her left upper chest. What additional physical finding might be consistent with a diagnosis of an UE DVT?
    1. tenderness with plantar flexion
    2. hypopigmentation of extremity
    3. left upper extremity edema
  4. A risk factor particularly predisposing MR to a UE DVT is/are her
    1. cardiac pacemaker.
    2. CVC.
    3. previous pregnancies.
  5. Using the Constans clinical decision score for UE DVT, MR's score is ≥2. This indicates that MR's probability of a UE DVT is
    1. high.
    2. intermediate.
    3. low.
  6. Using the appropriate CPPR for PE, you find that MR has a score of >4. What is clinically indicated?
    1. Her calculated low likelihood of PE helps avoid unnecessary imaging.
    2. She has moderate/high probability of PE, requiring further evaluation.
    3. Since these CPPRs are not validated in outpatients, scoring is not helpful.
  7. If MR's only presenting respiratory sign or symptom in the ED was nonproductive cough and her Wells PE score was ≤4, D-dimer testing could help rule in or out a PE because
    1. normal levels help exclude VTE.
    2. abnormal results confirm VTE.
    3. false-positive results do not occur.
  8. If MR's Wells PE score was ≤4 and a highly sensitive D-dimer test was positive, which further testing (if any) would be indicated to exclude PE?
    1. no further testing would be needed since sensitivity is ≥95%
    2. lower extremity bilateral distal venous ultrasound
    3. computed tomography pulmonary angiogram (CTPA)
  9. If MR has a “likely” classification for UE DVT using probability estimates, what imaging is indicated for evaluation for UE DVT?
    1. ventilation-perfusion (V/Q) scan
    2. duplex ultrasound
    3. adjusted CPPR
  10. MR's oncologist suggests that she undergo a V/Q scan to rule out a PE, in order to reduce her radiation exposure. If her Wells PE score was ≤4 and D-dimer was positive, you would base your treatment decision on knowledge that
    1. a V/Q scan is not indicated at this time because of her positive D-dimer.
    2. the specificity and sensitivity of V/Q scans is equivalent to that of other imaging testing.
    3. CPTA can be done if the V/Q scan is nondiagnostic.
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