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Suspected pulmonary embolism in a combined hormonal contraception user — DFSRH MCQ

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HardWells ScoreSuspected pulmonary embolism in a combined hormonal contraception userDFSRH

A 46-year-old woman attends an integrated sexual health service for repeat combined oral contraception. She reports 2 days of right-sided pleuritic chest pain and breathlessness, with one episode of scant haemoptysis. Her left calf is visibly swollen, and palpation along the deep venous system reproduces her pain. Her pulse is 98 beats/min, blood pressure 126/74 mmHg, respiratory rate 18/min and oxygen saturation 97% on air. She has no history of venous thromboembolism, malignancy, recent surgery or immobilisation. Following initial clinical assessment and chest radiography, an alternative respiratory diagnosis remains at least as likely as pulmonary embolism; nevertheless, pulmonary embolism remains clinically suspected. A quantitative D-dimer result can be available within 2 hours. Which is the most appropriate next step in the diagnostic pathway?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Obtain a quantitative D-dimer without interim anticoagulation; arrange CTPA if the result is positive

Explanation lettering: B = shown as A · A = shown as B · E = shown as C · C = shown as D · D = shown as E

Her two-level PE Wells score is exactly 4: clinical signs and symptoms of DVT score 3 points and haemoptysis scores 1 point. The pulse does not exceed 100 beats/min, and the clinician does not judge an alternative diagnosis less likely than PE. Combined hormonal contraception increases VTE risk but is not itself a PE Wells criterion. Under NICE's two-level classification, a score of 4 or less is “PE unlikely”, whereas only a score above 4 is “PE likely”. A quantitative D-dimer is therefore the next investigation. Because its result will be available within 4 hours, routine interim therapeutic anticoagulation is not indicated while awaiting it. A positive result leads to immediate pulmonary imaging, usually CTPA; a negative result makes PE unlikely. B incorrectly treats 4 as crossing the imaging threshold. C would be appropriate if the D-dimer result could not be obtained within 4 hours. D is inappropriate because PERC is intended for low-suspicion presentations without concerning features; this patient has haemoptysis and unilateral leg findings, so PE cannot be ruled out by that approach. E may appear attractive because she has DVT signs, but ultrasonography should not replace the NICE PE diagnostic pathway when PE is clinically suspected; leg ultrasonography has a role in specified later branches or when DVT is being evaluated separately.

Reference: Venous thromboembolic diseases: diagnosis, management and thrombophilia testing — Recommendations (Last updated 2 August 2023) — https://www.nice.org.uk/guidance/ng158/chapter/Recommendations NG158 visual summary: suspected pulmonary embolism diagnosis and initial management (2 August 2023) — https://www.nice.org.uk/guidance/ng158/resources/visual-summary-pdf-11193380893 Venous thromboembolic diseases: diagnosis, management and thrombophilia testing — Rationale and impact (Last updated 2 August 2023) — https://www.nice.org.uk/guidance/NG158/chapter/rationale-and-impact