Pulmonary embolism: clinical findings were not very helpful for diagnosis.

Clinical bottom line (level 1b)

  1. Around a fifth of patients with pleuritic pain had a pulmonary embolism.
  2. No individual clinical sign or symptom was good enough to rule in or rule out pulmonary embolism. Thus clinicians need a high level of suspicion to consider it as a diagnosis and further tests are needed.
Hull et al: Archives of Internal Medicine 1988; 148: 838-844
Expires October 2003

The study

Setting: emergency departments, two hospitals, Canada

173 patients (aged range 17 to 88 years; mean 47, 55% female) consecutive outpatients with pleuritic chest pain

Excluded if
  • dye allergy
  • critically ill with known primary cardiorespiratory disorder



    • Independent blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
    Reference standard:
    • Either of
      • v/q scan - if abnormal had pulmonary angiogram within 72 hours
      • autopsy
      No PE if normal v/q scan and negative angiogram.
    Diagnostic test:
    • history and physical and chest X-ray by one physician
    • IPG, if positive confirmed by venogram

    The evidence

    pre-test probability of pulmonary embolism: 21%, (95% CI: 15% to 27%)

    diagnostic test pulmonary embolism no pulmonary embolism LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    initial symptoms: 40 years old or more 30 76 1.5
    (1.2 to 1.9)     		28% 0.37
    (0.18 to 0.80)     		9%
    central chest pain 3 21 0.5
    (0.17 to 1.7)     		13% 1.1
    (0.96 to 1.2)     		22%
    dyspnoea at rest 22 65 1.3
    (0.94 to 1.8)     		25% 0.74
    (0.48 to 1.2)     		16%
    dyspnoea on mild-to-moderate exertion 28 73 1.5
    (1.2 to 1.9)     		28% 0.48
    (0.25 to 0.90)     		11%
    haemoptysis 8 21 1.5
    (0.70 to 3.0)     		28% 0.92
    (0.76 to 1.1)     		19%
    syncope 3 6 1.9
    (0.50 to 7.2)     		33% 0.96
    (0.86 to 1.1)     		20%
    pleural friction rub 5 13 1.5
    (0.56 to 3.8)     		28% 0.95
    (0.83 to 1.1)     		20%
    raised jugular venous pressure 1 5 0.8
    (0.09 to 6.3)     		17% 1.0
    (0.94 to 1.1)     		21%
    central cyanosis 1 4 1.0
    (0.11 to 8.3)     		20% 1.0
    (0.94 to 1.1)     		21%
    respiratory rate > 20 per min 27 62 1.7
    (1.3 to 2.2)     		30% 0.46
    (0.25 to 0.82)     		11%
    use of accessory muscles 6 15 1.5
    (0.64 to 3.6)     		29% 0.94
    (0.80 to 1.1)     		20%
    chest wall tenderness 4 28 0.5
    (0.20 to 1.5)     		13% 1.1
    (0.97 to 1.3)     		23%
    left parasternal heave 0 1 0.0
    ( to )     		0% 1.0
    (0.99 to 1.0)     		21%
    abnormal chest examination 22 63 1.3
    (0.97 to 1.8)     		26% 0.72
    (0.46 to 1.1)     		16%
    total 36 137


    diagnostic test pulmonary embolism no pulmonary embolism LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    other findings: history of DVT 9 21 1.6
    (0.82 to 3.3)     		30% 0.89
    (0.72 to 1.1)     		19%
    history of PE 5 15 1.3
    (0.49 to 3.3)     		25% 0.97
    (0.84 to 1.1)     		20%
    surgery in last 6 months 12 26 1.8
    (0.99 to 3.1)     		32% 0.82
    (0.64 to 1.1)     		18%
    pelvic surgery 4 10 1.5
    (0.51 to 4.6)     		29% 0.96
    (0.85 to 1.1)     		20%
    other surgery 8 16 1.9
    (0.89 to 4.1)     		33% 0.88
    (0.73 to 1.1)     		19%
    cancer 8 8 3.8
    (1.5 to 9.4)     		50% 0.83
    (0.69 to 0.99)     		18%
    inflammatory or infectious condition 6 18 1.3
    (0.54 to 3.0)     		25% 0.96
    (0.82 to 1.1)     		20%
    ischaemic heart disease 7 24 1.1
    (0.52 to 2.4)     		23% 0.98
    (0.82 to 1.2)     		20%
    COPD 3 13 0.9
    (0.26 to 2.9)     		19% 1.0
    (0.91 to 1.1)     		21%
    CCF 2 6 1.3
    (0.27 to 6.0)     		25% 0.99
    (0.91 to 1.1)     		21%
    temperature > 38 C 0 3 0.0
    ( to )     		0% 1.0
    (1.0 to 1.1)     		21%
    white cell count >10 19 42 1.7
    (1.2 to 2.6)     		31% 0.68
    (0.47 to 0.98)     		15%
    abnormal chest X-ray 24 58 1.6
    (1.2 to 2.1)     		29% 0.58
    (0.36 to 0.94)     		13%
    IPG positive 10 3 13
    (3.7 to 44)     		77% 0.74
    (0.60 to 0.91)     		16%
    total 36 137


    diagnostic test pulmonary embolism no pulmonary embolism LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    predisposing factor 23 61 1.3
    (0.98 to 1.8)     		27% 0.67
    (0.40 to 1.1)     		16%
    predisposing factor or suspected DVT 26 70 1.3
    (1.0 to 1.6)     		27% 0.58
    (0.30 to 1.1)     		14%
    predisposing factor, suspected DVT, or pleural effusion 29 74 1.4
    (1.1 to 1.7)     		28% 0.39
    (0.17 to 0.92)     		10%
    in patients < 40 predisposing factor, suspected DVT, or pleural effusion 5 36 1.6
    (1.3 to 1.9)     		12% 0.0
    (0.0 to 0.71)     		0%
    in patients 40 or more, predisposing factor, suspected DVT, or pleural effusion 24 38 1.3
    (1.0 to 1.7)     		39% 0.46
    (0.19 to 1.1)     		18%
    total 34 118

    • predisposing factor:
      • history of recent surgery or trauma
      • cancer
      • CCF
      • oral contraceptive use
      • pregnancy
      • history of venous thromboembolism

    Comments

    1. No individual clinical sign or symptom was found to be useful.

    Citation

    1. Hull RD, Raskob GE, Carter CJ, et al: Pulmonary embolism in outpatients with pleuritic chest pain. Archives of Internal Medicine 1988; 148: 838-844
    Contributor: Chris Ball and Clare Wotton, October 2000
    Reviewer:

    Clinical Question.
    Patient pleuritic pain
    Intervention or Exposure clinical signs and symptoms
    Outcome diagnosis of pulmonary embolism