Pulmonary embolism physical examination: Difference between revisions
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| [[File:Siren.gif|30px|link=Pulmonary embolism resident survival guide]]|| <br> || <br> | |||
| [[Pulmonary embolism resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | |||
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{{Pulmonary embolism}} | {{Pulmonary embolism}} | ||
'''Editor(s)-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com], {{ATI}}; {{AE}} {{Rim}} | '''Editor(s)-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com], {{ATI}}; {{AE}} {{Rim}} | ||
==Overview== | ==Overview== | ||
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> 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]]. | [[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]]. | ||
==Physical Examination== | ==Physical Examination== | ||
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=====Strength===== | =====Strength===== | ||
*The pulse may be weak if the patient is in shock. | *The pulse may be weak if the patient is in [[shock]]. | ||
=====Symmetry===== | =====Symmetry===== | ||
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====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 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> | *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=== | ||
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===Neck=== | ===Neck=== | ||
*[[Jugular venous pressure#Assessment of Jugular Venous Distention|Jugular venous distension]] may be seen in cases of massive pulmonary embolism. | *[[Jugular venous pressure#Assessment of Jugular Venous Distention|Jugular venous distension]] may be seen in cases of massive [[pulmonary embolism]]. | ||
===Heart=== | ===Heart=== | ||
====Inspection==== | ====Inspection==== | ||
*[[Parasternal heave]] secondary to the development of [[right ventricular failure]] may be present in massive PE. | *[[Parasternal heave]] secondary to the development of [[right ventricular failure]] may be present in massive [[PE]]. | ||
====Auscultation==== | ====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> | *[[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]]. | *[[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]]. | * [[Graham-Steell murmur]] is suggestive of [[pulmonary regurgitation]]. | ||
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* [[Crackles]] may be present. | * [[Crackles]] may be present. | ||
* [[Pleural friction rub]] 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. | ||
===Extremities=== | ===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> | 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 [[tenderness]] | ||
* Unilateral calf or thigh [[pitting edema]] | * Unilateral calf or thigh [[pitting edema]] | ||
* Unilateral calf or thigh swelling | *Unilateral calf or thigh swelling | ||
* Difference in calf diameters > 3 cm (the calf circumference is measured 10 cm below the tibial tuberosity) | * 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) | * Difference in thigh diameters (the thigh circumference is measured 10-15 cm above the [[patella]]) | ||
* Unilateral calf or thigh warmth | * Unilateral calf or thigh warmth | ||
* Unilateral calf or thigh [[erythema]] | * Unilateral calf or thigh [[erythema]] | ||
* Palpable cord (a thickened palpable vein suggestive of [[vein thrombosis|thrombosed vein]]) | * Palpable cord (a thickened palpable vein suggestive of [[vein thrombosis|thrombosed vein]]) | ||
* Dilatation of unilateral collateral [[superficial veins]] | * Dilatation of [[unilateral]] collateral [[superficial veins]] | ||
* Localized tenderness upon palpation of the [[deep veins]] | * Localized [[tenderness]] upon palpation of the [[deep veins]] | ||
** Posterior calf | ** [[Posterior]] calf | ||
** Popliteal fossa | ** [[Popliteal fossa]] | ||
** Inner anterior thigh | ** Inner [[anterior]] thigh | ||
==Supportive Trial Data== | ==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> | 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%), | *[[Tachypnea]] (~54%), | ||
*[[DVT|Signs of deep venous thrombosis]] (~47%), | *[[DVT|Signs of deep venous thrombosis]] (~47%), | ||
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==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Hematology]] | [[Category:Hematology]] | ||
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[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Intensive care medicine]] | [[Category:Intensive care medicine]] | ||
Latest revision as of 23:53, 29 July 2020
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Pulmonary embolism physical examination On the Web |
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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: 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.