Algorithm for Evaluation of Suspected Pulmonary Embolism 2. A chest radiograph with normal findings in a 64-year-old woman who presented with worsening breathlessness. ‘Pulmonary embolism: an often forgotten differential diagnosis for abdominal pain’ G Y Kang, G Y Kang Department of Cardiology, The Fifth People’s Hospital of Dongguan (also called Taiping People's Hospital of Dongguan) , The Dongguan Affiliated Hospital of Medical College of Jinan University, Dongguan, Guangdong, China. [Medline]. Bauersachs R, Berkowitz SD, Brenner B, Buller HR, Decousus H, Gallus AS, et al. 1986 Jul. Several factors increase patient susceptibility to thrombus formation. Tick LW, Nijkeuter M, Kramer MH, Hovens MM, Büller HR, Leebeek FW, et al. 185(1):135-49. To reach the lungs, thromboemboli travel through the right side of the heart. Aksay E, Yanturali S, Kiyan S. Can elevated troponin I levels predict complicated clinical course and inhospital mortality in patients with acute pulmonary embolism?. 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Lower-extremity venogram shows outlining of an acute deep venous thrombosis in the popliteal vein with contrast enhancement. Diagnosis. Far left, after stent placement, image shows wide patency and rapid flow through the previously obstructed region. Once pulmonary embolism is suspected in the differential diagnosis, it should be excluded for the sake of patient’s health and safety. 1997 May-Jun. 163 (9):701-11. Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. 2013 Jul 2. 345:e6564. [Full Text]. [Medline]. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. 1993 Mar. [Medline]. 2007 Jan. 242(1):15-21. Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, et al. Circulation. [Medline]. Takayasu arteritis 3. misidentification of pulmonary veins for arteries 4. arterial bifurcations (or branchpoints) can mimic PE but usually easily distinguished on multiplanar assessment 5. artifact may cause pseudofilling defects and can be caused by 5.1. breathing motion 5.2. beam hardening 5.2.1. hyperconcentrated contrast in the superior vena cava 5.2.2. medical devices e.g. Kuklina EV, Meikle SF, Jamieson DJ, Whiteman MK, Barfield WD, Hillis SD, et al. [Medline]. Schulman S, Kearon C, Kakkar AK, Mismetti P, Schellong S, Eriksson H, et al. Thromb Res. [Medline]. [Guideline] Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. 2012 Apr. Prognostic value of plasma lactate levels among patients with acute pulmonary embolism: the thrombo-embolism lactate outcome study. Curr Opin Hematol. Fibrinolysis of pulmonary emboli--steer closer to Scylla. 2009 Mar 26. 2011 Jan. 29(1):26-32. Clin Chest Med. 366(14):1287-97. 2006 Dec. 98(12):1967-72. [Medline]. Posteroanterior and lateral chest radiograph findings are normal, which is the usual finding in patients with pulmonary embolism. Ward MJ, Sodickson A, Diercks DB, Raja AS. Middle left, after 12 hours of catheter-directed thrombolysis, an obstruction at the left common iliac vein is evident. 178(4):425-30. [Medline]. Garcia D, Ageno W, Libby E. Update on the diagnosis and management of pulmonary embolism. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Gibson CM, Chi G, Halaby R, Korjian S, Daaboul Y, Jain P, et al. Blood Adv. among the major differential diagnoses to consider in the patient with dyspnea are the following: Airway Obstruction; Asthma; Chronic obstructive pulmonary disease (COPD) Mechanical obstruction (foreign body, tumore) Obstructive sleep apnea; Infection [Medline]. [Medline]. [Medline]. 39(4):919-26. Bernstein D, Coupey S, Schonberg SK. High D-dimer levels increase the likelihood of pulmonary embolism. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMzAwOTAxLWRpZmZlcmVudGlhbA==. 119(6):699-703. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. 2013 Sep 23. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction. Am J Med. 2000 Nov 1. 2011 Jun. Eur Respir J. Such missed diagnoses occur in approximately 400,000 patients in the United States per year; approximately 100,000 deaths could be prevented with proper diagnosis and treatment. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). 1995 Dec. 36(12):2380-7. [Medline]. [Medline]. Multidetector computed tomography for acute pulmonary embolism: diagnosis and risk stratification in a single test. Alonso-Martínez JL, Urbieta-Echezarreta M, Anniccherico-Sánchez FJ, Abínzano-Guillén ML, Garcia-Sanchotena JL. Nuss R, Hays T, Chudgar U, Manco-Johnson M. Antiphospholipid antibodies and coagulation regulatory protein abnormalities in children with pulmonary emboli. Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, et al. Minor forms of pulmonary embolism after abdominal operations. [Medline]. [Medline]. 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], Homogeneous, circumferential vessel wall swelling, Among outpatients presenting with dyspnea, <4 % are diagnosed with PE. This ultrasonogram shows a thrombus in the distal superficial saphenous vein, which is under the artery. 8(3):339-49. Differential diagnosis, Diagnosis, Pulmonary embolism, CKS. Sequential images demonstrate treatment of iliofemoral deep venous thrombosis due to May-Thurner (Cockett) syndrome. [Medline]. The superficial femoral vein (lateral vein) has the appearance of 2 parallel veins, when in fact, it is 1 lumen containing a chronic linear thrombus. 2008 Mar 6. [Medline]. Stein PD, Matta F. Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. Share cases and questions with Physicians on Medscape consult. Pulmonary Embolism Presenting as Flank Pain: A Case Series. N Engl J Med. The PIOPED Investigators. Many patients receiving … [Medline]. Am J Med. Diagnosis of PAS is challenging, since it can be difficult to distinguish from a pulmonary embolism. 2011 Jul 4. Vichinsky EP, Neumayr LD, Earles AN, Williams R, Lennette ET, Dean D, et al. [Medline]. Prognostic value of ECG among patients with acute pulmonary embolism and normal blood pressure. 2015 Nov 3. [Medline]. 15(1):R23. [Full Text]. [Medline]. Becattini C, Vedovati MC, Agnelli G. Diagnosis and prognosis of acute pulmonary embolism: focus on serum troponins. 154(11):709-18. Basic Pathology. This perfusion scan shows bilateral perfusion defects. 135 (7):648-655. 2008 May. J Pediatr Hematol Oncol. Spyropoulos AC, Ageno W, Albers GW, Elliott CG, Halperin JL, Hiatt WR, et al. 121(3):877-905. Stasis is often considered the most prominent factor, which, in conjunction with either vessel damage or hypercoagula… 2010 Dec. 17(12):1543-9. . The diagnostic challenge is that the "classic" presentation of the condition, with abrupt onset of pleuritic chest pain, shortness of breath, and hypoxia, is rarely seen. [Medline]. J Nucl Med. [Full Text]. 2011 May 24. /viewarticle/927356 Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis. Ann Emerg Med. Pulmonary embolism in pediatric patients survey of CT pulmonary angiography practices and policies. [Full Text]. (Right and left are reversed.). CTPA is the reference standard for the diagnosis of acute PE.. Computed tomography angiogram in a 53-year-old man with acute pulmonary embolism. 61(3):330-8. 311(23):2414-21. Eur Respir J. 2012 Jun. 336(20):1422-7. Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Philadelphia, Pa: WB Saunders; 1997:. Chest. 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