A 26 year old woman who is 15 weeks pregnant presents to your department complaining of pleuritic chest pain. She is P1G0 and has no medical history of note.
Her vital signs are:
Sats 99% RA
T 37.0 oC
Describe your risk stratification of this patient.
Describe your imaging strategy for this patient.
How will you minimise any imaging risks to this patient for your chosen imaging modality?
There really isn't a right answer to this question, because in the real world there also isn't a right answer.
BUT, you need to be able to write something 'consultoid'.
We would answer:
1. Wells'/PERC not validated in pregnant patient 2. Literature suggests NPV of d-dimer maintained, but PPV lowers 3. Therefore if no other RFs on Wells' run d-dimer: if -ve may obviate need for further imaging.
Again, no standard response. But, having a sensible answer is worthwhile.
1. Most PEs arise from lower limb DVTS 2. .: doppler U/SS both legs - if +ve for anticoagulation without further Ix 3. If -ve, for CXR: exclude LRTI/Ptx as Dx 4. If CXR clear for perfusion only scan: if perfusion defect then consider V matching or therapeutic anticoagulation without further Ix (cons obstetrics and respiratory med)
So, this is a bit easier, and pertains to your answer to the previous question.
CXR - shield abdomen if possible. V/Q scan:
consider perfusion only scan
IDC to minimise contrast accumulation in bladder
If we were talking about a CTPA we would have mentioned breast shields, abdominal shielding if possible and discussion with radiology RE a low dose scan.
Now we are aware that people often have strong opinions on this as an issue. We are very happy for discussion of the issues via the VSG - bring on the debate!
P.S. If you are after the opinion that matters most (the examiners'!) the official exam report noted:
FACEM SAQ Exam 2010.1 – Question 4
The overall pass rate for this question was 47/70 (67.1%)
Discussion of supportive tests, definitive tests, risk benefit analysis
Rational approach to reducing radiation risk (when discussing the definitive tests)
Features of unsuccessful answers
Clear statement showing lack of understanding of radiation risk (CTPA and V/Q)