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]

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.

The patient may appear anxious due to difficulty breathing. More severe cases may be associated with cyanosis.

• The patient may have a low grade fever

• Tachycardia is present in 26% of the cases.^[2]

• The pulse is regular.

• The pulse may be weak if the patient is in shock.

• The pulses are symmetric.

• 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.

• 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]

• Cyanosis may be present in the setting of massive pulmonary embolism.
• Edema may be present in case of right heart failure.

• Jugular venous distension may be seen in cases of massive pulmonary embolism.

• Parasternal heave secondary to the development of right ventricular failure may be present in massive PE.

• 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.

• 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.

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

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%).

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