Pulmonary embolism (PE) is the occlusion of one or more pulmonary arteries by thrombi that originate elsewhere, typically in the large veins of the legs or pelvis. Risk factors for PE are conditions that impair venous return, conditions that cause endothelial injury or dysfunction, and underlying hypercoagulable states. Symptoms of PE are nonspecific and include dyspnea, pleuritic chest pain, and, in more severe cases, light-headedness, presyncope, syncope, or cardiorespiratory arrest. Signs are also nonspecific and may include tachypnea, tachycardia, and, in more severe cases, hypotension. Diagnosis of PE is with CT angiography, ventilation/perfusion scanning, or occasionally, pulmonary arteriography. Treatment is with anticoagulants and, sometimes, clot dissolution with thrombolytics or surgical removal. When anticoagulation is contraindicated, an inferior vena caval filter should be placed. Preventive measures include anticoagulants and/or mechanical compression of the legs in hospitalized patients.
Patients diagnosed with unprovoked PE should undergo age-appropriate screening for malignancy, and patients with recurrent emboli should have work-up for hypercoagulable states. In the case of this patient, age-appropriate screening was negative for malignancy. However, she was diagnosed with deep venous thrombosis in her left lower extremity 2 months later despite being therapeutic on warfarin. Work-up revealed iliac vein compression from an enlarged uterus, and she underwent hysterectomy with no recurrent events.
See Pulmonary embolism (PE) in The Manuals for more details.
References
Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 1997; 350:1795.
Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003; 349:1227.
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