PowerPoint Presentation

Group 1 PresentationPulmonary EmbolismIntroduction to Pulmonary EmbolismTypical ScenarioTeam Based ApproachNursePhysicianHistory and ExaminationBarriers to CareDecision Support ToolsGeneral OverviewPrediction Rules and CalculatorsEHRs and ApplicationsTestsDiagnosis and Treatment Plan

Our presentation will be based on pulmonary embolism. Our agenda for this discussion will include an introduction to the disease, go through a team-based patient scenario, show barriers to care, tools that make treatment more efficient and affordable, available tests for improving the clinical decisions process, and then the diagnosis and treatment plan.1http://video.about.com/quitsmoking/Pulmonary-Embolism.htmIntroduction toPulmonary Embolism

Pulmonary embolism is blockage in one or more arteries in your lungs. In most cases, pulmonary embolism is caused by blood clots that travel to your lungs from another part of your body most commonly, your legs. Pulmonary embolism is a complication of deep vein thrombosis (DVT), which is clotting in the veins farthest from the surface of the body. Pulmonary embolism can occur in otherwise healthy people. Common signs and symptoms include sudden and unexplained shortness of breath, chest pain and a cough that may bring up blood-tinged sputum. Pulmonary embolism can be life-threatening, but immediate treatment with anti-clotting medications can greatly reduce the risk of death. Taking measures to prevent blood clots in your legs also can help protect you against pulmonary embolism.

Please watch this short informative video for more information about pulmonary embolism. Please excuse the lead-in advertisement.2Patient Scenario

65 year old womanSudden onset of shortness of breathHas not seen this physician before No electronic health record on fileNon-SmokerModerate exercise each weekTraveled to see relatives on a five hour plane ride The physician, along with nurses and other healthcare professionals are working in the emergency department where a 65 year old female patient arrives. This patient has not been to this hospital before and thus does not have an existing electronic medical record in the system. One will be created for her, but it will only contain the information from this visit moving forward. The patient has a chief complaint of shortness of breath, which started earlier in the day. She is a non-smoker and exercises once or twice a week. She just flew from Texas to Chicago to visit her daughter and grandchildren the previous day. 3Team-Based Diagnosis and Treatment of PEMany members of the healthcare team are involved in helping diagnose, treat, and educate patientsPatients with Pulmonary Embolism frequently enter the system through the ERTriage personnel, including nurses play a major role in early assessment, information gathering, and patient comfort Pulmonary embolism is a condition that is not easy to diagnose and can require many questions and assessment methods to come up with a pre-test probability. Because of its complexity, a patient may have many stops in a hospital and see many different team members before a diagnosis is confirmed.

Because pulmonary embolism can be life threatening and symptoms can seem severe, many patients will present to the Emergency Department. Triage personnel, primarily nurses will normally be the first line of intervention for the patient. As a critical part of the healthcare team, the ED nurse plays a major role in early assessment, information gathering for the provider, and ensuring the patient is at ease throughout the entire episode of care.4The Role of NursesFirst Step in the ProcessNurses are at the forefront of patient careEstimated shortage of 340,000 nurses by 2020Govern every clinical aspect of medicine, from ER care to geriatrics

Image from: http://www.nursing.keller.com/images/nurse876.gif

Information from powerpoint on Nurses:Shortages in faculty, classrooms, and clinical sites is slowing the preparation of our nurses! Which could have a negative impact on our patient outcomes.Decline in attracting nurses into the profession & retaining them:So many other options available w/in HCIncrease demand for higher quality of care/nurse burnout (increase demand on documentation and capturing patient information in record d/t CMS requriements/public reporting etc.,-initiatives/requirements fall on nurse)Govt Retention Strategies:-09 Stimulus Package 13.4 million in financial assistance for loan repayments to nurses who agree to practice in facilities w/critical shortages& to become nurse faculty-Even w/ stimulus package novice nurses are finding it difficult to find jobs d/t hiring freezes/budget cuts within hospitals

5Nurse ResponsibilitiesTaking vital signsProviding Initial AssessmentsProviding patient notes for cliniciansImplement physician orders

Image: http://towntalkradio.com/blog/uncategorized/wellman-union-school-nurse/

Nurse takes vitals, makes initial notes, checks IV and other fluids, brings the patient a pillow and blanket to make her feel comfortable. She also must not give the patient fluids or food even if she asks since some tests require taking the test on an empty stomach. This is where and when the physician comes in to assess the patient.

6Nurse InterviewNurse : Hello my name is ____, I will be your nurse today. Just in case you forget, I will write my name on the board as well as the hours I am here today. Mr.____, I see that youre here because youre not feeling well. Can you please explain to me whats going on?

Patients response:Nurse: I see, well I will certainly convey these details to Dr.___. Now Mr. ____, I need to take your pulse, blood pressure, and temperature, is that ok?Patients response: Yes.Nurse takes his blood pressure.Nurse: I see that your blood pressure is a bit elevated. Do you normally have high blood pressure?Patients response:

7Nurse: Assessing SituationsFirst protective barrier in preventing epidemics

Nursing process includes methods to assess, diagnose, plan, and interveneNote: For information only, no narrative included on this slideNurses Next Step: Consulting the Physician

Effectively communicate with physician regarding the patients health

Take detailed notes for the physician

Take down orders from the physicianImage taken from: http://static.imt.ie/wp-content/uploads/2011/03/Doctor-and-nurse-with-medical-chart1.jpg

9Physician Interview Time is of the essence Time management is critical and the physician must be efficient. Making the correct diagnosisA physician is not always so lucky to find an easy diagnosis of say a dislocated finger or someone needing stiches. Difficult diagnoses such as Pulmonary embolisms can slow a down a physician in the emergency department, but special care must be taken to not miss this potentially fatal diagnosis. Use clues given to you by the nurseNurses will gather a lot of clues during the initial interview, one must not duplicate efforts by repeating questions. As the provider enters the examination room there are factors in play that he or she has experienced many times before. For patients potentially suffering from pulmonary embolism, time management is critical in optimum health care of the patient.

Many diseases are easily diagnosed, with providers seeing an obvious clue like a bone protruding from a dislocated finger. For many others, the provider has a good idea of the diagnosis within the first two minutes of the examination. The more experienced the provider, the easier the interview, and the more rapidly clues are put into clusters and primary and secondary hypotheses are formed. Pulmonary embolism isnt such an easy pre-test diagnosis to make, and special care must be taken to ensure nothing is missed.

The provider will either review the chart and nurse notes prior to seeing the patient, or will spend the first minute or so going over the items that the nurse has highlighted to help the diagnosis process begin.10The Interview ProcessOpen vs Closed QuestionsOpen Questions:Questions that require a longer responseA dialog formTell me more about thatWhat brought you in today

Closed Questions:Have a limited scope of appropriate answersSometimes require just yes or no responses. Do either of your legs hurt?Is there any pain while breathing?

Both used to gain clues.

OPEN VS CLOSED QuestionsNo matter how talented a physician is, he will be unsuccessful in making a correct diagnosis unless he has a number of clues to base his hypothesis off of. To begin this process of clue gathering, it is best to start with what the nurse has already found out.From the nurses interview the physician has learned that while gardening the early in the day, Ms. Benes stood up quickly and it caused her to feel dizzy to the point where she had to go inside and lie down. She did not want to come to the hospital, but at the persistence of her daughter she came. As a result, the physician has been warned that she has been somewhat difficult to manage and extracting information from. In order to combat this the physician will use both open and closed questions in order to extract the necessary information from the patient.

From here the physician can use both open and closed questions to gather more clues. By simply listening to what is troubling the patient a number of diagnoses can be ruled out. The best way to start this is though the asking of both open and closed questions. Open questions are those which can return a wide variety of responses in a dialog form. Examples of open questions are what is bothering you today? or Tell me more about that pain you are feeling. Closed questions, on the other hand, have a very limited scope of what would be appropriate responses, often times just yes and no. Examples of closed questions are Do either of your legs hurt? or Is there any pain when you breathe?

11Provider Interview: Open and Closed Questions Physician: Hello Ms. Benes, Im Dr. Van Nostrand, why dont we start with you telling me a little bit about what brought you in today.

Patient: Well, it started yesterday when I was gardening with my grandchildren. I stood up too quickly and became lightheaded. After that happened I went inside to rest for a bit and since then I have been finding it difficult to catch my breath. I really think it is nothing, but my daughter insisted that I come in to see you. I dont see the point in wasting time when we have so much to do before I leave on Friday.

Physician: Yes, the nurse tells me you are here visiting and you flew in from Texas. So it sounds like you have shortness of breath and some lightheadedness. Is this correct? Is there anything else are you experiencing?

Patient: I suppose, I have had a little bit of a cough since I have arrived, but a lot of times the air here will bother me. I think it is all of the car exhaust.

Physician: What about any pain in one or both of your legs?

Patient: No, I dont believe so. Physician: I noticed you have been coughing a little bit. Is that new?Patient: Yes, it started this morning.

In the case of Ms. Benes, open and closes questions can be used strategically to start from broad information and to narrow down to the specific. Dr. Van Nostrands first question of Tell me about what brought you in today is an open question which will begin the dialog. This allows the patient to open up and tell her story. Not all of the information will be relevant but clues can be picked up along the way perhaps leading the physician to more questions. After his first question he already has some clues to go off of. The patient is presenting dyspnea. This symptom, unfortunately, does not narrow down the possibilities of a potential diagnosis so the physician will have to keep gathering clues. From here Dr. Van Nostrand follows up on another potential clue following up on her traveling. By learning that Ms. Benes has travelled recently this, along with the dyspnea, would support the diagnosis of a pulmonary embolism. This is because long periods of sitting can cause deep vein thrombosis which has been shown to lead to pulmonary embolism (Cutler, 1998). Yet, even with these two clues, it is not inconclusive of what the patients condition is. A pulmonary embolism is a difficult diagnosis to make so he will need a lot more evidence to support this. This is because an analysis of over 7000 with suspected pulmonary embolism has shown that no one symptom can negate or confirm the diagnosis of pulmonary embolism. Instead, the diagnosis has to be made with using multiple symptoms. (Moores, King, & Holley, 2011)

Cutler, P. (1998). Problem solving in clinical medicine : from data to diagnosis (2nd ed.). Baltimore: Williams & Wilkins.

Moores, L. K., King, C. S., & Holley, A. B. (2011). Current approach to the diagnosis of acute nonmassive pulmonary embolism. Chest, 140(2), 509-518. doi: 10.1378/chest.10-2468

12Provider Interview: Open and Closed Questions Cont.Physician : When you cough is it productive? That is, does anything come out?

Patient : No, not really, it is just a tickle in my throat really.

Physician : Have you been traveling a lot recently, before this trip?

Patient : Yes, I just retired so Im seeing all my grandchildren.

Physician : Do you happen to know if you have ever had a pulmonary embolism before?

Patient : I havent even heard of that before, so I dont think so.

Physician : Have you had surgery recently?

Patient : No, I have not.

Physician : Okay, I understand. If it is alright with you, Im going to preform my examination now.

During the physical examination, no remarkable new clues surfaced leaving the diagnosis still to be somewhat mysterious. The physician has a number of potential diagnoses in mind but none that he can say with a large level of confidence. Part of the problem is the physician has a lot of barriers to overcome in order to make the correct diagnosis.

13Barriers to for Making DiagnosisLimits to patients information No access the patients medical record.Pulmonary embolism is a difficult diagnosis to makeThere is no one thing that established or negates diagnosisThe symptoms like dyspnea are very common PE is potentially fatal so special concerns must be given. There are a lot of potential indicators of PE, it would be hard to remember all of themTesting does not solve the problem on its own Most tests lack appropriate sensitivity or specificity to be used in isolation

The physician in this scenario has a lot of barriers to overcome in order to make the correct diagnosis. First of all, this is the first time he is seeing this patient and thus has very limited information regarding her history. She very well could have a complex medical past that would lead the physician to pursue a certain diagnoses which for the typical patient is rare. For a patient with a particular medical history this alternative diagnosis could be more probable. In addition to this, the physician has no access to the patients medical record. Sometimes it is possible to call a patients primary care physician to gather some more information or perhaps have something sent over. However, this coordination is very difficult and unlikely to happen. Because of this, the physician may just depend on a brief and incomplete history provided orally by the patient during the visit. Due to time constraints in addition to the patient forgetting certain details of his or her medical history, the patients medical history will be incomplete.

An additional issue that the physician must overcome is the fact that a Pulmonary Embolism (PE) is a difficult diagnosis to make. There are a lot of different components that can lead a physician to suspect PE but each case can be unique. Remembering all of the components which may point to PE may be difficult for physicians to memorize.

Also, there are many different tests that can be performed to help determine PE. The physician would like avoid performing a barrage of tests inconveniencing both the patients time and money. Instead, he would hope to perform as few tests as possible and be as least invasive as possible. Unfortunately, most of the tests available for PE lack the necessary specificity or sensitivity to be used alone (Moores et al., 2011).

Individually, these barriers may be manageable, but when paired together a physician can run the risk of missing a diagnosis. In order to assist the physician in properly diagnosing cases of PE, there are tools available in health information technology (HIT)

14How Evidence Based Health Information Helps With DiagnosesClinical TrialsClinicaltTrials.GovClinical prediction rules Clinical prediction pathways Diagnosis decision support tools MedCalWells PE Scoring System Revised Geneva Scoring System EHRShared Electronic Health RecordsProviders today are gaining access to more and more printed, web-based, and application-based support tools to treat patients. Clinical trials, prediction rules, decision support systems, and electronic health records are all putting more information in a providers reach while reducing the time to retrieve it.15

http://www.clinicaltrials.gov/ct2/results/map?cond=%22Pulmonary+Embolism%22Physician ResourcesClinical TrialsWhen searching for information on a disease such as pulmonary embolism, a provider has many tools at his or her disposal within the evidence based medicine pyramid. At the middle to top of the pyramid are clinical trials, located at locations such as ClinicalTrials.gov. This site offers up-to-date information for locating federally and privately supported clinical trials for a wide range of diseases and conditions. This map provides links to nearly 200 studies worldwide on pulmonary embolism, and the overall site receives over 50 million page views per month 65,000 visitors daily.

The U.S. National Institutes of Health (NIH), through its National Library of Medicine (NLM), has developed this site in collaboration with the Food and Drug Administration (FDA), as a result of the FDA Modernization Act, which was passed into law in November 1997. See the FDA document - Guidance for Industry: Information Program on Clinical Trials for Serious or Life-Threatening Diseases and Conditions (March 2002).

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http://www.imagingpathways.health.wa.gov.au/includes/dipmenu/pe/chart.htmlPhysician ResourcesClinical Decision PathwaysOther tools that the provider has are clinical prediction rules, which can either be automated or mapped out in the form of pathway diagrams. Clinical prediction rules are now well accepted as key components in the diagnostic approach to pulmonary embolism. The post-test probability of pulmonary embolism depends not only on the accuracy of the test but also on the pretest probability as determined by these prediction rules.

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http://www.hearthealthywomen.org/tests-diagnosis/featured/deep-vein-thrombosis-a-pulmonary-embolism-diagnosis.htmlPhysician ResourcesClinical Decision PathwaysA pathway diagram that may be more suited for our presentation is one found specifically for female patients. One in three women with a blood clot in the veins of the leg suffers a pulmonary embolism (Kearon, 2003).

Kearon C. Natural history of venous thromboembolism. Circulation. Jun 17 2003;107(23 Suppl 1):I22-3018

Physician ResourcesWells PE Scoring SystemThe majority of our research shows that the greatest evidence collected to help physicians assess patients for pulmonary embolism points to the Wells Scoring System. We used the tool as a component of the MedCalc3000 computerized medical reference and tool set as part of our course instruction.

The American Association of Family Practitioners and the American College of Physicians guideline advocates use of the Wells prediction rule for evaluating patients with suspected pulmonary embolism. However, the guideline notes that the Wells rule performs better in younger patients without comorbidities or a history of venous thromboembolism. One thing to note with this scoring system is that a heavy weight of this score is based on a physician's subjective prejudgment of the likelihood of pulmonary embolism.

http://emedicine.medscape.com/article/1918940-overview#aw2aab6b3

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Physician ResourcesRevised Geneva PE Scoring SystemAnother validated clinical prediction rule for use in the diagnosis of pulmonary embolism is the revised Geneva score (LeGal, 2006). The performance of this scoring system appears equivalent to that of the Wells score with the major difference being this score depends only on objective measures.

Best Evidence] Le Gal G, Righini M, Roy PM, Sanchez O, Aujesky D, Bounameaux H, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. Feb 7 2006;144(3):165-7120EHR and CDS ToolsClinical prediction tools have been shown to be efficient, accurate, and safe for guiding non-invasive testing for PEProviders arent always willing to use systematic approachesEducational interventions and paper guidelines generally have little effectComputer-based clinical decision support tools may be beneficialClinical probability estimates have been shown to be efficient, accurate, and safe for guiding noninvasive testing for pulmonary embolism (Stein and Torbicki). However, providers do not always use systematic diagnostic approaches, which increases overall risks for misdiagnosis and recurrent venous thromboembolism (Roy, Hagan). Effective interventions to improve diagnostic decision making for pulmonary embolism are needed. Because educational interventions and paper guideline dissemination generally have little effect (5), a point-of-care, computer-based clinical decision-support system may have some promise.

Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients care. Lancet. 2003;362:1225-30. [PMID:14568747]

Hagen PJ, van Strijen MJ, Kieft GJ, Graafsma YP, Prins MH, Postmus PE. The application of a Dutch consensus diagnostic strategy for pulmonary embolismin clinical practice. Neth J Med. 2001;59:161-9. [PMID: 11578790]

Roy PM, Meyer G, Vielle B, Le Gall C, Verschuren F, Carpentier F, et al; EMDEPU Study Group. Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism. Ann Intern Med. 2006;144:157-64. [PMID: 16461959]

Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, et al; PIOPED II investigators. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Am J Med. 2006; 119:1048-55. [PMID: 17145249]

Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galie` N, Pruszczyk P, et al; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29:2276-315. [PMID: 18757870]21Shared Electronic Health Records

There are many situations in which an individual will be injured or fall ill in a location too far to be seen by their normal healthcare professional. When this takes place the physician tasks to care for this person is not privileged to the complete patient picture. This is because the physician will not have access to the patients full medical record. This increases the possibility that a diagnosis could be missed. Thankfully, with the adoption of EHRs around the United States there is a hope that eventually the sharing of EHRs will become easy for the appropriate physicians to access. This idea has been attempted in the United Kingdom but the UKs massive HIT initiative has fallen short of its original goals (Campbell, 2011). Even though, this is the case the idea behind universally accessible EHRs is still a good one.

Campbell, D. (2011). NHS Told to Abandon Delayed IT Project. The Guardian. Retrieved from http://www.guardian.co.uk/society/2011/sep/22/nhs-it-project-abandoned

22Shared Electronic Health RecordBenefitsDecease duplicated effortIncreased efficiency Decease cost Increase patient safety Complete patient profile In This Case StudyPresence of previous diagnoses of pulmonary embolisms or vein thrombosis would have altered the patients Wells PE scoring system There is a lot to gain for practices and hospitals to use shared EHRs. First of all it will lower health care costs. This will be accomplished by reducing instances of duplicated efforts across healthcare organizations. If a patient has a CT scan taken in one hospital there would be no need to redo this if the patient found themselves seeing a different specialist. Instead it could just be shared via the EHR. Reducing duplicated efforts would also increase patient safety(Schabetsberger et al., 2005). Along with this, a patient would no longer be subjected to multiple blood draws, x-rays, and other procedures with potential complications. Another important gain of shared EHRs, is the physician now has a complete picture of the patients condition. If the doctor described in the scenario above were to be able to access the patients EHR and found a history of cancer or previous pulmonary embolisms, it would greatly impact his opinion on the likelihood of PE being the correct diagnosis. If the patient had a history of PE or vein thrombosis, the Wells PE Scoring would have been a point and a half high which could potentially take a patients likelihood for PE from intermediate to high.

Schabetsberger, T., Ammenwerth, E., Gobel, G., Lechleitner, G., Penz, R., vogl, R., & Wozak, F. (2005). What are Functional Requirements of Future Shared Electronic Health Records? . Connecting Medical Informatics and Bio-Informatics. Retrieved from http://www.magic5.unile.it/PapDoc/Article/MIE2005/TOC%20Scientific%20Contributions/Computerized%20Patient%20Record/138.pdf

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EHR and CDS ToolsDiagnostic Work-Up PE PredictionAccording to another study, most patients do not get a validated diagnostic workup despite the availability of non-invasive techniques and guidelines available. This study tested the effect of provider with access to paper based guidelines as well as handheld computing devices. The hand-held tool was designed to provide the probability of pulmonary embolism at each stage of a diagnostic work-up. It supplied the physician with this information in real time, whereas physicians in the paper guidelines group had to actively search for it.

In this randomized trial, distributing guidelines for diagnosing pulmonary embolism improved diagnostic decision making in emergency departments. Use of the hand-held device led to significantly greater improvements than use of paper guidelines, increasing the proportion of patients who received appropriate diagnostic work-up by an absolute 19.3%. Finding suggested that a handheld CDS tool improves adherence to guidelines for diagnosing pulmonary embolism and improves the diagnosis of pulmonary embolism in clinical practice.

On this screen we attempt to show in each step of the diagnostic work-up, the tool calculates the post-test probability of pulmonary embolism according to the test result. It advises physicians to consider pulmonary embolism excluded if post-test probability decreases to less than 5% and confirmed if it increases to greater than 85% (Kearon, 2003).

Kearon C. Diagnosis of pulmonary embolism. CMAJ. 2003;168:183-94. [PMID: 12538548]24

EHR and CDS ToolsDiagnostic Work-Up PE PredictionThis screen shows where if the post-test probability is between 5% and 85%, the tool provides a new list of appropriate tests and uses the post-test probability from the most recent test as the pretest probability for subsequent testing. As a note to the viewer, the tool does not require physicians to follow the systems recommendations.25d-Dimer level and clinical suspicion entry tools and decision support statements 1 and 2.

Raja A S et al. Radiology 2012;262:468-474EHR and CDS ToolsCT Pulmonary Angiography Decision SupportThis tool was created based a study to determine the effect of evidence-based clinical decision support on the use and yield of CT pulmonary angiography for acute pulmonary embolism in the emergency department. The tool required a D-Dimer result as well as the providers suspicion of pulmonary embolism as input and provided evidence based advice on whether or not to continue with the ordering of the CT scan. The overall results after 2 years resulted in a 20% reduction in CT scan orders, along with a 69% increase in CT results yield.

The algorithms detection of the presence or absence of PE had a sensitivity of 91.3%, a specificity of 98.7%, a positive predictive value of 91.3%, a negative predictive value of 98.7%, and an accuracy of 97.8%.

EHR and CDS ToolsI-Phone QxMD PE Clinical Probability CalculatorAs healthcare becomes more mobile and the prevalence of smartphones and tablets hit the Health IT market, the provider of tomorrow will be more comfortable with technology. This application shows that the Wells Scoring Calculator for pre-test scoring of pulmonary embolism probability has already made its way to the I-Phone and Android market. This is another indicator where health information is being made more easily accessible by providers, and may be able to help narrow the gap for clinical decision support tools in rural areas where infrastructure and expense are barriers to access.27Medical Informatics and NursingPicture Archiving and Communication System (PACS)

Computerized Physician Order Entry (CPOE)

Epic System

Information gathered from: http://www.ohsu.edu/academic/dmice/research/cpoe/index.phphttp://www.nursingtimes.net/forums-blogs-ideas-debate/nursing-blogs/technology-can-help-nurses-improve-patient-care/5001545.article

28Pulmonary Embolism TestsD-Dimer Blood TestHigh levels may suggest clottingChest X-RayCant detect PEVentilation-Profusion Scan (lung scan)Show blood flow to lungsNot as reliable for smokersSpiral Computed Tomography (CT)Increased precision for detectionFaster than conventional CT scanCT Pulmonary Angiogram (CTPA)Very precise Gold StandardExpensive, invasive, riskyUltrasoundBedside U/S in EDsMRIPregnant/dye-sensitive patients

The Mayo Clinic provides a list of the various tests for pulmonary embolism. The D-Dimer is a blood test used to detect clotting, and is coupled with the patient history to determine a pre-test probability for the disease. Based on our providers judgment from his findings and information gathered to this point, he would have myriad choices of imaging tests at his disposal. He may be guided by the availability of equipment, a patients health plan, clinical practice guidelines, his test of choice, or various other factors. In our text, Cutler states that pulmonary arteriography is the gold standard, but the test is expensive and invasive.

http://www.mayoclinic.com/health/pulmonary-embolism/DS00429/DSECTION=tests-and-diagnosis

29Case Diagnosis30Treatment Plan31