Thromboembolism Clinical Presentation
- Author: Vera A De Palo, MD; Chief Editor: Harris Gellman, MD more...
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.
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.
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