Pulmonary embolism physical examination: Difference between revisions

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{{Pulmonary embolism}}
{{Pulmonary embolism}}
{{PE editors}}
{{PE editors}}
'''''Synonyms and Keywords:''''' PE


==Overview==
==Overview==
The decision to do medical imaging is usually based on clinical grounds, i.e. the medical history, symptoms and findings on physical examination, followed by an assessment of clinical probability.
Pulmonary embolism is associated with the presence of [[tachycardia]], [[tachypnea]] and signs of [[right ventricular failure]] including [[Jugular venous pressure#Assessment of Jugular Venous Distention|jugular venous distension]], [[Heart sounds#Third heart sound S3|right sided S3]] and [[Parasternal heave|parasternal lift]] which is present in cases of massive PE.<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=2012-04-29}}</ref>


==Appearance of the Patient==
==Appearance of the Patient==
The patient may appear anxious because of difficulty in breathing. More severe cases may be associated with [[cyanosis]] (bluish discoloration, usually of lips and fingers).
The patient may appear anxious because of difficulty in breathing. More severe cases may be associated with [[cyanosis]].
 
==Vital Signs==
==Vital Signs==
===Temperature===
===Temperature===
Patient is generally afebrile.
*Patient is often afebrile.


===Pulse===
===Pulse===
====Rate====
=====Rate=====
Tachycardia may be present
*[[Tachycardia]] may be present.<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=2012-04-29}}</ref>
 
=====Rhythm=====
*The pulse is regular.


====Rhythm====
=====Strength=====
*The pulse may be bounding and strong.


The pulse may be regular.
=====Symmetry=====
*The pulses are symmetric.


====Strength====
The pulse may be bounding and strong
====Symmetry====
The pulses may be symmetric.
===Respiratory Rate===
===Respiratory Rate===
Tachypnea may be present.
*[[Tachypnea]] may be present.<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=2012-04-29}}</ref>
 
*Lowered  [[Oxygen saturation|SpO2]] level on room air.  
*Lowered  [[Oxygen saturation|SpO2]] level on room air.  


===Blood Pressure===
===Blood Pressure===
*The patient may be [[hypotensive]] secondary to circulatory collapse in cases of massive PE.<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=2012-04-29}}</ref> In the absence of immediate management, the patient may progress to developing [[shock]] and [[sudden cardiac arrest]]. Approximately, 15% of all cases with [[Sudden cardiac death|sudden cardiac arrest]] are attributed to PE.<ref>??</ref>


The patient is generally [[hypotensive]].
==Skin==
*[[Cyanosis]] may be present depending on the severity of PE.


Without immediate intervention it might lead to [[shock]] or even [[Collapse (medical)|collapse]]. About 15% of all cases of [[Sudden cardiac death|sudden death]] are attributable to PE.
==Skin==
Cyanosis may be present depending upon the severity of PE.
==Neck==
==Neck==
Patients with Submassive PE present with signs of RV dysfunctions, which are as follows:
*[[Jugular venous pressure#Assessment of Jugular Venous Distention|Jugular venous pressure]] may be elevated in cases of massive PE.
* Distended neck veins.
 
==Heart==
==Heart==
[[Parasternal heave]] may be present.
=====Inspection=====
*[[Parasternal heave]] may be present in cases of massive PE, secondary to the development of [[right ventricular failure]].
 
===Auscultation===
===Auscultation===
* Prominent second heart sound ([[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|P2]]).
*[[S2|Prominent P2 component of second heart sound]] may be present.<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=2012-04-29}}</ref>
*[[Heart sounds#Third heart sound S3|Right sided S3]] may be present in cases of massive PE, secondary to the development of [[right ventricular failure]].
* Murmur of [[tricuspid regurgitation]].
* Murmur of [[tricuspid regurgitation]].
However, these signs have poor sensitivity.
 
==Lung==
*Reduced [[breath sounds]] may be present.
*[[Rales]] may be present.
 
==Extremities==
==Extremities==
Thorough assessment should be made for the presence of a [[deep vein thrombosis]].
Signs of [[deep vein thrombosis]] ''(listed below)'' may be present in majority of patients with PE.<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=2012-04-29}}</ref>
:*[[Edema|Limb edema]],
:*[[Erythema]],
:*[[Tender]],
:*Palpable cord in the calf or thighs reflecting thrombosed veins.
 
==Supportive trial data==
The '''''Prospective Investigation Of Pulmonary Embolism Diagnosis II (PIOPED II) study''''' identified the following signs to be present in the majority of patients with angiographically proven 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=2012-04-29}}</ref>
*[[Tachypnea]] (~54%),
*[[DVT|Signs of deep venous thrombosis]] (~47%),
*[[Tachycardia]] (~24%),
*[[Rales]] (~18),
*[[Breath sounds|Reduced breath sounds]] (~17%),
*[[S2|Prominent P2 component of second heart sound]] (~15%),
*[[JVD|Elevated jugular venous pressure]] (~14%).


==References==
==References==

Revision as of 14:42, 29 April 2012

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

Synonyms and Keywords: PE

Overview

Pulmonary embolism is associated with the presence of tachycardia, tachypnea and signs of right ventricular failure including jugular venous distension, right sided S3 and parasternal lift which is present in cases of massive PE.[1]

Appearance of the Patient

The patient may appear anxious because of difficulty in breathing. More severe cases may be associated with cyanosis.

Vital Signs

Temperature

  • Patient is often afebrile.

Pulse

Rate
Rhythm
  • The pulse is regular.
Strength
  • The pulse may be bounding and strong.
Symmetry
  • The pulses are symmetric.

Respiratory Rate

Blood Pressure

Skin

  • Cyanosis may be present depending on the severity of PE.

Neck

Heart

Inspection

Auscultation

Lung

Extremities

Signs of deep vein thrombosis (listed below) may be present in majority of patients with PE.[1]

Supportive trial data

The Prospective Investigation Of Pulmonary Embolism Diagnosis II (PIOPED II) study identified the following signs to be present in the majority of patients with angiographically proven pulmonary embolism.[1]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 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 2012-04-29. Unknown parameter |month= ignored (help)
  2. ↑ ??

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