Correct!
5. All of the above

The cause of the patient’s symptoms is not totally clear. A chest x-ray is indicated because of his shortness of breath and is shown in Figure 2.

Figure 2. Initial portable chest x-ray taken in the emergency room.

Crystalloid fluids are indicated because of the patient’s hypotension. His troponins were mildly elevated at 0.86 ng/ml (normal <0.01 ng/ml). Additional laboratory obtained include:

• Electrolytes (Na+ 122, Cl- 76, K+ 3.6, HCO3- 27)
• Lactic acid 5.5 mmol/L (Normal < 1 mmol/L)
• AST 760 U/L, ALT 913 U/L, alkaline phosphatase 181 IU/L (all modestly elevated)
• INR 20.1
• D-dimer 9.18 mcg/mL (normal <0.5 mcg/mL)

Which of the following is/are true? (Click on the correct answer to proceed to the fourth of seven pages)

1. A point of care ultrasound may be useful in diagnosing the cause of the hypotension
2. The elevated D-dimer is diagnostic of a pulmonary embolism
3. The elevated lactic acid likely indicates inadequate tissue perfusion
4. 1 and 3
5. All of the above

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