Respiratory medicine: pulmonary embolism work-up: practice question

A General Medicine question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

Try it

General Medicine · Respiratory medicine: pulmonary embolism work-up

Sample item

A 29-year-old woman has had 2 days of pleuritic left-sided chest pain after a 9-hour flight. Heart rate is 84 per minute, SpO2 is 98% on air, and there is no leg swelling, haemoptysis, previous venous thromboembolism, recent surgery or cancer. The pain is reproduced by pressing on the costal cartilages, and an alternative diagnosis is judged more likely than pulmonary embolism. What is the most appropriate next step?

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

B. Plasma D-dimer, stopping the work-up for embolism if it is normal

With a low pre-test probability (a Wells score of 0 or 1, or a pulmonary embolism rule-out criteria approach), a sensitive D-dimer assay is the right first test because a negative result excludes pulmonary embolism with a very low miss rate. Imaging is reserved for a positive D-dimer or higher pre-test probability, which avoids needless radiation and contrast exposure. D-dimer is of little use when the probability is high.

Option by option

  • A. Empirical therapeutic low molecular weight heparin for 3 months without imaging

    Empirical anticoagulation for 3 months without confirming the diagnosis exposes her to bleeding risk with a low chance of benefit.

  • B. Plasma D-dimer, stopping the work-up for embolism if it is normal (correct)

    Correct. A normal D-dimer in a low-probability patient safely rules out pulmonary embolism.

  • C. Bilateral lower limb venous Doppler first

    Leg Doppler is not a screening step in a patient with no leg symptoms and a low pre-test probability.

  • D. CT pulmonary angiography straight away

    Immediate CT angiography exposes a low-risk young woman to radiation and yields mostly false positives or incidental findings.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

More General Medicine questions

Questions about this General Medicine question

What is the answer to this General Medicine question?

The best answer is B, Plasma D-dimer, stopping the work-up for embolism if it is normal. With a low pre-test probability (a Wells score of 0 or 1, or a pulmonary embolism rule-out criteria approach), a sensitive D-dimer assay is the right first test because a negative result excludes pulmonary embolism with a very low miss rate.

Why is "Empirical therapeutic low molecular weight heparin for 3 months witho…" not the answer?

Empirical anticoagulation for 3 months without confirming the diagnosis exposes her to bleeding risk with a low chance of benefit.

Why is "Bilateral lower limb venous Doppler first" not the answer?

Leg Doppler is not a screening step in a patient with no leg symptoms and a low pre-test probability.

Why is "CT pulmonary angiography straight away" not the answer?

Immediate CT angiography exposes a low-risk young woman to radiation and yields mostly false positives or incidental findings.

What concept does this question test?

It tests Respiratory medicine: pulmonary embolism work-up in General Medicine. Imaging is reserved for a positive D-dimer or higher pre-test probability, which avoids needless radiation and contrast exposure. D-dimer is of little use when the probability is high.

How hard is this question?

We tag it as a multi-step question: it asks you to combine more than one idea. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Respiratory medicine: pulmonary embolism work-up?

For each disease know the classic presentation, the best test, and the first-line treatment. Then use the flashcards and the other General Medicine questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.