Pulmonary embolism history and symptoms

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]

A proper history and physical exam is crucial to establish an accurate diagnosis of pulmonary embolism (PE). The symptoms of pulmonary embolism (PE) depend on the severity of the disease, ranging from mild dyspnea, chest pain, and cough, to sustained hypotension and shock.^[1][2] A PE may also be an incidental finding in so far as many patients are asymptomatic.^[2][3] Sudden death can be the initial presentation of PE. One of the first steps in the management of PE is the determination of the Wells score for PE, whose criteria can be ascertained solely on the basis of history and physical exam. Symptoms of DVT of the lower extremity may be present.

As depicted in the image below, the majority of patients with venous thromboembolism (VTE), that is DVT, PE, or both, are asymptomatic.

The Prospective Investigation Of Pulmonary Embolism Diagnosis II (PIOPED II) study identified the triad of symptoms, dyspnea, chest pain, and tachypnea, present in a majority of patients with a confirmed pulmonary embolism.^[1][4] Symptoms of PE include:

• Dyspnea (78–81%)^[5]
  
• Pleuritic chest pain (39–56%)^[5]
  
• Fainting (22–26%)^[5]
  
• Cough (20%)^[6]
  
• Substernal chest pain (12%)^[6]
  
• Hemoptysis (11%)^[6]
  
• Wheezing
  
• Cyanosis (11%)^[5]
  
• Fever (7%)^[5]
  
• Symptoms suggestive of shock (in case of massive PE)
  • Altered mental status
  • Cold extremities
  • Cyanosis
  • Oliguria
• Sudden death may be the initial presentation of PE.

Since VTE involves both DVT and PE, the patient can present with complaints of either of the diseases. Therefore it is important to inquire about the symptoms of both diseases.

The classical symptoms of DVT include:

• Pain in the affected area
• Swelling of the affected area
• Erythema around the affected area
• Dilation of the surface veins and erythema of the overlying area

However, sometimes there may be no symptoms referable to the location of the DVT.

• Front View:Edematous Right Leg
  Front View:Edematous Right Leg
• Rear View:Left limb edema localized to calf.
  Rear View:Left limb edema localized to calf.
• Front View:Left limb edema localized to calf.
  Front View:Left limb edema localized to calf.

• In phlegmasia alba dolens, the leg is pale and cold with a diminished arterial pulse.

• In phlegmasia cerulea dolens, there is an acute and near-total venous occlusion of the entire extremity outflow, including the iliac and femoral veins. The leg is usually painful, cyanosed and edematous.

If VTE is suspected or diagnosed, a complete history should be elicited, including the following:

• Risk factors^[7][6]
  • Chemotherapy
    
  • Chronic heart failure
    
  • Respiratory failure
    
  • Hormone replacement therapy
    
  • Cancer
    
  • Oral contraceptive pills
    
  • Stroke
    
  • Pregnancy
    
  • Postpartum
    
  • Prior history of VTE
    
  • Thrombophilia
    
  • Advanced age
    
  • Laparoscopic surgery
    
  • Prepartum
    
  • Obesity
    
  • Varicose veins
• Triggers^[7][6]
  • Bone fracture (hip or leg)
    
  • Hip replacement surgery
    
  • Knee replacement surgery
    
  • Major general surgery
    
  • Significant trauma
    
  • Spinal cord injury
    
  • Athroscopic knee surgery
    
  • Central venous lines
    
  • Chemotherapy
    
  • Bed rest for more than 3 days
    
  • Prolonged car or air travel
    
  • Laparoscopic surgery
    
  • Prepartum
    
• Previous episode of VTE
  • Age
  • Location
• Past medical history of diseases associated with hyperviscosity
  • Atherosclerosis
  • Collagen vascular disease
  • Heart failure
  • Myeloproliferative disease
  • Nephrotic syndrome
  • Autoimmune diseases
  • Polycythemia vera
  • Hyperhomocysteinemia
  • Paroxysmal nocturnal hemoglobinuria
  • Waldenstrom macroglobulinemia
  • Multiple myeloma
• History of thrombophilia
  • Factor V Leiden mutation
  • Prothrombin gene mutation G20210A
  • Protein C or Protein S deficiency
  • Antithrombin (AT) deficiency
  • Antiphospholipid syndrome (APS)
• Abortion
  • Abortion at second or third trimester of pregnancy (suggestive of an inherited thrombophilia or APS)
• Drugs that may increase the risk of VTE
  • Hydralazine
  • Phenothiazine
  • Procainamide
  • Tamoxifen
  • Bevacizumab
  • Glucocorticoids
• Family history (suggestive of inherited thrombophilia)
  • Deep vein thrombosis
  • Pulmonary embolism
  • Recurrent miscarriage
• Social history
  • Heavy cigarette smoking (>25 cigarettes per day)
  • Intravenous drug use (if injected directly in femoral vein)
  • Alcohol

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