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Clinical Evaluation

PE. Clinical Evaluation. Presenting Complaint. Most common presenting complaint: dyspnoea Chest pain Syncope Cough Leg pain. HPC. Dyspnoea is sudden and unexplained Chest pain. Non pleuritic Pleuritic Syncope indicates a massive PE

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Clinical Evaluation

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  1. PE Clinical Evaluation

  2. Presenting Complaint • Most common presenting complaint: dyspnoea • Chest pain • Syncope • Cough • Leg pain

  3. HPC • Dyspnoea is sudden and unexplained • Chest pain. • Non pleuritic • Pleuritic • Syncope indicates a massive PE • Fever, diaphoresis, apprehension due to inflammation, possibly shock • Palpitations, tachycardia • Hemoptysis, cough • Signs of DVT

  4. Risk Factors • ?Prolonged immobilization (> 3 days) • Postoperative state • Trauma to lower extremities • Pregnancy and early puerperium • Cancer (lung, pancreas, alimentary and genitourinary tracts) • Trauma, burns • Advanced age (>60) • Obesity • Hematologic disease (e.g., antithrombin III deficiency, protein C deficiency, protein S deficiency, lupus anticoagulant, polycythemia vera, dysfibrinogenemia, paroxysmal nocturnal hemoglobinuria, factor V Leiden mutation, G20210A prothrombin mutation) • COPD, diabetes mellitus • Prolonged air travel • Oestrogen-containing birth control pills • Prior history of DVT or PE • CHF

  5. Examination • Pleuritic rub. Crackles, Tachypnoea • Cardiovascular changes following a massive PE: • Shock • Elevated JVP • Right ventricular heave (heel of hand is placed over left parasternal region and lifted off with each systole) • Mitral regurgitation • Increased S3 on inspiration (the galloping heart has a sound like the “Kentucky Derby”: Ken(S1)-tuck(S2)-y(S3) at the lower left sternal border and the –y increases with inspiration) • Loud, early P2 component (pulmonary valve closure) of S2 (in other words, the second heart sound (S2 made up of P2 and A2) is split because of early closure of the pulmonary valve (P2) ahead of the aortic valve (A2) due to increased pulmonary artery pressure caused by the embolism • Evidence of DVT (calf swelling, pain, inflammation).

  6. Determining the Pre-Test Probability • Risk score interpretation (probability of DVT): >6 points: high risk (78.4%); 2 to 6 points: moderate risk (27.8%); <2 points: low risk (3.4%)

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