Pulmonary embolism physical examination
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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]
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 be febrile
Pulse
Rate
- Tachycardia may be present.[1]
Rhythm
- The pulse is regular.
Strength
- The pulse may be bounding and strong.
Symmetry
- The pulses are symmetric.
Respiratory Rate
- Tachypnea may be present.[1]
- Lowered oxygen saturation levels.
Blood Pressure
- The patient may be hypotensive secondary to circulatory collapse in cases of massive PE.[1] Shock and sudden cardiac arrest are negative consequences that may occur in the absence of immediate management. Approximately 15% of all sudden cardiac arrest cases are attributed to PE.[2]
Skin
- Cyanosis may be present, depending on the severity of PE.
Neck
- Jugular venous distension may be seen in cases of massive PE.
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.[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.
Lungs
- Reduced breath sounds may be present.
- Rales 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 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
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