History

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 higher 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]

Differential Diagnoses

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Media Gallery

Venous Thromboembolism (VTE). Pulmonary embolism within the pulmonary artery.
Venous Thromboembolism (VTE). 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.
Venous Thromboembolism (VTE). 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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Author

Vera A De Palo, MD, MBA, FCCP Medical Director/Consultant, Respiratory Therapy Program, New England Institute of Technology; Consulting Physician, TruCare

Vera A De Palo, MD, MBA, FCCP is a member of the following medical societies: American College of Chest Physicians, Massachusetts Medical Society, Rhode Island Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

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

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedic Surgery, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Acknowledgements

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.