Quick answer
How should I present a pulmonary embolism case on rounds?
Lead with the sudden dyspnea, pleuritic chest pain, and hemoptysis, and name the cancer and recent immobility that make this cancer-associated thrombosis likely. Give the CTPA and echo findings showing right-heart strain, then the troponin and platelet count, which shape anticoagulation choice. End with monitoring level and how thrombocytopenia and cancer affect the anticoagulant decision.
Before you speak
Define the moment and the information you actually have
An emergency-department presentation immediately after CT pulmonary angiography and bedside echocardiogram confirm a large clot burden.
The emergency and ICU teams deciding on anticoagulation and monitoring level.
History, vital signs, cancer and treatment history, CTPA, bedside echocardiogram, troponin, and platelet count. A full coagulation panel and bleeding-risk score are not itemized.
About 90 seconds
Fictional training case: The presentation is locked to the simulated patient JSON. It names important unknowns instead of inventing an examination, vital signs, allergies, or tests.
Complete spoken example
First, read it once without stopping
The paragraph breaks show the clinical shape. In a real presentation, pause briefly between ideas rather than announcing the headings.
Mr. Sullivan is a 55-year-old man with metastatic lung cancer on chemotherapy who presents with 24 hours of severe, rapidly worsening shortness of breath, pleuritic chest pain, and coughing up blood.
He started chemotherapy and immunotherapy four weeks ago and has been mostly bedbound with fatigue for the past two weeks. His wife noticed his right leg was slightly swollen yesterday, and he now feels lightheaded and is gasping for air sitting upright.
He has metastatic non-small cell lung cancer diagnosed two months ago and hypertension, and is on a carboplatin, pemetrexed, and pembrolizumab regimen along with amlodipine. He quit smoking two months ago after a 40-pack-year history.
CT pulmonary angiography shows a saddle embolus across the main pulmonary artery bifurcation with extensive bilateral clot burden. Bedside echocardiogram shows severe right-ventricular dilatation with an RV-to-LV ratio of 1.3 and systolic dysfunction. Troponin is elevated at 186, his platelet count is low at 118, and his creatinine is normal at 1.0.
My diagnosis is acute submassive pulmonary embolism with right-ventricular strain, most likely cancer-associated thrombosis given his active malignancy, recent chemotherapy, and immobility.
I would give supplemental oxygen, admit to a monitored step-down unit for continuous cardiac and blood-pressure observation, and start anticoagulation once a clinician confirms his platelet count, calculated creatinine clearance, and bleeding risk support it, generally preferring a parenteral agent initially given his instability and thrombocytopenia. I would escalate to the interventional PE team immediately if his blood pressure drops or he shows further hemodynamic collapse.
Build the presentation
Give every sentence one job
A presentation is a compressed clinical argument, not a chart read aloud. These six moves keep the facts connected to your reasoning.
Opening one-liner
Name the cancer context and the acute presentation together
“Mr. Sullivan is a 55-year-old man with metastatic lung cancer on chemotherapy who presents with 24 hours of severe, rapidly worsening shortness of breath, pleuritic chest pain, and coughing up blood.”
Why it belongs: Naming the active cancer alongside the acute respiratory symptoms immediately raises pulmonary embolism from cancer-associated thrombosis as a leading concern.
This is a cancer patient with breathing trouble and some blood in his cough.
Mr. Sullivan has metastatic lung cancer and presents with sudden, severe shortness of breath, pleuritic chest pain, and hemoptysis.
Why: Naming the cancer and the specific symptom triad together is what should trigger urgent evaluation for PE.
History of present illness
Give the immobility and leg-swelling clues
“He started chemotherapy and immunotherapy four weeks ago and has been mostly bedbound with fatigue for the past two weeks. His wife noticed his right leg was slightly swollen yesterday, and he now feels lightheaded and is gasping for air sitting upright.”
Why it belongs: Recent immobility and unilateral leg swelling are specific risk factors and clues for a venous source, and his distress and lightheadedness suggest hemodynamic compromise worth flagging early.
He's been resting a lot and has a swollen leg.
He has been mostly bedbound for two weeks, and his wife noticed new right leg swelling yesterday.
Why: Naming the duration of immobility and the specific leg finding is more useful than a general statement of fatigue.
Relevant background
Summarize the cancer, treatment, and smoking history
“He has metastatic non-small cell lung cancer diagnosed two months ago and hypertension, and is on a carboplatin, pemetrexed, and pembrolizumab regimen along with amlodipine. He quit smoking two months ago after a 40-pack-year history.”
Why it belongs: Active cancer and recent chemotherapy are the key prothrombotic risk factors, and the smoking history adds further cardiopulmonary context.
He's on chemo for his cancer and has a smoking history.
He has metastatic lung cancer on a carboplatin, pemetrexed, and pembrolizumab regimen, diagnosed two months ago.
Why: Naming the specific regimen and diagnosis timing is more precise than a general mention of chemotherapy.
Objective data
State the imaging, echo, and lab findings
“CT pulmonary angiography shows a saddle embolus across the main pulmonary artery bifurcation with extensive bilateral clot burden. Bedside echocardiogram shows severe right-ventricular dilatation with an RV-to-LV ratio of 1.3 and systolic dysfunction. Troponin is elevated at 186, his platelet count is low at 118, and his creatinine is normal at 1.0.”
Why it belongs: The saddle embolus and right-ventricular strain on echo classify this as at least submassive pulmonary embolism, the elevated troponin confirms right-heart myocardial injury, and the low platelet count directly affects anticoagulant selection and bleeding-risk monitoring.
His CT and echo were bad and his troponin was high.
CTPA shows a saddle embolus with bilateral clot burden, and echo shows an RV-to-LV ratio of 1.3 with troponin elevated at 186.
Why: Naming the specific ratio and troponin value lets the team judge severity precisely.
Assessment
Commit to the diagnosis and its severity category
“My diagnosis is acute submassive pulmonary embolism with right-ventricular strain, most likely cancer-associated thrombosis given his active malignancy, recent chemotherapy, and immobility.”
Why it belongs: Naming the severity category, not just 'pulmonary embolism,' is what determines the intensity of monitoring and whether reperfusion therapy needs to be considered.
He has a PE from his cancer.
This is acute submassive pulmonary embolism with right-ventricular strain, most likely cancer-associated thrombosis.
Why: Naming the severity category directly signals the level of monitoring required.
Plan
Sequence stabilization, anticoagulation choice, and escalation criteria
“I would give supplemental oxygen, admit to a monitored step-down unit for continuous cardiac and blood-pressure observation, and start anticoagulation once a clinician confirms his platelet count, calculated creatinine clearance, and bleeding risk support it, generally preferring a parenteral agent initially given his instability and thrombocytopenia. I would escalate to the interventional PE team immediately if his blood pressure drops or he shows further hemodynamic collapse.”
Why it belongs: The plan makes anticoagulation conditional on his bleeding risk and platelet count rather than automatic, and states a clear escalation trigger for reperfusion therapy.
I'll start him on blood thinners and watch him.
I would start anticoagulation once bleeding risk and platelet count are confirmed safe, favoring a parenteral agent given his instability.
Why: Making the anticoagulant choice conditional on real safety checks is more accurate than a blanket statement.
Do not fill the blanks
Say what has not yet been established
Real presentations often happen before the chart is complete. A brief, explicit limitation is safer and more credible than a polished invention.
Full coagulation panel and calculated creatinine clearance
Say: “A full coagulation panel and a calculated creatinine clearance are not documented in this simulation; his serum creatinine is normal, but clearance still needs to be calculated before finalizing anticoagulant choice and dosing.”
Coagulation status and calculated renal clearance both affect which anticoagulant is safest here.
Formal bleeding-risk score
Say: “A formal bleeding-risk score is not calculated in this simulation, and I would complete one before committing to long-term anticoagulation.”
His low platelet count and active hemoptysis both raise bleeding-risk concerns that a score would formalize.
Clinical compression
What leads, what stays, and what can wait?
| Source detail | Decision | Reason |
|---|---|---|
| Sudden severe dyspnea, pleuritic chest pain, and hemoptysis over 24 hours | Lead | This acute symptom triad defines the presentation and its urgency. |
| Two weeks of bedbound immobility and new unilateral leg swelling | Lead | These are the specific risk factors and clues pointing toward a venous thromboembolic source. |
| Retired engineer, quit smoking two months ago | Compress | Relevant background but not a leading finding once the acute presentation is established. |
| Saddle embolus with right-ventricular strain on echo | Lead | This is the decisive imaging finding that classifies severity and drives monitoring level. |
| Platelet count of 118 | Include | It directly affects anticoagulant choice and bleeding-risk monitoring and should not be omitted. |
After the presentation
Likely attending questions
Answer the question first, then give the evidence. If the source case does not contain the answer, say what you would verify.
Why is his platelet count relevant to anticoagulation?
A platelet count of 118, while not critically low, still needs to be factored into anticoagulant choice and bleeding-risk monitoring, especially given his active hemoptysis; further drops would need reassessment before continuing.
Why call this submassive rather than massive PE?
Massive PE is defined by sustained hypotension or shock, which is not documented here; right-ventricular strain with troponin elevation but preserved blood pressure places this in the submassive, or intermediate-high risk, category, which still requires close monitoring for deterioration.
What would change your anticoagulant choice?
His calculated creatinine clearance, the full coagulation panel, and ongoing bleeding all need to be confirmed; cancer-associated thrombosis often favors low-molecular-weight heparin or a direct oral anticoagulant with oncology input once he is stable.
Self-check
A 30-second check before you present
- Name the active cancer and recent chemotherapy in the opening sentence.
- State the specific risk factors: immobility and unilateral leg swelling.
- Give the exact CTPA and echo findings, not just 'PE confirmed.'
- State the troponin and platelet values explicitly.
- Name the severity category (submassive versus massive), not just 'PE.'
- Make anticoagulation conditional on bleeding risk and renal function.
- State the monitoring level and escalation trigger.
- State what coagulation and bleeding-risk information is still needed.
Common presentation problems
Repair the habits that make a case hard to follow
Saying 'PE confirmed' without stating severity
Repair: State whether right-heart strain is present and name the severity category.
Starting anticoagulation without checking platelets or bleeding risk
Repair: State that platelet count, renal function, and bleeding risk are confirmed first.
Omitting the cancer-thrombosis mechanism
Repair: Name active malignancy, recent chemotherapy, and immobility as the likely cause.
Giving a vague escalation plan like 'watch him closely'
Repair: State the specific trigger, such as a drop in blood pressure, for escalating to reperfusion therapy.
Frequently asked questions
Oral case presentation questions
Should I name a specific anticoagulant and dose?
State the class you favor and why (parenteral given instability and thrombocytopenia), but leave the exact agent and dose to follow confirmation of renal function and bleeding risk.
Do I need to explain the Wells score calculation in the presentation?
You can mention that his Wells score was high given his cancer, immobility, and leg findings, which supported proceeding directly to CTPA rather than a D-dimer; a full breakdown is not usually needed unless asked.
How long should this presentation be?
This worked example targets about 90 seconds. A hemodynamically unstable patient may need a much faster initial alert focused on vitals and imaging alone.
Practice out loud
Turn the patient encounter into your own presentation
Bedside English lets you interview an AI patient, then practice presenting the collected case to an AI attending and respond to follow-up questions.
Editorial record
Sources, provenance, and review boundary
The patient facts come from simulated case pulm_023. Clinical framing and presentation design were checked against the sources below. This page teaches clinical communication and reasoning; it is not medical advice or a local protocol.
- 2019 ESC Guidelines for the Diagnosis and Management of Acute Pulmonary EmbolismEuropean Society of Cardiology · accessed 2026-09-03
- Feedback on Oral Presentations during RoundsStanford Medicine · accessed 2026-09-03
- Clinical Teaching Tools: OMP and SNAPPSUCSF Medical Education · accessed 2026-09-03
Published: · Last source, safety, and language review: