Reduction of Risk Potential, Physiological Integrity, NCLEX-RN - Full Vignette with Extended Explana

Описание: A 28-year-old man presents to a critical access emergency department with pleuritic chest pain, hemoptysis, and mild hypoxemia following a prolonged flight. His medical history includes Budd-Chiari syndrome and prior B12 deficiency, but he is not on anticoagulation. With classic findings but significant imaging limitations, how should clinicians approach urgent diagnosis when standard resources are unavailable? What assessment strategies can help prevent missed life-threatening pathology in this complex situation?

VIDEO INFO
Category: Reduction of Risk Potential, Physiological Integrity, NCLEX-RN
Difficulty: Easy - Basic level - Suitable for medical students
Question Type: Diagnostic Failure
Case Type: Resource Limited

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QUESTION
A 28-year-old man presents to a critical access ED with pleuritic chest pain and hemoptysis after a 12-hour flight three days ago. He works in food service. He denies illicit drug use and reports social alcohol intake 3-4 drinks/week. He has no known allergies. Past history includes peripheral neuropathy after a prior B12 deficiency and Budd-Chiari syndrome status post TIPS; he is not taking anticoagulation....

OPTIONS
A. Obtain bilateral leg compression ultrasonography now; if DVT is found or pretest probability stays high, start anticoagulation and arrange transfer.
B. Delay all testing until transfer to perform CT pulmonary angiography with iodinated contrast because anticoagulation should not be started without definitive chest imaging.
C. Administer oral N-acetylcysteine and isotonic bicarbonate infusion now to prevent contrast-associated kidney injury while awaiting same-night CT pulmonary angiography.
D. Order cardiac MRI with gadolinium as a substitute for CTPA because gadolinium is interchangeable for diagnosing acute pulmonary embolism.

CORRECT ANSWER
A. Obtain bilateral leg compression ultrasonography now; if DVT is found or pretest probability stays high, start anticoagulation and arrange transfer.

EXPLANATION
With no iodinated contrast available and the V/Q scan offline, the most feasible next step that reduces the risk of missed pulmonary embolism is bilateral leg compression ultrasonography. If a proximal DVT is found in a patient with compatible symptoms and positive D-dimer, immediate anticoagulation is warranted and transfer can be arranged for definitive imaging later. If the pretest probability remains high despite a negative leg study, starting anticoagulation while arranging transfer is reasonable because the bleeding risk is acceptable and delays to chest imaging are substantial.

Delaying all testing until transfer is unsafe because clinically significant delays of 6-8 hours in a hypoxic patient with recent long-haul travel and hemoptysis increase the risk of decompensation and missed treatment opportunities. Administering N-acetylcysteine and bicarbonate while waiting for same-night CTPA is misguided during a contrast shortage, and high-quality trial data show no benefit of either strategy compared with isotonic saline. Ordering cardiac MRI with gadolinium is not an established substitute for CTPA in acute PE and would not solve the diagnostic problem.

In summary, the correct answer is to obtain bilateral leg compression ultrasonography now and, if positive or if clinical probability stays high, to initiate anticoagulation and arrange transfer....


Further reading:

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