Intended for healthcare professionals

Practice Easily Missed?

Pulmonary embolism

51app 2024; 384 doi: (Published 08 February 2024) Cite this as: 51app 2024;384:e071662
  1. Brandon C Maughan, associate professor1,
  2. Angela F Jarman, assistant professor2,
  3. Alexa Redmond, medical student3,
  4. Geert-Jan Geersing, general practitioner and associate professor4,
  5. Jeffrey A Kline, professor and vice chair of research5
  1. 1Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
  2. 2Department of Emergency Medicine, University of California Davis, Sacramento, CA
  3. 3Oregon Health and Science University, Portland, OR
  4. 4Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
  5. 5Department of Emergency Medicine, Wayne State School of Medicine, Detroit, MI
  1. Correspondence to B Maughan maughabr{at}ohsu.edu

What you need to know

  • Diagnosis of pulmonary embolism (PE) is frequently missed. An estimated 12-36% of patients with PE are misdiagnosed during initial evaluation in emergency departments or primary care clinics

  • Delayed and missed diagnoses are more common in older adults, in patients with chronic cardiopulmonary disease, those with low pre-test risk of PE, and in patients presenting with cough or gradual onset dyspnoea. Most patients with PE have no symptoms of deep vein thrombosis, and many have no chest pain.

  • Using D-dimer thresholds adjusted for age or probability may reduce false positive results and rates of computed tomography pulmonary angiography scans.

A 71 year old woman with hypertension, coronary artery disease, and heart failure presents to her GP with fatigue and breathlessness at rest over the past 10 days. She reports a mild non-productive cough and occasional sore throat during this time, and says that deep breaths make her chest feel “heavy.” She has had no fever, chest pain, abdominal pain, leg pain, or other abnormal symptoms apart from a brief episode of near syncope a few days ago that resolved without intervention. Her heart rate is 96 beats/min, blood pressure 148/78, respiratory rate 22 breaths/min, and she has an oxygen saturation level of 92% on room air; she is afebrile.

On examination, she has mild tachypnoea but no jugular venous distension, no cardiac murmur, and normal lung sounds. She has trace swelling of both lower legs and normal distal pulses. An electrocardiogram (ECG) shows sinus rhythm without evidence of ischaemia. Point-of-care tests for covid-19 and influenza are both negative. The clinician suspects the patient may have mild heart failure or a viral bronchitis and advises her to double her furosemide dose over the next three days.

The woman calls the clinic four days later with continued breathlessness. She is referred to the …

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