Pulmonary embolism physical examination: Difference between revisions
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===Vital Signs=== | ===Vital Signs=== | ||
====Temperature==== | ====Temperature==== | ||
*The patient may | *The patient may have a [[low grade fever]] | ||
====Pulse==== | ====Pulse==== | ||
=====Rate===== | =====Rate===== | ||
*[[Tachycardia]] | *[[Tachycardia]] is present in 26% of the cases. | ||
=====Rhythm===== | =====Rhythm===== | ||
*The pulse is regular. | *The pulse is regular. | ||
| Line 29: | Line 28: | ||
====Respiratory Rate==== | ====Respiratory Rate==== | ||
*[[Tachypnea]] | *[[Tachypnea]] is present in 70% of the cases. | ||
*[[Hypoxia]] may be present, but the [[hyperventilation]] associated with pulmonary embolism may actually drive down the PCO2. | *[[Hypoxia]] may be present, but the [[hyperventilation]] associated with pulmonary embolism may actually drive down the PCO2. | ||
====Blood Pressure==== | ====Blood Pressure==== | ||
*The patient may be [[hypotensive]] secondary to circulatory collapse in cases of massive 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> The state of [[shock]] may progress to [[sudden cardiac arrest]] and or [[pulseless electrical activity]] in the absence of immediate management. Approximately | *The patient may be [[hypotensive]] secondary to circulatory collapse in cases of massive 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> The state of [[shock]] may progress to [[sudden cardiac arrest]] and or [[pulseless electrical activity]] in the absence of immediate management. Approximately 5% of all [[Sudden cardiac death|sudden cardiac arrest]] cases are attributed to pulmonary emboli.<ref name="pmid10826469">{{cite journal| author=Kürkciyan I, Meron G, Sterz F, Janata K, Domanovits H, Holzer M et al.| title=Pulmonary embolism as a cause of cardiac arrest: presentation and outcome. | journal=Arch Intern Med | year= 2000 | volume= 160 | issue= 10 | pages= 1529-35 | pmid=10826469 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10826469 }} </ref> | ||
===Skin=== | ===Skin=== | ||
*[[Cyanosis]] may be present in the setting of massive pulmonary embolism. | *[[Cyanosis]] may be present in the setting of massive pulmonary embolism. | ||
* [[Edema]] may be present in case of [[right heart failure]]. | |||
===Neck=== | ===Neck=== | ||
| Line 49: | Line 49: | ||
*[[Heart sounds#Third heart sound S3|Right sided S3]] may be present in cases of a massive pulmonary embolism secondary to the development of [[right ventricular failure]]. | *[[Heart sounds#Third heart sound S3|Right sided S3]] may be present in cases of a massive pulmonary embolism secondary to the development of [[right ventricular failure]]. | ||
*A [[murmur]] due to [[tricuspid regurgitation]] may be heard on auscultation. | *A [[murmur]] due to [[tricuspid regurgitation]] may be heard on auscultation. | ||
* [[Graham-Steell murmur]] is suggestive of [[pulmonary regurgitation]]. | |||
===Lungs=== | ===Lungs=== | ||
*Reduced [[breath sounds]] may be present. | * Reduced [[breath sounds]] may be present. | ||
*[[Rales]] may be present. | * [[Rales]] may be present. | ||
* [[Crackles]] may be present. | |||
* [[Pleural friction rub]] may be present. | |||
*[[Pulmonary hypertension]] and RV overload are commonly seen during the physical exam and diagnosis. | *[[Pulmonary hypertension]] and RV overload are commonly seen during the physical exam and diagnosis. | ||
Revision as of 21:15, 5 June 2014
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Pulmonary Embolism Microchapters |
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Diagnosis |
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Pulmonary Embolism Assessment of Probability of Subsequent VTE and Risk Scores |
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Treatment |
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Follow-Up |
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Special Scenario |
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Trials |
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Case Studies |
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Pulmonary embolism physical examination On the Web |
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Directions to Hospitals Treating Pulmonary embolism physical examination |
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Risk calculators and risk factors for Pulmonary embolism physical examination |
Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief:
Overview
Pulmonary emboli are associated with the presence of tachycardia and tachypnea. Signs of right ventricular failure include jugular venous distension, a right sided S3, and a parasternal lift. These signs are often present in cases of massive pulmonary emboli.[1]
Physical Examination
Appearance of the Patient
The patient may appear anxious due to difficulty breathing. More severe cases may be associated with cyanosis.
Vital Signs
Temperature
- The patient may have a low grade fever
Pulse
Rate
- Tachycardia is present in 26% of the cases.
Rhythm
- The pulse is regular.
Strength
- The pulse may be weak if the patient is in shock.
Symmetry
- The pulses are symmetric.
Respiratory Rate
- Tachypnea is present in 70% of the cases.
- Hypoxia may be present, but the hyperventilation associated with pulmonary embolism may actually drive down the PCO2.
Blood Pressure
- The patient may be hypotensive secondary to circulatory collapse in cases of massive pulmonary embolism.[1] The state of shock may progress to sudden cardiac arrest and or pulseless electrical activity in the absence of immediate management. Approximately 5% of all sudden cardiac arrest cases are attributed to pulmonary emboli.[2]
Skin
- Cyanosis may be present in the setting of massive pulmonary embolism.
- Edema may be present in case of right heart failure.
Neck
- Jugular venous distension may be seen in cases of massive pulmonary embolism.
Heart
Inspection
- Parasternal heave secondary to the development of right ventricular failure may be present in massive PE.
Auscultation
- Prominent P2 component of second heart sound may be present due to elevated pulmonary pressures.[1]
- Right sided S3 may be present in cases of a massive pulmonary embolism secondary to the development of right ventricular failure.
- A murmur due to tricuspid regurgitation may be heard on auscultation.
- Graham-Steell murmur is suggestive of pulmonary regurgitation.
Lungs
- Reduced breath sounds may be present.
- Rales may be present.
- Crackles may be present.
- Pleural friction rub may be present.
- Pulmonary hypertension and RV overload are commonly seen during the physical exam and diagnosis.
Extremities
Signs of deep vein thrombosis (listed below) may be present in majority of patients with PE.[1]
- Limb edema
- Limb erythema
- Limb tenderness
- Palpable cords in the calf or thighs due to 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 a confirmed pulmonary embolism diagnosed by angiography.[1]
- Tachypnea (~54%),
- Signs of deep venous thrombosis (~47%),
- Tachycardia (~24%),
- Rales (~18),
- Reduced breath sounds (~17%),
- Prominent P2 component of second heart sound (~15%),
- Jugular venous pressure (~14%).
References
- ↑ 1.0 1.1 1.2 1.3 1.4 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) - ↑ Kürkciyan I, Meron G, Sterz F, Janata K, Domanovits H, Holzer M; et al. (2000). "Pulmonary embolism as a cause of cardiac arrest: presentation and outcome". Arch Intern Med. 160 (10): 1529–35. PMID 10826469.