And then we wanna think about our focus history.
So in our focus history we wanna think about risk factors,
family history and then any prior history.
So what are the risk factors?
One of the key risk factors is immobilization.
So has the patient been hospitalized?
Have they been lying in bed because they've another kind of an injury?
Did they recently have surgery?
Classically after surgery or during hospitalization,
patients will get DVT prophylaxis.
So they’ll get either things on their legs that squeeze their legs
that prevent the DVT, they’ll get injections of Lovenox
or low-molecular-weight heparin in their abdomen.
So there’s things that can be done during those period of immobility
that can prevent DVT but they’re not always 100% effective.
And people aren’t always totally compliant with those treatments.
The other thing that sometimes people associate in immobilization is very long plane flights.
So patients who get on a plane they sit in their seat for a long period of time,
they don’t get up to use the bathroom, that technically is a period of immobilization.
So I always ask about whether or not people who’ve been in long flights.
You know, this doesn’t matter like, did you fly on a short 2-hour flight?
It’s more of those kind of longer distance, longer haul kind of experiences.
And I have actually taking care of a patient
who after on a very long flight did in fact develop a pulmonary embolus.
So asking about that, and immobilization are key things to do.
Also you wanna think about estrogen and a state of pregnancy.
So is the patient on any oral contraceptive agents?
You know, not all oral contraceptive agents contain estrogen,
but a large proportion of them do.
Also patients when they're in a post-menopausal
sometimes will take estrogen replacement therapy.
So you wanna kind of try and get that information out of someone.
Patients who are pregnant have a higher estrogenic state.
In order to maintain the pregnancy the body secretes more estrogen and the placenta does.
And in the state of pregnancy, patients will have elevated estrogen level.
So that’s another risk factor. And then lastly malignancy.
Malignancies can predispose patients to clotting
and also you may have some of that immobility that takes place as well.
So asking about any history of cancer
or any currently active treated cancer can help you make this diagnosis.
Family history of clotting disorders is also very important to ask about.
So you wanna ask about, I generally say first degree relatives.
So mother, father, brothers or sisters that potentially have had any kind of clotting.
This is something that really can,
kind of sway me one way or the other
about what I’m gonna do for additional diagnostic testing.
So keeping that in mind, is there any family history of clotting?
And then for the patient, have they ever had a DVT or pulmonary embolus before?
And some of these situations especially in our current situation,
patients are generally maintain on life-long anti-coagulation
But in this situation sometimes patients are only advised
to take these medications for shorter periods of time
especially on what we call a provoked PE
So provoked PE is something that develop during hospitalization or after a surgery.
And in those situations they might have the patient
only take the anti-coagulation medication for a period of time and then they stop it.
So asking about if the patients has ever had a DVT
or pulmonary embolus before can help steer you again
to figure out what diagnostic testing to get.
And on your physical exam it’s very important to remember
that the exam findings can be very non-specific.
You might not have anything that kind of jumps out to you on your exam.
You wanna think about tachycardia, is the patient’s heart rate fast?
Unexplained tachycardia in the patient in the emergency department
should always prompt you to rethinking pulmonary embolus.
Unexplained tachycardia is one of those things
that we’re always thinking about, always saying why is the patient’s heart rate fast?
Especially, if you can’t find another etiology like a fever, or pain.
You wanna think about PE.
The lung exam generally patients will have clear lungs,
so you’ll listen to their lungs , you won’t hear anything very exciting.
It’s important to remember there have been some studies out there
that show that there’s an association with COPD,
so patients who are being admitted to the hospital and pulmonary embolus.
So those patients potentially may have wheezing in their lungs.
But clear lungs is one of the most common findings for patients with pulmonary embolus.
You wanna examine their lower extremities
Do they have any leg swelling or tenderness?
Tenderness in the posterior portion of the calf is what we call Homan’s sign.
So if you go ahead and you squeeze the back portion of the patient’s legs
and it hurts them, that could be denoted as a positive Homan’s sign.
Now classically you’re looking for swelling in one of the legs versus the other.
But you can definitely go ahead and think about swelling in both legs
could potentially be a presentation of a DVT as well.
So you wanna make sure you’re taking note of that.
Patients may also have chronic legs swelling.
So you wanna think about that as well.
So how do we make the diagnosis?
So we’ve taken our history, we’ve ask all of those important questions.
We‘ve figured out if patients has risk factors.
You wanna do your physical exam.
Again, the physical exam may not potentially help you that much here.
The leg swelling I would say would be the one thing that will help you the most.
But the patient may not have anything that jumps out on you in terms of physical examination.
Then we wanna think about our diagnostics and our decision roles.
And this is really the thing that I think helps the most
when we’re thinking about pulmonary embolus.