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Thromboembolism Clinical Presentation

  • Author: Vera A De Palo, MD; Chief Editor: Harris Gellman, MD  more...
Updated: Nov 25, 2015


With pulmonary embolism (PE), the patient often experiences acute onset of shortness of breath; sometimes the patient even pinpoints the moment of distress. Complaints related to signs of deep vein thrombosis (DVT), lower-extremity swelling, and warmth to touch or tenderness may be present. Dyspnea is the most frequent symptom of PE.

With a smaller PE near the pleura, the patient may complain of pleuritic chest pain, cough, or hemoptysis. Sometimes, massive PE can present with syncope. The patient may have a sense of impending doom, with apprehension and anxiety. History may reveal the presence of one or more causes or risk factors.


Physical Examination

Some patients have signs of DVT, lower-extremity swelling, and tenderness and warmth to touch. Clinical signs of pulmonary thromboembolism also include the following:

  • Tachypnea (respiratory rate exceeding 18 breaths/min) is the most common sign of PE
  • Tachycardia often is present
  • The second heart sound can be accentuated
  • Fever may be present
  • Lung examination findings frequently are normal
  • Cyanosis may be present

In the appropriate clinical setting, when shortness of breath, hypoxemia, and tachycardia are present, there should be a high clinical suspicion of PE until it is ruled out. Timely anticoagulation is important; 5-7% of recurrences are fatal.

The likelihood of PE in a patient in whom it is suspected may be assessed by the Wells clinical decision rule. The criteria are scored as follows:

  • Clinical symptoms of DVT (3 points)
  • Other diagnoses less likely than PE (3 points)
  • Heart rate greater than 100 beats/min (1.5 points)
  • Immobilization for at least 3 days or surgery in previous 4 weeks (1.5 points)
  • Previous DVT/PE (1.5 points)
  • Hemoptysis (1 point)
  • Malignancy (1 point)

In the modified Wells criteria, PE is likely when the score is greater than 4 and unlikely when the score is less than 4. Highly sensitive D-dimer is coupled into the decision algorithm.[19]

Contributor Information and Disclosures

Vera A De Palo, MD Associate Professor, Department of Medicine, The Warren Alpert Medical School of Brown University; Associate Chief of Medicine, Memorial Hospital of Rhode Island

Vera A De Palo, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, Rhode Island Medical Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.


Abdallah E Kharnaf, MD Resident Physician, Department of Medicine, Memorial Hospital of Rhode Island, The Warren Alpert Medical School of Brown University

Abdallah E Kharnaf, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.


Michael J Belanger, MD Clinical Instructor, Department of Orthopedics, Harvard Medical School

Disclosure: Nothing to disclose.

Jegan Krishnan, MBBS, FRACS, PhD Professor, Chair, Department of Orthopedic Surgery, Flinders University of South Australia; Senior Clinical Director of Orthopedic Surgery, Repatriation General Hospital; Private Practice, Orthopaedics SA, Flinders Private Hospital

Jegan Krishnan, MBBS, FRACS, PhD, is a member of the following medical societies: Australian Medical Association, Australian Orthopaedic Association, and Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jerome D Wiedel, MD Chair, Professor, Department of Orthopedics, University of Colorado Health Sciences Center

Disclosure: Nothing to disclose.

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Pulmonary embolism within the pulmonary artery.
Ventilation-perfusion scan. Left image: Posterior view of normal findings on ventilation scan. Right image: Posterior view of a perfusion scan that reveals a perfusion defect in the left upper quadrant. The defect in the middle of the image is due to the position of the heart.
Helical CT scan of the pulmonary arteries. A filling defect in the right pulmonary artery is present, consistent with a pulmonary embolism.
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