Pulmonary embolism differential diagnosis: Difference between revisions
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| [[File:Siren.gif | | <figure-inline><figure-inline><figure-inline><figure-inline>[[File:Siren.gif|link=Pulmonary embolism resident survival guide|41x41px]]</figure-inline></figure-inline></figure-inline></figure-inline>|| <br> || <br> | ||
| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | | [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | ||
|} | |} | ||
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Pulmonary_embolism]] | |||
{{CMG}} {{ATI}}; {{AE}} {{Rim}} | {{CMG}} {{ATI}}; {{AE}} {{Rim}} | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
===Differential Diagnosis Based on Symptoms=== | ===Differential Diagnosis Based on Symptoms=== | ||
Pulmonary embolism (PE) should be differentiated from other diseases presenting with chest pain, shortness of breath and tachypnea. The differentials include the following: | Pulmonary embolism (PE) should be differentiated from other diseases presenting with [[chest pain]], [[shortness of breath]] and [[tachypnea]]. The differentials include the following:<ref name="pmid24550636">{{cite journal |vauthors=Brenes-Salazar JA |title=Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era |journal=J Emerg Trauma Shock |volume=7 |issue=1 |pages=57–8 |year=2014 |pmid=24550636 |pmc=3912657 |doi=10.4103/0974-2700.125645 |url=}}</ref><ref name="urlCT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics">{{cite web |url=http://pubs.rsna.org/doi/full/10.1148/rg.245045008 |title=CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics |format= |work= |accessdate=}}</ref><ref name="pmid23940438">{{cite journal |vauthors=Bĕlohlávek J, Dytrych V, Linhart A |title=Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism |journal=Exp Clin Cardiol |volume=18 |issue=2 |pages=129–38 |year=2013 |pmid=23940438 |pmc=3718593 |doi= |url=}}</ref><ref name="urlPulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022657/ |title=Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health |format= |work= |accessdate=}}</ref><ref name="pmid20118395">{{cite journal |vauthors=Ramani GV, Uber PA, Mehra MR |title=Chronic heart failure: contemporary diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=2 |pages=180–95 |year=2010 |pmid=20118395 |pmc=2813829 |doi=10.4065/mcp.2009.0494 |url=}}</ref><ref name="pmid18215495">{{cite journal |vauthors=Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL |title=Symptom distress and quality of life in patients with advanced congestive heart failure |journal=J Pain Symptom Manage |volume=35 |issue=6 |pages=594–603 |year=2008 |pmid=18215495 |pmc=2662445 |doi=10.1016/j.jpainsymman.2007.06.007 |url=}}</ref><ref name="pmid19168510">{{cite journal |vauthors=Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ |title=Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology |journal=Eur. J. Heart Fail. |volume=11 |issue=2 |pages=130–9 |year=2009 |pmid=19168510 |pmc=2639415 |doi=10.1093/eurjhf/hfn013 |url=}}</ref><ref name="pmid9465867">{{cite journal |vauthors=Takasugi JE, Godwin JD |title=Radiology of chronic obstructive pulmonary disease |journal=Radiol. Clin. North Am. |volume=36 |issue=1 |pages=29–55 |year=1998 |pmid=9465867 |doi= |url=}}</ref><ref name="pmid14651761">{{cite journal |vauthors=Wedzicha JA, Donaldson GC |title=Exacerbations of chronic obstructive pulmonary disease |journal=Respir Care |volume=48 |issue=12 |pages=1204–13; discussion 1213–5 |year=2003 |pmid=14651761 |doi= |url=}}</ref><ref name="pmid23833163">{{cite journal |vauthors=Nakawah MO, Hawkins C, Barbandi F |title=Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome |journal=J Am Board Fam Med |volume=26 |issue=4 |pages=470–7 |year=2013 |pmid=23833163 |doi=10.3122/jabfm.2013.04.120256 |url=}}</ref><ref name="pmid20511488">{{cite journal |vauthors=Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK |title=Pericardial disease: diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=6 |pages=572–93 |year=2010 |pmid=20511488 |pmc=2878263 |doi=10.4065/mcp.2010.0046 |url=}}</ref><ref name="pmid23610095">{{cite journal |vauthors=Bogaert J, Francone M |title=Pericardial disease: value of CT and MR imaging |journal=Radiology |volume=267 |issue=2 |pages=340–56 |year=2013 |pmid=23610095 |doi=10.1148/radiol.13121059 |url=}}</ref><ref name="pmid11680112">{{cite journal |vauthors=Gharib AM, Stern EJ |title=Radiology of pneumonia |journal=Med. Clin. North Am. |volume=85 |issue=6 |pages=1461–91, x |year=2001 |pmid=11680112 |doi= |url=}}</ref><ref name="pmid23507061">{{cite journal |vauthors=Schmidt WA |title=Imaging in vasculitis |journal=Best Pract Res Clin Rheumatol |volume=27 |issue=1 |pages=107–18 |year=2013 |pmid=23507061 |doi=10.1016/j.berh.2013.01.001 |url=}}</ref><ref name="pmid16891436">{{cite journal |vauthors=Suresh E |title=Diagnostic approach to patients with suspected vasculitis |journal=Postgrad Med J |volume=82 |issue=970 |pages=483–8 |year=2006 |pmid=16891436 |pmc=2585712 |doi=10.1136/pgmj.2005.042648 |url=}}</ref><ref name="pmid123074">{{cite journal |vauthors=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW |title=The electrocardiogram in acute pulmonary embolism |journal=Prog Cardiovasc Dis |volume=17 |issue=4 |pages=247–57 |year=1975 |pmid=123074 |doi= |url=}}</ref><ref name="pmid23413894">{{cite journal |vauthors=Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML |title=Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease |journal=COPD |volume=10 |issue=1 |pages=62–71 |year=2013 |pmid=23413894 |doi=10.3109/15412555.2012.727918 |url=}}</ref><ref name="pmid23000104">{{cite journal |vauthors=Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H |title=Electrocardiogram in pneumonia |journal=Am. J. Cardiol. |volume=110 |issue=12 |pages=1836–40 |year=2012 |pmid=23000104 |doi=10.1016/j.amjcard.2012.08.019 |url=}}</ref><ref name="pmid26209947">{{cite journal |vauthors=Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S |title=Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis |journal=Int. J. Cardiol. |volume=199 |issue= |pages=170–9 |year=2015 |pmid=26209947 |doi=10.1016/j.ijcard.2015.06.087 |url=}}</ref><ref name="pmid20112390">{{cite journal |vauthors=Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S |title=Cardiac involvement in Churg-Strauss syndrome |journal=Arthritis Rheum. |volume=62 |issue=2 |pages=627–34 |year=2010 |pmid=20112390 |doi=10.1002/art.27263 |url=}}</ref> | ||
<small> | |||
{| | {| | ||
|-style="background: #4479BA; color: #FFFFFF; text-align: center;" | |- style="background: #4479BA; color: #FFFFFF; text-align: center;" | ||
! rowspan="2" |<small>Diseases</small> | ! rowspan="2" |<small>Diseases</small> | ||
! colspan="3" |<small>Diagnostic tests</small> | ! colspan="3" |<small>Diagnostic tests</small> | ||
| Line 42: | Line 44: | ||
** Intra-luminal filling defect | ** Intra-luminal filling defect | ||
*On [[MRI]]: | *On [[MRI]]: | ||
** Narrowing of involved vessel | ** Narrowing of involved [[Blood vessel|vessel]] | ||
** No contrast seen distal to obstruction | ** No contrast seen distal to [[obstruction]] | ||
** Polo-mint sign (partial filling defect surrounded by contrast) | ** Polo-mint sign (partial filling defect surrounded by contrast) | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* S1Q3T3 pattern representing acute right heart strain | * [[Pulmonary embolism electrocardiogram|S1Q3T3]] pattern representing acute [[right heart]] strain | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* Fleischner sign (enlarged pulmonary artery), Hampton hump, Westermark's sign | * [[Fleischner sign]] (enlarged pulmonary artery), [[Hampton's hump|Hampton hump]], [[Westermark's sign]] | ||
| style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
| style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
| Line 55: | Line 57: | ||
| style="background: #F5F5F5; padding: 5px;" |✔ (In case of massive PE) | | style="background: #F5F5F5; padding: 5px;" |✔ (In case of massive PE) | ||
| style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
| style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
| style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
| style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
| style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Hypercoagulating conditions (Factor V Leiden, thrombophilia, deep vein thrombosis, immobilization, malignancy, pregnancy) | *Hypercoagulating conditions ([[Factor V Leiden]], [[thrombophilia]], [[deep vein thrombosis]], immobilization, [[malignancy]], [[pregnancy]]) | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
* May be associated with metabolic alkalosis and syncope | * May be associated with [[metabolic alkalosis]] and [[syncope]] | ||
|- | |- | ||
| style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Congestive heart failure]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Congestive heart failure]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*On CT scan: | *On [[Computed tomography|CT scan]]: | ||
** Mediastinal lymphadenopathy | ** [[Mediastinal lymphadenopathy]] | ||
** | ** Hazy [[mediastinal]] fat | ||
*On MRI: | *On [[Magnetic resonance imaging|MRI]]: | ||
** Abnormality of cardiac chambers (hypertrophy, dilation) | ** Abnormality of [[cardiac]] chambers ([[Hypertrophy (medical)|hypertrophy]], dilation) | ||
** Delayed enhancement MRI may help characterize the myocardial tissue (fibrosis) | ** Delayed enhancement [[MRI]] may help characterize the [[myocardial]] [[Tissue (biology)|tissue]] ([[fibrosis]]) | ||
** Late enhancement of contrast in conditions such as myocarditis, sarcoidosis, | ** Late enhancement of contrast in conditions such as [[myocarditis]], [[sarcoidosis]], [[amyloidosis]], [[Anderson-Fabry disease|Anderson-Fabry]]'s disease, [[Chagas disease]]) | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity) | *Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity) | ||
** | **[[S wave|S]]V1 or [[S wave|S]]V2 + [[R wave|R]]V5 or [[R wave|R]]V6 ≥3.5 mV | ||
**Total QRS amplitude in each of the limb leads ≤0.8 mV | **Total [[QRS complex|QRS]] amplitude in each of the limb leads ≤0.8 mV | ||
** R/S ratio <1 in lead V4 | ** [[R wave|R]]/[[S wave|S]] ratio <1 in lead V4 | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Cardiomegaly | *[[Cardiomegaly]] | ||
| style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
| style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
| style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
| style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
| style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
| style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
| style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
| style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
| style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
| style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Previous myocardial infarction | *Previous [[myocardial infarction]] | ||
*Hypertension (systemic and pulmonary) | *[[Hypertension]] ([[Systemic hypertension|systemic]] and [[Pulmonary hypertension|pulmonary]]) | ||
*Cardiac arrythmias | *[[Cardiac arrhythmia|Cardiac arrythmias]] | ||
*Viral infections (myocarditis) | *[[Viral]] infections ([[myocarditis]]) | ||
*Congenital heart defects | *[[Congenital heart disease|Congenital heart defects]] | ||
| style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Right heart | *[[Right heart failure]] associated with: | ||
**Hepatomegaly | **[[Hepatomegaly]] | ||
**Positive | **Positive hepato-jugular reflex | ||
**Increased jugular venous pressure | **Increased [[jugular venous pressure]] | ||
**Peripheral edema | **[[Peripheral edema]] | ||
*Left heart | *[[Left heart failure]] associated with: | ||
**Pulmonary edema | **[[Pulmonary edema]] | ||
**Eventual right heart | **Eventual [[right heart failure]] | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Percarditis]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Percarditis]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*On contrast enhanced CT scan: | *On contrast enhanced [[Computed tomography|CT scan]]: | ||
**Enhancement of the pericardium (due to inflammation) | **Enhancement of the [[pericardium]] (due to [[inflammation]]) | ||
**Pericardial effusion | **[[Pericardial effusion]] | ||
**Pericardial calcification | **[[Pericardial calcification]] | ||
*On gadolinium-enhanced fat-saturated T1-weighted MRI: | *On [[gadolinium]]-enhanced fat-saturated [[Magnetic resonance imaging|T1-weighted MRI]]: | ||
**Pericardial enhancement (due to inflammation) | **[[Pericardial]] enhancement (due to [[inflammation]]) | ||
**Pericardial effusion | **[[Pericardial effusion]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*ST elevation | *ST elevation | ||
*PR depression | *PR depression | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Large collection of fluid inside the pericardial sac (pericardial effusion) | *Large collection of fluid inside the pericardial sac (pericardial effusion) | ||
*Calcification of pericardial sac | *Calcification of pericardial sac | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ (Low grade) | | style="background: #F5F5F5; padding: 5px;" |✔ (Low grade) | ||
|style="background: #F5F5F5; padding: 5px;" |✔ (Relieved by sitting up and leaning forward) | | style="background: #F5F5F5; padding: 5px;" |✔ (Relieved by sitting up and leaning forward) | ||
|style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
|style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
|style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
|style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Infections: | *Infections: | ||
**Viral (Coxsackie virus, Herpes virus, Mumps virus, HIV) | **[[Viral]] (Coxsackie virus, [[Herpes simplex virus|Herpes virus]], [[Mumps virus]], [[Human Immunodeficiency Virus (HIV)|HIV]]) | ||
**Bacteria (Mycobacterium tuberculosis-common in developing countries) | **[[Bacteria]] ([[Mycobacterium tuberculosis]]-common in developing countries) | ||
**Fungal (Histoplasmosis) | **[[Fungal]] ([[Histoplasmosis]]) | ||
*Idiopathic in a large number of cases | *Idiopathic in a large number of cases | ||
*Autoimmune | *[[Autoimmune]] | ||
*Uremia | *[[Uremia]] | ||
*Malignancy | *[[Malignancy]] | ||
*Previous myocardial infarction | *Previous [[myocardial infarction]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*May be clinically classified into: | *May be clinically classified into: | ||
**Acute (< 6 weeks) | **Acute (< 6 weeks) | ||
| Line 147: | Line 149: | ||
**Chronic (> 6 months) | **Chronic (> 6 months) | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pneumonia]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pneumonia]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*On [[Computed tomography|CT scan]]: (not generally indicated) | |||
*Consolidation (alveolar/lobar pneumonia) | **[[Consolidation (medicine)|Consolidation]] ([[alveolar]]/lobar pneumonia) | ||
*Peribronchial nodules (bronchopneumonia) | **Peribronchial [[nodules]] ([[bronchopneumonia]]) | ||
*Ground-glass opacity (GGO) | **[[Ground glass opacification on CT|Ground-glass opacity]] (GGO) | ||
*Abscess | **[[Abscess]] | ||
*Pleural effusion | **[[Pleural effusion]] | ||
**On MRI: | **On [[MRI]]: | ||
*Not indicated | *Not indicated | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Prolonged PR interval | *Prolonged [[PR interval]] | ||
*Transient T wave inversions | *Transient [[T wave]] inversions | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Consolidation (alveolar/lobar pneumonia) | *[[Consolidation (medicine)|Consolidation]] ([[alveolar]]/lobar [[pneumonia]]) | ||
*Peribronchial nodules (bronchopneumonia) | *Peribronchial [[nodules]] (bronchopneumonia) | ||
*Ground-glass opacity (GGO) | *Ground-glass opacity (GGO) | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
|style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
|style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Ill-contact | *Ill-contact | ||
*Travelling | *Travelling | ||
*Smoking | *[[Smoking]] | ||
*Diabetic | *[[Diabetes mellitus|Diabetic]] | ||
*Recent hospitalization | *Recent hospitalization | ||
*Chronic obstructive pulmonary disease | *[[Chronic obstructive pulmonary disease]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Requires sputum stain and culture for diagnosis | *Requires [[Sputum|sputum stain]] and culture for diagnosis | ||
*Empiric management usually started before culture results | *[[Empiric therapy|Empiric management]] usually started before [[Culture collection|culture]] results | ||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Vasculitis]] | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Vasculitis]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*On CT scan: (Takayasu arteritis) | *On [[Computed tomography|CT scan]]: ([[Takayasu's arteritis|Takayasu arteritis]]) | ||
**Vessel wall thickening | **[[Blood vessel|Vessel]] wall thickening | ||
**Luminal narrowing of pulmonary artery | **Luminal narrowing of [[pulmonary artery]] | ||
**Masses or nodules (ANCA-associated granulomatous vasculitis) | **Masses or nodules ([[Anti-neutrophil cytoplasmic antibody|ANCA]]-associated granulomatous vasculitis) | ||
*On MRI: | *On [[Magnetic resonance imaging|MRI]]: | ||
Homogeneous, circumferential vessel wall swelling | Homogeneous, circumferential [[Blood vessel|vessel]] wall [[swelling]] | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Right or left bundle-branch block (Churg-Strauss syndrome) | *[[Bundle branch block|Right or left bundle-branch block]] ([[Churg-Strauss syndrome]]) | ||
*Atrial fibrillation (Churg-Strauss syndrome) | *[[Atrial fibrillation]] ([[Churg-Strauss syndrome]]) | ||
*Non-specific ST segment and T wave changes | *Non-specific [[ST interval|ST segment]] and [[T wave]] changes | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Nodules | *[[Nodule (medicine)|Nodules]] | ||
*Cavitation | *[[Cavitation]] | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |- | | style="background: #F5F5F5; padding: 5px;" | - | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" |✔ | | style="background: #F5F5F5; padding: 5px;" |✔ | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Takayasu arteritis usually found in persons aged 4-60 years with a mean of 30 | *[[Takayasu's arteritis|Takayasu arteritis]] usually found in persons aged 4-60 years with a mean of 30 | ||
*Giant-cell arteritis usually occurrs in persons aged > 60 years | *[[Giant-cell arteritis]] usually occurrs in persons aged > 60 years | ||
*Churg-Strauss syndrome may present with asthma, sinusitis, transient pulmonary infiltrates and neuropathy alongwith cardiac involvement | *[[Churg-Strauss syndrome]] may present with [[asthma]], [[sinusitis]], transient [[pulmonary]] infiltrates and neuropathy alongwith [[cardiac]] involvement | ||
*Granulomatous vasculitides may present with | *Granulomatous vasculitides may present with [[nephritis]] and [[upper airway]] ([[nasopharyngeal]]) destruction | ||
| style="background: #F5F5F5; padding: 5px;" | | |||
|- | |- | ||
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Chronic obstructive pulmonary disease]] (COPD) | | style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Chronic obstructive pulmonary disease]] (COPD) | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*On CT scan: | *On [[Computed tomography|CT scan]]: | ||
**Chronic bronchitis may show bronchial wall thickening, scarring with bronchovascular irregularity, fibrosis | **[[Chronic bronchitis]] may show [[bronchial]] wall thickening, scarring with bronchovascular irregularity, [[fibrosis]] | ||
**Emphysema may show alveolar septal destruction and airspace enlargement (Centrilobular- upper lobe, panlobular- lower lobe) | **[[Emphysema]] may show [[alveolar]] septal destruction and airspace enlargement (Centrilobular- upper lobe, panlobular- lower lobe) | ||
**Giant bubbles | **Giant bubbles | ||
* | *On [[MRI]]: | ||
**Increased diameter of pulmonary arteries | **Increased diameter of [[pulmonary arteries]] | ||
**Peripheral pulmonary vasculature attentuation | **Peripheral [[pulmonary]] [[vasculature]] attentuation | ||
**Loss of retrosternal airspace due to right ventricular enlargement | **Loss of retrosternal airspace due to right ventricular enlargement | ||
**Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung | **Hyperpolarized Helium MRI may show progressively poor ventilation and destruction of lung | ||
|style="background: #F5F5F5; padding: 5px;" | | | style="background: #F5F5F5; padding: 5px;" | | ||
*Multifocal atrial tachycardia (atleast 3 distinct P wave morphologies) | *[[Multifocal atrial tachycardia]] (atleast 3 distinct [[P waves|P wave]] morphologies) | ||
| style="background: #F5F5F5; padding: 5px;" | | |||
*Enlarged [[lung]] shadows ([[emphysema]]) | |||
*Flattening of [[diaphragm]] ([[emphysema]]) | |||
| style="background: #F5F5F5; padding: 5px;" |✔ | |||
| style="background: #F5F5F5; padding: 5px;" |✔ | |||
| style="background: #F5F5F5; padding: 5px;" | - | |||
| style="background: #F5F5F5; padding: 5px;" | - | |||
| style="background: #F5F5F5; padding: 5px;" | - | |||
| style="background: #F5F5F5; padding: 5px;" |✔ | |||
| style="background: #F5F5F5; padding: 5px;" |✔ | |||
| style="background: #F5F5F5; padding: 5px;" | - | |||
| style="background: #F5F5F5; padding: 5px;" | - | |||
| style="background: #F5F5F5; padding: 5px;" | - | |||
| style="background: #F5F5F5; padding: 5px;" | | |||
*[[Smoking]] | |||
*[[Alpha 1-antitrypsin deficiency|Alpha-1 antitrypsin deficiency]] | |||
*Increased [[sputum]] production ([[chronic bronchitis]]) | |||
*[[Cough]] | |||
| style="background: #F5F5F5; padding: 5px;" | | |||
*[[Alpha 1-antitrypsin deficiency|Alpha 1 antitrypsin deficiency]] may be associated with [[hepatomegaly]] | |||
|} | |} | ||
Latest revision as of 22:43, 19 February 2019
<figure-inline><figure-inline><figure-inline><figure-inline> </figure-inline></figure-inline></figure-inline></figure-inline> |
Resident Survival Guide |
Editor-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 must be distinguished from other life-threatening causes of chest pain including acute myocardial infarction, aortic dissection, and pericardial tamponade, as well as a large list of non-life-threatening causes of chest discomfort and shortness of breath.
Differential Diagnosis
Differential Diagnosis Based on Symptoms
Pulmonary embolism (PE) should be differentiated from other diseases presenting with chest pain, shortness of breath and tachypnea. The differentials include the following:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]
| Diseases | Diagnostic tests | Physical Examination | Symptoms | Past medical history | Other Findings | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CT scan and MRI | EKG | Chest X-ray | Tachypnea | Tachycardia | Fever | Chest Pain | Hemoptysis | Dyspnea on Exertion | Wheezing | Chest Tenderness | Nasalopharyngeal Ulceration | Carotid Bruit | |||
| Pulmonary embolism |
|
|
|
✔ | ✔ | ✔ (Low grade) | ✔ | ✔ (In case of massive PE) | ✔ | - | - | - | - |
|
|
| Congestive heart failure |
|
✔ | ✔ | ✔ | - | - | ✔ | - | - | - | - |
|
| ||
| Percarditis |
|
|
|
✔ | ✔ | ✔ (Low grade) | ✔ (Relieved by sitting up and leaning forward) | - | ✔ | - | - | - | - |
|
|
| Pneumonia |
|
|
|
✔ | ✔ | ✔ | ✔ | - | ✔ | ✔ | - | - | - |
|
|
| Vasculitis |
|
|
✔ | ✔ | ✔ | ✔ | ✔ | ✔ | - | ✔ | ✔ | ✔ |
|
||
| Chronic obstructive pulmonary disease (COPD) |
|
|
✔ | ✔ | - | - | - | ✔ | ✔ | - | - | - |
|
| |
Life Threatening Differential Diagnosis
Common Differential Diagnosis in Outpatients
Among outpatients presenting with dyspnea, <4 % are diagnosed with PE.[21] Common differential diagnoses include:[21]
Complete List of Differential Diagnosis
- Acute coronary syndrome
- Acute heart failure[21]
- Asthma acute exacerbation
- Acute respiratory distress syndrome
- Anemia
- Angina pectoris
- Anxiety disorders
- Aortic stenosis
- Atrial fibrillation (diagnosis and management)
- Bronchitis
- Cardiogenic shock
- Cardiac tamponade
- Chronic obstructive pulmonary disease exacerbation[21]
- Community acquired pneumonia[21]
- Cor pulmonale
- Costochondritis
- Dilated cardiomyopathy
- Distributive shock
- Emphysema
- Fat embolism
- Hemorrhagic shock
- Herpes zoster
- Hyperventilation
- Mediastinitis
- Mitral stenosis
- Musculoskeletal pain
- Myocardial infarction
- Myocardial ischemia
- Myocarditis
- Noncardiogenic pulmonary edema
- Pericarditis
- Pleuritis
- Pneumonia
- Pneumothorax
- Pulmonary hypertension, primary
- Pulmonary hypertension, secondary
- Restrictive cardiomyopathy
- Rib fracture
- Salicylate intoxication
- Septic shock
- Silicone pulmonary embolism[22]
- Sudden cardiac death
- Superior vena cava syndrome
- Syncope
- Toxic shock syndrome
- Trauma to the chest
- Unstable angina
References
- ↑ Brenes-Salazar JA (2014). "Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era". J Emerg Trauma Shock. 7 (1): 57–8. doi:10.4103/0974-2700.125645. PMC 3912657. PMID 24550636.
- ↑ "CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics".
- ↑ Bĕlohlávek J, Dytrych V, Linhart A (2013). "Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism". Exp Clin Cardiol. 18 (2): 129–38. PMC 3718593. PMID 23940438.
- ↑ "Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health".
- ↑ Ramani GV, Uber PA, Mehra MR (2010). "Chronic heart failure: contemporary diagnosis and management". Mayo Clin. Proc. 85 (2): 180–95. doi:10.4065/mcp.2009.0494. PMC 2813829. PMID 20118395.
- ↑ Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL (2008). "Symptom distress and quality of life in patients with advanced congestive heart failure". J Pain Symptom Manage. 35 (6): 594–603. doi:10.1016/j.jpainsymman.2007.06.007. PMC 2662445. PMID 18215495.
- ↑ Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ (2009). "Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology". Eur. J. Heart Fail. 11 (2): 130–9. doi:10.1093/eurjhf/hfn013. PMC 2639415. PMID 19168510.
- ↑ Takasugi JE, Godwin JD (1998). "Radiology of chronic obstructive pulmonary disease". Radiol. Clin. North Am. 36 (1): 29–55. PMID 9465867.
- ↑ Wedzicha JA, Donaldson GC (2003). "Exacerbations of chronic obstructive pulmonary disease". Respir Care. 48 (12): 1204–13, discussion 1213–5. PMID 14651761.
- ↑ Nakawah MO, Hawkins C, Barbandi F (2013). "Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome". J Am Board Fam Med. 26 (4): 470–7. doi:10.3122/jabfm.2013.04.120256. PMID 23833163.
- ↑ Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK (2010). "Pericardial disease: diagnosis and management". Mayo Clin. Proc. 85 (6): 572–93. doi:10.4065/mcp.2010.0046. PMC 2878263. PMID 20511488.
- ↑ Bogaert J, Francone M (2013). "Pericardial disease: value of CT and MR imaging". Radiology. 267 (2): 340–56. doi:10.1148/radiol.13121059. PMID 23610095.
- ↑ Gharib AM, Stern EJ (2001). "Radiology of pneumonia". Med. Clin. North Am. 85 (6): 1461–91, x. PMID 11680112.
- ↑ Schmidt WA (2013). "Imaging in vasculitis". Best Pract Res Clin Rheumatol. 27 (1): 107–18. doi:10.1016/j.berh.2013.01.001. PMID 23507061.
- ↑ Suresh E (2006). "Diagnostic approach to patients with suspected vasculitis". Postgrad Med J. 82 (970): 483–8. doi:10.1136/pgmj.2005.042648. PMC 2585712. PMID 16891436.
- ↑ Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW (1975). "The electrocardiogram in acute pulmonary embolism". Prog Cardiovasc Dis. 17 (4): 247–57. PMID 123074.
- ↑ Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML (2013). "Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease". COPD. 10 (1): 62–71. doi:10.3109/15412555.2012.727918. PMID 23413894.
- ↑ Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H (2012). "Electrocardiogram in pneumonia". Am. J. Cardiol. 110 (12): 1836–40. doi:10.1016/j.amjcard.2012.08.019. PMID 23000104.
- ↑ Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S (2015). "Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis". Int. J. Cardiol. 199: 170–9. doi:10.1016/j.ijcard.2015.06.087. PMID 26209947.
- ↑ Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S (2010). "Cardiac involvement in Churg-Strauss syndrome". Arthritis Rheum. 62 (2): 627–34. doi:10.1002/art.27263. PMID 20112390.
- ↑ 21.0 21.1 21.2 21.3 21.4 Squizzato A, Luciani D, Rubboli A, Di Gennaro L, Gennaro LD, Landolfi R; et al. (2013). "Differential diagnosis of pulmonary embolism in outpatients with non-specific cardiopulmonary symptoms". Intern Emerg Med. 8 (8): 695–702. doi:10.1007/s11739-011-0725-1. PMID 22094406.
- ↑ Restrepo CS, Artunduaga M, Carrillo JA, Rivera AL, Ojeda P, Martinez-Jimenez S; et al. (2009). "Silicone pulmonary embolism: report of 10 cases and review of the literature". J Comput Assist Tomogr. 33 (2): 233–7. doi:10.1097/RCT.0b013e31817ecb4e. PMID 19346851.