Pulmonary embolism history and symptoms: Difference between revisions

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__NOTOC__
__NOTOC__
{| class="infobox" style="float:right;"
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| [[File:Siren.gif|30px|link=Pulmonary embolism resident survival guide]]|| <br> || <br>
| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
{{Pulmonary embolism}}
{{Pulmonary embolism}}
'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org]; {{AE}} {{CZ}}
'''Editor(s)-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com], {{ATI}}; {{AE}} {{Rim}}


==Overview==
==Overview==
The symptoms of a pulmonary embolism (PE) depends on the severity of the disease. A Pulmonary embolism may be an incidental finding because a majority of patients may be asymptomatic.<ref name="pmid20399319">{{cite journal |author=Stein PD, Matta F, Musani MH, Diaczok B |title=Silent pulmonary embolism in patients with deep venous thrombosis: a systematic review |journal=[[The American Journal of Medicine]] |volume=123 |issue=5 |pages=426–31 |year=2010 |month=May |pmid=20399319 |doi=10.1016/j.amjmed.2009.09.037 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(09)01111-5 |accessdate=2012-04-26}}</ref><ref name="pmid20592294">{{cite journal |author=Agnelli G, Becattini C |title=Acute pulmonary embolism |journal=[[The New England Journal of Medicine]] |volume=363 |issue=3 |pages=266–74 |year=2010 |month=July |pmid=20592294 |doi=10.1056/NEJMra0907731 |url=http://www.nejm.org/doi/abs/10.1056/NEJMra0907731?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-26}}</ref> The common symptoms of PE range from mild [[dyspnea]], [[chest pain]], and [[tachypnea]], to sustained [[hypotension]] and [[shock]].<ref name="pmid17904458">{{cite journal |author=Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, Hull RD, Leeper KV, Sostman HD, Tapson VF, Buckley JD, Gottschalk A, Goodman LR, Wakefied TW, Woodard PK |title=Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II |journal=[[The American Journal of Medicine]] |volume=120 |issue=10 |pages=871–9 |year=2007 |month=October |pmid=17904458 |pmc=2071924 |doi=10.1016/j.amjmed.2007.03.024 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(07)00463-9 |accessdate=2012-04-26}}</ref><ref name="pmid20592294">{{cite journal |author=Agnelli G, Becattini C |title=Acute pulmonary embolism |journal=[[The New England Journal of Medicine]] |volume=363 |issue=3 |pages=266–74 |year=2010 |month=July |pmid=20592294 |doi=10.1056/NEJMra0907731 |url=http://www.nejm.org/doi/abs/10.1056/NEJMra0907731?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-26}}</ref> The absence of these symptoms may be associated with a reduced clinical probability of PE, however it does not exclude the diagnosis of PE. The [[Deep vein thrombosis history and symptoms|symptoms]] of lower extremity [[Deep vein thrombosis|deep venous thrombosis]] may also be present.
A proper history and physical exam is crucial to establish an accurate diagnosis of [[pulmonary embolism]] (PE).  The [[symptoms]] of [[pulmonary embolism]] (PE) depend on the [[severity]] of the disease, ranging from mild [[dyspnea]], [[chest pain]], and [[cough]], to sustained [[hypotension]] and [[shock]].<ref name="pmid17904458">{{cite journal |author=Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, Hull RD, Leeper KV, Sostman HD, Tapson VF, Buckley JD, Gottschalk A, Goodman LR, Wakefied TW, Woodard PK |title=Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II |journal=[[The American Journal of Medicine]] |volume=120 |issue=10 |pages=871–9 |year=2007 |month=October |pmid=17904458 |pmc=2071924 |doi=10.1016/j.amjmed.2007.03.024 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(07)00463-9 |accessdate=2012-04-26}}</ref><ref name="pmid20592294">{{cite journal |author=Agnelli G, Becattini C |title=Acute pulmonary embolism |journal=[[The New England Journal of Medicine]] |volume=363 |issue=3 |pages=266–74 |year=2010 |month=July |pmid=20592294 |doi=10.1056/NEJMra0907731 |url=http://www.nejm.org/doi/abs/10.1056/NEJMra0907731?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-26}}</ref> A [[PE]] may also be an incidental finding in so far as many patients are asymptomatic.<ref name="pmid20592294">{{cite journal |author=Agnelli G, Becattini C |title=Acute pulmonary embolism |journal=[[The New England Journal of Medicine]] |volume=363 |issue=3 |pages=266–74 |year=2010 |month=July |pmid=20592294 |doi=10.1056/NEJMra0907731 |url=http://www.nejm.org/doi/abs/10.1056/NEJMra0907731?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-26}}</ref><ref name="pmid20399319">{{cite journal |author=Stein PD, Matta F, Musani MH, Diaczok B |title=Silent pulmonary embolism in patients with deep venous thrombosis: a systematic review |journal=[[The American Journal of Medicine]] |volume=123 |issue=5 |pages=426–31 |year=2010 |month=May |pmid=20399319 |doi=10.1016/j.amjmed.2009.09.037 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(09)01111-5 |accessdate=2012-04-26}}</ref> [[Sudden death]] can be the initial presentation of PE. One of the first steps in the management of [[PE]] is the determination of the [[Wells score for PE]], whose criteria can be ascertained solely on the basis of history and physical exam. [[Deep vein thrombosis history and symptoms|Symptoms of DVT]] of the lower extremity may be present.
 
==History and Symptoms==
As depicted in the image below, the majority of patients with [[venous thromboembolism]] (VTE), that is [[DVT]], [[PE]], or both, are [[asymptomatic]].


==Common symptoms<ref name="pmid9867786">{{cite journal |author=Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J |title=Use of a clinical model for safe management of patients with suspected pulmonary embolism |journal=[[Annals of Internal Medicine]] |volume=129 |issue=12 |pages=997–1005 |year=1998 |month=December |pmid=9867786 |doi= |url= |accessdate=2012-04-26}}</ref><ref name="pmid10051264">{{cite journal |author=Miniati M, Prediletto R, Formichi B, Marini C, Di Ricco G, Tonelli L, Allescia G, Pistolesi M |title=Accuracy of clinical assessment in the diagnosis of pulmonary embolism |journal=[[American Journal of Respiratory and Critical Care Medicine]] |volume=159 |issue=3 |pages=864–71 |year=1999 |month=March |pmid=10051264 |doi= |url=http://ajrccm.atsjournals.org/cgi/pmidlookup?view=long&pmid=10051264 |accessdate=2012-04-26}}</ref>==
[[File:Challenge of Assessing VTE.JPG|300x400px|The challenge in diagnosis of VTE]]
*Acute onset of exertional dyspnea or [[dyspnea]] at rest.
*Pleuritic or substernal [[chest pain]].<ref name="pmid17904458">{{cite journal |author=Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, Hull RD, Leeper KV, Sostman HD, Tapson VF, Buckley JD, Gottschalk A, Goodman LR, Wakefied TW, Woodard PK |title=Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II |journal=[[The American Journal of Medicine]] |volume=120 |issue=10 |pages=871–9 |year=2007 |month=October |pmid=17904458 |pmc=2071924 |doi=10.1016/j.amjmed.2007.03.024 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(07)00463-9 |accessdate=2012-04-26}}</ref>


*[[Hemoptysis]] secondary to distal vessel embolism with subsequent [[pulmonary infarction]] ([[alveolar hemorrhage]]).<ref name="pmid9377961">{{cite journal |author=Stein PD, Henry JW |title=Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes |journal=[[Chest]] |volume=112 |issue=4 |pages=974–9 |year=1997 |month=October |pmid=9377961 |doi= |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=9377961 |accessdate=2012-04-26}}</ref>
===Symptoms of PE===
 
The Prospective Investigation Of Pulmonary Embolism Diagnosis II (PIOPED II) study identified the triad of [[symptoms]], [[dyspnea]], [[chest pain]], and [[tachypnea]], present in a majority of patients with a confirmed [[pulmonary embolism]].<ref name="pmid17904458">{{cite journal |author=Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, Hull RD, Leeper KV, Sostman HD, Tapson VF, Buckley JD, Gottschalk A, Goodman LR, Wakefied TW, Woodard PK |title=Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II |journal=[[The American Journal of Medicine]] |volume=120 |issue=10 |pages=871–9 |year=2007 |month=October |pmid=17904458 |pmc=2071924 |doi=10.1016/j.amjmed.2007.03.024 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(07)00463-9 |accessdate=2012-04-26}}</ref><ref name="pmid16738268">{{cite journal |author=Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, Leeper KV, Popovich J, Quinn DA, Sos TA, Sostman HD, Tapson VF, Wakefield TW, Weg JG, Woodard PK |title=Multidetector computed tomography for acute pulmonary embolism |journal=[[The New England Journal of Medicine]] |volume=354 |issue=22 |pages=2317–27 |year=2006 |month=June |pmid=16738268 |doi=10.1056/NEJMoa052367 |url=http://dx.doi.org/10.1056/NEJMoa052367 |accessdate=2012-04-26}}</ref> Symptoms of PE include:
*Circulatory collapse with subsequent [[syncope]], sustained [[hypotension]], and [[shock]] are associated with a massive pulmonary embolism.<ref name="pmid21422387">{{cite journal |author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK |title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association |journal=[[Circulation]] |volume=123 |issue=16 |pages=1788–830 |year=2011 |month=April |pmid=21422387 |doi=10.1161/CIR.0b013e318214914f |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21422387 |accessdate=2012-04-26}}</ref><ref name="pmid20592294">{{cite journal |author=Agnelli G, Becattini C |title=Acute pulmonary embolism |journal=[[The New England Journal of Medicine]] |volume=363 |issue=3 |pages=266–74 |year=2010 |month=July |pmid=20592294 |doi=10.1056/NEJMra0907731 |url=http://www.nejm.org/doi/abs/10.1056/NEJMra0907731?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-26}}</ref>
* [[Dyspnea]] (78–81%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref> <br>
* [[Pleuritic chest pain]] (39–56%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref>  <br>
* [[Fainting]] (22–26%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref> <br>
* [[Cough]] (20%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
* [[Substernal chest pain]] (12%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
* [[Hemoptysis]] (11%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
* [[Wheezing]] <br>
* [[Cyanosis]] (11%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref> <br>
* [[Fever]] (7%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref> <br>
*[[Symptoms]] suggestive of [[shock]] (in case of massive PE)
** [[Altered mental status]]
** [[Cold extremities]]
** [[Cyanosis]]
** [[Oliguria]]
* [[Sudden death]] may be the initial presentation of [[PE]].


*Progressively worsening [[dyspnea]] can appear in patients with pre-existing [[pneumonia]] or [[heart failure]].
===Symptoms of [[DVT]]===


* Regarding chest pain, the pain may be pleuritic.<ref name="pmid17904458">{{cite journal| author=Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA et al.| title=Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. | journal=Am J Med | year= 2007 | volume= 120 | issue= 10 | pages= 871-9 | pmid=17904458 | doi=10.1016/j.amjmed.2007.03.024 | pmc=PMC2071924 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17904458  }} (uncontrolled [[case series]])</ref><ref name="pmid3355304">{{cite journal| author=Hull RD, Raskob GE, Carter CJ, Coates G, Gill GJ, Sackett DL et al.| title=Pulmonary embolism in outpatients with pleuritic chest pain. | journal=Arch Intern Med | year= 1988 | volume= 148 | issue= 4 | pages= 838-44 | pmid=3355304 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3355304  }} </ref><ref name="pmid1909617">{{cite journal| author=Stein PD, Terrin ML, Hales CA, Palevsky HI, Saltzman HA, Thompson BT et al.| title=Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. | journal=Chest | year= 1991 | volume= 100 | issue= 3 | pages= 598-603 | pmid=1909617 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1909617  }} </ref> However, the reliability of assessing pleuritic may be low<ref name="pmid11823768">{{cite journal| author=Kline JA, Nelson RD, Jackson RE, Courtney DM| title=Criteria for the safe use of D-dimer testing in emergency department patients with suspected pulmonary embolism: a multicenter US study. | journal=Ann Emerg Med | year= 2002 | volume= 39 | issue= 2 | pages= 144-52 | pmid=11823768 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11823768  }} </ref> and a [[meta-analysis]] concludes that assessing pleuritic pain is not helpful.<ref name="pmid18089542">{{cite journal| author=West J, Goodacre S, Sampson F| title=The value of clinical features in the diagnosis of acute pulmonary embolism: systematic review and meta-analysis. | journal=QJM | year= 2007 | volume= 100 | issue= 12 | pages= 763-9 | pmid=18089542 | doi=10.1093/qjmed/hcm113 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18089542  }} </ref>
Since [[VTE]] involves both [[DVT]] and [[PE]], the patient can present with complaints of either of the diseases. Therefore it is important to inquire about the [[symptoms]] of both diseases.


==Supportive trial data==
====Common Symptoms of [[DVT]]====
The '''''Prospective Investigation Of Pulmonary Embolism Diagnosis II (PIOPED II) study''''' identified the following triad of symptoms present in a majority of patients with a confirmed pulmonary embolism.<ref name="pmid17904458">{{cite journal |author=Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, Hull RD, Leeper KV, Sostman HD, Tapson VF, Buckley JD, Gottschalk A, Goodman LR, Wakefied TW, Woodard PK |title=Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II |journal=[[The American Journal of Medicine]] |volume=120 |issue=10 |pages=871–9 |year=2007 |month=October |pmid=17904458 |pmc=2071924 |doi=10.1016/j.amjmed.2007.03.024 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(07)00463-9 |accessdate=2012-04-26}}</ref><ref name="pmid16738268">{{cite journal |author=Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, Leeper KV, Popovich J, Quinn DA, Sos TA, Sostman HD, Tapson VF, Wakefield TW, Weg JG, Woodard PK |title=Multidetector computed tomography for acute pulmonary embolism |journal=[[The New England Journal of Medicine]] |volume=354 |issue=22 |pages=2317–27 |year=2006 |month=June |pmid=16738268 |doi=10.1056/NEJMoa052367 |url=http://dx.doi.org/10.1056/NEJMoa052367 |accessdate=2012-04-26}}</ref>
The classical symptoms of [[DVT]] include:  
*[[Dyspnea]]
* [[Pain and nociception|Pain]] in the affected area
*[[Pleuritic chest pain|Chest pain]]
* [[Swelling]] of the affected area
*[[Tachypnea]]
* [[Erythema]] around the affected area
* [[Dilation]] of the surface [[veins]] and [[erythema]] of the overlying area


==ESC 2008 Guideline Recommendation- Suspected High-risk PE (DO NOT EDIT)==
However, sometimes there may be no symptoms referable to the location of the [[DVT]].
<ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP |title=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) |journal=[[European Heart Journal]] |volume=29 |issue=18 |pages=2276–315 |year=2008 |month=September|pmid=18757870 |doi=10.1093/eurheartj/ehn310 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18757870|accessdate=2012-04-26}}</ref>


<gallery>
Image:Extremities dvt.jpg|Front View:Edematous Right Leg
Image:Extremities dvt2.jpg|Rear View:Left limb edema localized to calf.
Image:Extremities dvt3.jpg|Front View:Left limb edema localized to calf. 
</gallery>


{|class="wikitable"
====Less Common Symptoms of [[DVT]]====
|-
* In [[phlegmasia alba dolens]], the leg is pale and cold with a diminished [[arterial]] pulse.  
| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>In high-risk PE, as indicated by the presence of [[shock]] or [[hypotension]], emergency [[Pulmonary embolism diagnosis algorithm#CT equipped hospitals|CT]] or bedside [[Pulmonary embolism echocardiography|echocardiography]] is recommended for diagnostic purposes. ''([[European society of cardiology#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>


|}
* In [[phlegmasia cerulea dolens]], there is an [[acute]] and near-total [[venous]] occlusion of the entire extremity outflow, including the [[iliac vein|iliac]] and [[femoral vein]]s. The leg is usually painful, [[cyanosis|cyanosed]] and [[edema|edematous]].


==Guideline Resources==
===Complete History===
[http://eurheartj.oxfordjournals.org/content/29/18/2276.long 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]<ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP |title=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) |journal=[[European Heart Journal]] |volume=29 |issue=18 |pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18757870 |accessdate=2012-04-26}}</ref>  
If [[VTE]] is suspected or diagnosed, a complete history should be elicited, including the following:
* '''Risk factors'''<ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>
** [[Chemotherapy]]<br>
** [[Chronic heart failure]]<br>
** [[Respiratory failure]]<br>
** [[Hormone replacement therapy]]<br>
** [[Cancer]]<br>
** [[Oral contraceptive pills]] <br>
** [[Stroke]] <br>
** [[Pregnancy]] <br>
** [[Postpartum]] <br>
** Prior history of [[VTE]] <br>
** [[Thrombophilia]] <br>
** Advanced [[age]] <br>
** [[Laparoscopic surgery]] <br>
** Prepartum <br>
** [[Obesity]] <br>
** [[Varicose veins]]
* '''Triggers'''<ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870 }} </ref>
** [[Bone fracture]] ([[hip]] or [[leg]]) <br>
** [[Hip replacement surgery]]<br>
** Knee replacement surgery<br>
** [[General surgery|Major general surgery]]<br>
** [[Trauma|Significant trauma]]<br>
** [[Spinal cord injury]]<br>
** Athroscopic knee surgery<br>
** [[Central venous line]]s<br>
** [[Chemotherapy]]<br>
** Bed rest for more than 3 days <br>
** Prolonged car or air travel <br>
** [[Laparoscopic surgery]] <br>
** Prepartum <br>
* '''Previous episode of [[VTE]]'''
** Age
** Location
* '''Past medical history of diseases associated with hyperviscosity'''
** [[Atherosclerosis]]
** [[Collagen vascular disease]]
** [[Heart failure]]
** [[Myeloproliferative disease]]
** [[Nephrotic syndrome]]
** [[Autoimmune diseases]]
**[[Polycythemia vera]]
** [[Hyperhomocysteinemia]]
** [[Paroxysmal nocturnal hemoglobinuria]]
** [[Waldenstrom macroglobulinemia]]
** [[Multiple myeloma]]
* '''History of [[thrombophilia]]'''
** [[Factor V Leiden mutation]]
** [[Prothrombin gene mutation G20210A]]
** [[Protein C]] or [[Protein S]] deficiency
** [[Antithrombin]] (AT) deficiency
** [[Antiphospholipid syndrome]] (APS)
* '''Abortion'''
** [[Abortion]] at second or third trimester of [[pregnancy]] (suggestive of an inherited [[thrombophilia]] or APS)
* '''Drugs that may increase the risk of [[VTE]]'''
** [[Hydralazine]]
** [[Phenothiazine]]
** [[Procainamide]]
** [[Tamoxifen]]
** [[Bevacizumab]]
** [[Glucocorticoids]]
* '''Family history (suggestive of [[inherited thrombophilia]])'''
** [[Deep vein thrombosis]]
** [[Pulmonary embolism]]
** Recurrent [[miscarriage]]
* '''Social history'''
** Heavy [[cigarette smoking]] (>25 cigarettes per day)
** [[Intravenous drug use]] (if injected directly in [[femoral vein]])
** [[Alcohol]]


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
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Latest revision as of 23:53, 29 July 2020
Resident
Survival
Guide

Pulmonary Embolism Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Pulmonary Embolism from other Diseases

Epidemiology and Demographics

Risk Factors

Triggers

Natural History, Complications and Prognosis

Diagnosis

Diagnostic criteria

Assessment of Clinical Probability and Risk Scores

Pulmonary Embolism Assessment of Probability of Subsequent VTE and Risk Scores

History and Symptoms

Physical Examination

Laboratory Findings

Arterial Blood Gas Analysis

D-dimer

Biomarkers

Electrocardiogram

Chest X Ray

Ventilation/Perfusion Scan

Echocardiography

Compression Ultrasonography

CT

MRI

Treatment

Treatment approach

Medical Therapy

IVC Filter

Pulmonary Embolectomy

Pulmonary Thromboendarterectomy

Discharge Care and Long Term Treatment

Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Follow-Up

Support group

Special Scenario

Pregnancy

Cancer

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Case #1

Pulmonary embolism history and symptoms On the Web

Most recent articles

Most cited articles

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Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Pulmonary embolism history and symptoms

CDC on Pulmonary embolism history and symptoms

Pulmonary embolism history and symptoms in the news

Blogs on Pulmonary embolism history and symptoms

Directions to Hospitals Treating Pulmonary embolism history and symptoms

Risk calculators and risk factors for Pulmonary embolism history and symptoms

Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

A proper history and physical exam is crucial to establish an accurate diagnosis of pulmonary embolism (PE). The symptoms of pulmonary embolism (PE) depend on the severity of the disease, ranging from mild dyspnea, chest pain, and cough, to sustained hypotension and shock.[1][2] A PE may also be an incidental finding in so far as many patients are asymptomatic.[2][3] Sudden death can be the initial presentation of PE. One of the first steps in the management of PE is the determination of the Wells score for PE, whose criteria can be ascertained solely on the basis of history and physical exam. Symptoms of DVT of the lower extremity may be present.

History and Symptoms

As depicted in the image below, the majority of patients with venous thromboembolism (VTE), that is DVT, PE, or both, are asymptomatic.

The challenge in diagnosis of VTE

Symptoms of PE

The Prospective Investigation Of Pulmonary Embolism Diagnosis II (PIOPED II) study identified the triad of symptoms, dyspnea, chest pain, and tachypnea, present in a majority of patients with a confirmed pulmonary embolism.[1][4] Symptoms of PE include:

Symptoms of DVT

Since VTE involves both DVT and PE, the patient can present with complaints of either of the diseases. Therefore it is important to inquire about the symptoms of both diseases.

Common Symptoms of DVT

The classical symptoms of DVT include:

However, sometimes there may be no symptoms referable to the location of the DVT.

Less Common Symptoms of DVT

Complete History

If VTE is suspected or diagnosed, a complete history should be elicited, including the following:

References

  1. ↑ 1.0 1.1 Stein PD, Beemath A, Matta F, Weg JG, Yusen RD, Hales CA, Hull RD, Leeper KV, Sostman HD, Tapson VF, Buckley JD, Gottschalk A, Goodman LR, Wakefied TW, Woodard PK (2007). "Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II". The American Journal of Medicine. 120 (10): 871–9. doi:10.1016/j.amjmed.2007.03.024. PMC 2071924. PMID 17904458. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 Agnelli G, Becattini C (2010). "Acute pulmonary embolism". The New England Journal of Medicine. 363 (3): 266–74. doi:10.1056/NEJMra0907731. PMID 20592294. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
  3. ↑ Stein PD, Matta F, Musani MH, Diaczok B (2010). "Silent pulmonary embolism in patients with deep venous thrombosis: a systematic review". The American Journal of Medicine. 123 (5): 426–31. doi:10.1016/j.amjmed.2009.09.037. PMID 20399319. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
  4. ↑ Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, Leeper KV, Popovich J, Quinn DA, Sos TA, Sostman HD, Tapson VF, Wakefield TW, Weg JG, Woodard PK (2006). "Multidetector computed tomography for acute pulmonary embolism". The New England Journal of Medicine. 354 (22): 2317–27. doi:10.1056/NEJMoa052367. PMID 16738268. Retrieved 2012-04-26. Unknown parameter |month= ignored (help)
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Cohen AT, Dobromirski M, Gurwith MM (2014). "Managing pulmonary embolism from presentation to extended treatment". Thromb Res. 133 (2): 139–48. doi:10.1016/j.thromres.2013.09.040. PMID 24182642.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "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. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
  7. ↑ 7.0 7.1 Anderson FA, Spencer FA (2003). "Risk factors for venous thromboembolism". Circulation. 107 (23 Suppl 1): I9–16. doi:10.1161/01.CIR.0000078469.07362.E6. PMID 12814980.

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