RESPIRATORY

PULMONARY EMBOLISM

Introduction

5 min

Introduce yourself and the group

Provide rationale for the session and relevance to clinical practice

Outline learning objectives:

Be able to take a focused history from a patient presenting with a probable pulmonary embolism and consider suitable differential diagnoses
Suggest and interpret the key findings of investigations in diagnosis of pulmonary embolism
Understand the acute management of pulmonary embolism

Explain structure of session

Total time:

60 min

Number of students:

1-5

Grade of students:

3rd to 5th year medical students

Created by:

Dr Charlotte Hayden

Uploaded:

13th September 2019

Last updated:

13th September 2019

Resources needed for this session:

Pen, paper, prescription chart, BNF

Students can scan the QR code opposite to view all investigation results on their phone as you work through the session.

Resources linked to this session:

none

Activity 1: History Taking and Examination

10 min

Ask the student(s) to take a focused history from the patient to include past medical history, drug history, family history and social history. This can be observed if capacity of tutors allows.

Activity 2: Diagnostic Reasoning and Case Based Discussion

5 min

Ask the student to present the key findings of the case.

What differential diagnoses have you considered and why are these less likely?
What investigations would be useful acutely and what are you expecting them to show?
What would be your initial management?

Feedback on history taking style (max 1 minute).

Activity 3: Bedside Tests

5 min

Allow the students to view the example arterial blood gas results from the patient. If none are available, use the example opposite.

Discuss the findings using the questions below as prompts:

Is there a pH disturbance?
Is it likely to be metabolic or respiratory driven?
What pathological process is driving this abnormality?

ABG

pH 7.35

pCO2 3.5kPa

pO2 7.5kPa

HCO3 23mmol.l

Activity 4: Basic Radiology Interpretation

5 min

Review the patient’s chest x-ray with the student. If none is available, use the image below. Ask the student(s) to systematically interpret the chest x-ray opposite (nb. it is normal).

Discuss the common x-ray findings in pulmonary embolism.

Activity 5: Advanced Radiology

5 min

Discuss the pros and cons of imaging modalities for diagnosing pulmonary embolism (VQ vs CTPA).

Using the image opposite, ask the students to identify key anatomy including:

heart
ascending and descending aorta
pulmonary arteries
right and left lung fields

Ask the students to identify the key pathology on the CTPA - right pulmonary embolus with infarction.

Activity 6: Prescribing Task

10 min

Ask the students to find a drug chart and prescribe the appropriate treatment dose LMWH. They can use a BNF if needed - the QR code opposite links to the BNF online site.

Discuss the role of thrombolysis in the management of acute PE.

Ask students to find the local guidelines on thrombolysis on the trust intranet.

Activity 7: Management Decisions

10 min

Ask students to find the local guidelines on outpatient management of patients with newly diagnosed PE. Alternatively, use the QR code to look up the BTS Pulmonary Embolism 2019 guidelines.

Discuss the following points:

Can a patient with a PE be managed as an outpatient?
What provision for follow-up does this hospital provide? e.g. a thrombosis clinic or ambulatory emergency care centre
What is the role of ECHO in acute pulmonary embolism?
Should all patients with unprovoked DVT be screened for malignancy?