PE Clinical Evaluation

Presenting Complaint Most common presenting complaint: dyspnoea Chest pain Syncope Cough Leg pain

HPC Dyspnoea is sudden and unexplained Chest pain. – Non pleuritic – Pleuritic Syncope indicates a massive PE Fever, diaphoresis, apprehension due to inflammation, possibly shock Palpitations, tachycardia Hemoptysis, cough Signs of DVT

Risk Factors ?Prolonged immobilization (> 3 days) Postoperative state Trauma to lower extremities Pregnancy and early puerperium Cancer (lung, pancreas, alimentary and genitourinary tracts) Trauma, burns Advanced age (>60) Obesity Hematologic disease (e.g., antithrombin III deficiency, protein C deficiency, protein S deficiency, lupus anticoagulant, polycythemia vera, dysfibrinogenemia, paroxysmal nocturnal hemoglobinuria, factor V Leiden mutation, G20210A prothrombin mutation) COPD, diabetes mellitus Prolonged air travel Oestrogen-containing birth control pills Prior history of DVT or PE CHF

Examination Pleuritic rub. Crackles, Tachypnoea Cardiovascular changes following a massive PE: – Shock – Elevated JVP – Right ventricular heave (heel of hand is placed over left parasternal region and lifted off with each systole) – Mitral regurgitation – Increased S3 on inspiration (the galloping heart has a sound like the “Kentucky Derby”: Ken(S1)-tuck(S2)-y(S3) at the lower left sternal border and the –y increases with inspiration) – Loud, early P2 component (pulmonary valve closure) of S2 (in other words, the second heart sound (S2 made up of P2 and A2) is split because of early closure of the pulmonary valve (P2) ahead of the aortic valve (A2) due to increased pulmonary artery pressure caused by the embolism Evidence of DVT (calf swelling, pain, inflammation).

Determining the Pre-Test Probability VariablePoints Clinical signs and symptoms of deep vein thrombosis (pain and leg swelling with palpation of the deep veins) 3 Alternative diagnosis less likely than pulmonary embolism 3 Heart rate > 100/minute 1.5 Immobilization > 3 days or surgery in the previous 4 weeks 1.5 Previous pulmonary embolism or deep venous thrombosis 1.5 Haemoptysis 1 Malignancy treated within the last 6 months 1 Risk score interpretation (probability of DVT): >6 points: high risk (78.4%); 2 to 6 points: moderate risk (27.8%); <2 points: low risk (3.4%)