One month of progressive dyspnea on exertion, Flipped t waves in ALL leads of the EKG, history of long travel (plane & car from florida to the NE on multiple occasions, room air hypoxia 92% without history of asthma/copd.

Step 1? D-dimer, of course. although, I think according to the Kline criteria, even if her d-dimer was negative, I would be obligated to pursue, you guessed it…

Step 2… a V/Q scan. Which was of course, indeterminant.

Here is the question I pose to you all…what do you do next? Not the text book answer (pulmonary angiogram and treat), but what do you really do in your practice? What does your hospital do? Radiologists? The internists? I got five different answers from four different people…

a) start her on heparin (from a fellow resident)

b) get a CT pulmonary angiogram (from radiology)

c) don’t do anything till we [medicine] get there (from internal med)

d) don’t order any more tests until they [medicine] get here (from the ED attending)

e) Sub-Q lovenox (from the attending the second time around)

What do you typically do in your practice at this point in the game (intermediate pretest probability, indeterminate v/q scan)? Where do you draw the line between ED workup and inpatient workup? (after all, this patient is being admitted regardless) I’m curious to see what happens in other institutions, and how far you take the initial workup. Would you have gotten a different study first? (doppler?) Dont forget, it’s late on a saturday night, so some techs are at home…