Pulmonary embolism physical examination: Difference between revisions

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Latest revision as of 23:53, 29 July 2020

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

Overview

Pulmonary embolism (PE) is 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 and submassive pulmonary emboli, also known as intermediate-risk and high-risk respectively.^[1]^[2] Since PE most commonly occurs as a complication of deep vein thrombosis (DVT), the physical examination should include an assessment of the lower extremities for erythema, tenderness, and/or swelling.

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.^[2]

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.^[2]
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.^[3]

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 may be present among patients with PE.^[1]

Unilateral calf or thigh tenderness
Unilateral calf or thigh pitting edema
Unilateral calf or thigh swelling
Difference in calf diameters > 3 cm (the calf circumference is measured 10 cm below the tibial tuberosity)
Difference in thigh diameters (the thigh circumference is measured 10-15 cm above the patella)
Unilateral calf or thigh warmth
Unilateral calf or thigh erythema
Palpable cord (a thickened palpable vein suggestive of thrombosed vein)
Dilatation of unilateral collateral superficial veins
Localized tenderness upon palpation of the deep veins
- Posterior calf
- Popliteal fossa
- Inner anterior thigh

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)
↑ ^2.0 ^2.1 ^2.2 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.
↑ 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.

Template:WH Template:WS

[pmid17904458-1] 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)

[pmid18757870-2] 2.0 ^2.1 ^2.2 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.

[pmid10826469-3] 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.

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[2]

[3]

@@ Line 1: / Line 1: @@
+__NOTOC__
+{| class="infobox" style="float:right;"
+|-
+| [[File:Siren.gif|30px|link=Pulmonary embolism resident survival guide]]|| <br> || <br>
+| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
+|}
 {{Pulmonary embolism}}
+'''Editor(s)-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com], {{ATI}}; {{AE}} {{Rim}}
-{{CMG}}
-'''Associate Editors-in-Chief:''' [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]
 ==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]] (PE) is associated with the presence of [[tachycardia]] and [[tachypnea]].  [[Signs]] of [[right ventricular failure]] include [[jugular venous distension]], a [[Heart sounds#Third heart sound S3|right sided S3]], and a [[Parasternal heave|parasternal lift]].  These [[signs]] are often present in cases of massive and submassive pulmonary emboli, also known as intermediate-risk and high-risk respectively.<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><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>  Since [[PE]] most commonly occurs as a complication of [[deep vein thrombosis]] (DVT), the physical examination should include an assessment of the lower extremities for [[erythema]], [[tenderness]], and/or [[swelling]].
-==Appearance of the Patient==
+==Physical Examination==
-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).
-==Vital Signs==
-===Temperature===
-Patient is generally afebrile.
-===Pulse===
+===Appearance of the Patient===
-====Rate====
+The patient may appear anxious due to difficulty breathing. More severe cases may be associated with [[cyanosis]].
-Tachycardia may be present
-====Rhythm====
+===Vital Signs===
+====Temperature====
+*The patient may have a [[low grade fever]]
-The pulse may be regular.
+====Pulse====
+=====Rate=====
+*[[Tachycardia]] is present in 26% of the cases.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>
+=====Rhythm=====
+*The pulse is regular.
-====Strength====
+=====Strength=====
-The pulse may be bounding and strong
+*The pulse may be weak if the patient is in [[shock]].
-====Symmetry====
-The pulses may be symmetric.
-===Respiratory Rate===
-Tachypnea may be present.
-*Lowered  [[Oxygen saturation|SpO2]] level on room air.
+=====Symmetry=====
+*The pulses are symmetric.
-===Blood Pressure===
+====Respiratory Rate====
+*[[Tachypnea]] is present in 70% of the cases.<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>
+*[[Hypoxia]] may be present, but the [[hyperventilation]] associated with pulmonary embolism may actually drive down the PCO2.
-The patient is generally [[hypotensive]].
+====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 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>
-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===
-==Skin==
+*[[Cyanosis]] may be present in the setting of massive pulmonary embolism.
-Cyanosis may be present.
+* [[Edema]] may be present in case of [[right heart failure]].
-Patients with Submassive PE present with signs of RV dysfunctions, which are as follows:
+===Neck===
-* Distended neck veins.
+*[[Jugular venous pressure#Assessment of Jugular Venous Distention|Jugular venous distension]] may be seen in cases of massive [[pulmonary embolism]].
-* [[Parasternal heave]].
-* Prominent second heart sound ([[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|P2]]).
-* Murmur of [[tricuspid regurgitation]].
-However, these signs have poor sensitivity.
-Thorough assessment should be made for the presence of a [[deep vein thrombosis]].
+===Heart===
+====Inspection====
+*[[Parasternal heave]] secondary to the development of [[right ventricular failure]] may be present in massive [[PE]].
+====Auscultation====
+*[[S2|Prominent P2 component of second heart sound]] may be present due to elevated pulmonary pressures.<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 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]] may be present among 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>
+* Unilateral calf or thigh [[tenderness]]
+* Unilateral calf or thigh [[pitting edema]]
+*Unilateral calf or thigh swelling
+* Difference in calf diameters > 3 cm (the calf circumference is measured 10 cm below the [[tibial]] [[tuberosity]])
+* Difference in thigh diameters (the thigh circumference is measured 10-15 cm above the [[patella]])
+* Unilateral calf or thigh warmth
+* Unilateral calf or thigh [[erythema]]
+* Palpable cord (a thickened palpable vein suggestive of [[vein thrombosis|thrombosed vein]])
+* Dilatation of [[unilateral]] collateral [[superficial veins]]
+* Localized [[tenderness]] upon palpation of the [[deep veins]]
+** [[Posterior]] calf
+** [[Popliteal fossa]]
+** Inner [[anterior]] thigh
+==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]].<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),
+*Reduced [[breath sounds]] (~17%),
+*[[S2|Prominent P2 component of second heart sound]] (~15%),
+*[[Jugular venous pressure]] (~14%).
 ==References==
-{{reflist|2}}
+{{Reflist|2}}
+{{WH}}
+{{WS}}
 [[Category:Hematology]]
@@ Line 53: / Line 98: @@
 [[Category:Cardiology]]
 [[Category:Emergency medicine]]
+[[Category:Intensive care medicine]]
-{{WH}}
-{{WS}}