Pulmonary Embolism – Clinical Features
1. Which of the following is the most common symptom of pulmonary embolism?
Cough
Dyspnea
Hemoptysis
Chest wall pain
Explanation: Dyspnea is the most common presenting symptom, occurring in over 80% of patients with PE.
2. Which clinical sign may indicate a large central pulmonary embolism?
Fever
Localized rales
Hematuria
Hypotension
Explanation: Hypotension is a serious sign often associated with massive or central PE due to right heart strain.
3. Which ECG finding is most specific for pulmonary embolism?
Left bundle branch block
ST elevation in V1–V3
S1Q3T3 pattern
Atrial fibrillation
Explanation: The S1Q3T3 pattern is classically associated with PE but occurs in a minority of cases.
4. What symptom strongly suggests a pulmonary infarct due to PE?
Sudden syncope
Orthopnea
Pleuritic chest pain with hemoptysis
Dry cough
Explanation: Pleuritic chest pain with hemoptysis suggests a peripheral embolus causing infarction.
5. Which physical finding suggests right ventricular strain in pulmonary embolism?
Bradycardia
Elevated jugular venous pressure
Clear lung fields
Muffled heart sounds
Explanation: JVP elevation is a sign of right heart strain, which can occur in large pulmonary emboli.
6. Which symptom in PE suggests massive embolism requiring urgent intervention?
Mild cough
Low-grade fever
Sudden syncope
Right-sided chest pain
Explanation: Syncope can indicate a large PE causing obstructive shock or severe right heart strain.
7. What is the significance of tachycardia in suspected PE?
It rules out PE
It suggests bronchospasm
It is unrelated
It supports PE diagnosis
Explanation: Sinus tachycardia is the most common ECG abnormality in PE and supports clinical suspicion.
8. Which finding is least likely in pulmonary embolism?
Tachypnea
Tachycardia
Pleuritic pain
Productive cough with purulent sputum
Explanation: Purulent sputum is more suggestive of pneumonia than PE, which usually causes hemoptysis if any.
9. Which physical sign may be seen in PE with pulmonary infarction?
Subcutaneous emphysema
Pleural rub
Egophony
Bronchial breath sounds
Explanation: Pleural rub indicates pleural irritation, which may occur with peripheral emboli causing infarction.
10. Which laboratory finding supports the diagnosis of PE?
Low D-dimer
Leukopenia
Low ESR
Elevated D-dimer
Explanation: Elevated D-dimer is a sensitive but nonspecific marker; a normal D-dimer may help exclude PE in low-risk patients.
11. Which auscultatory finding may be present in PE due to right heart strain?
Loud S1
S3 gallop
Loud P2
Opening snap
Explanation: A loud pulmonary component of the second heart sound (P2) suggests pulmonary hypertension and right heart strain, often seen in PE.
12. What is Westermark’s sign in PE?
Pleural effusion
Focal oligemia on chest X-ray
Hilar lymphadenopathy
Bilateral infiltrates
Explanation: Westermark’s sign is focal oligemia or decreased vascular markings distal to a PE, indicating pulmonary vessel occlusion.
13. Which of the following is true regarding pleuritic chest pain in PE?
It is rare in peripheral embolism
It radiates to the jaw
It is typically central and dull
It worsens with deep inspiration
Explanation: Pleuritic pain from PE worsens with inspiration and is more likely with peripheral emboli involving pleural surfaces.
14. Which sign on echocardiography suggests acute PE?
Left atrial dilation
Global LV hypokinesis
Right ventricular dilation and dysfunction
Mitral valve prolapse
Explanation: Acute PE can cause right ventricular strain, seen as RV dilation and hypokinesis on echocardiogram.
15. What does Hampton’s hump indicate in the context of PE?
Right heart enlargement
Wedge-shaped opacity on chest X-ray
Air bronchogram
Cavitation
Explanation: Hampton’s hump is a wedge-shaped opacity on CXR indicating pulmonary infarction due to PE.
16. Which of the following is most suggestive of a submassive PE?
Hypotension and syncope
Normal ECG
Normotension with RV dysfunction
Bradycardia with clear lungs
Explanation: Submassive PE refers to right ventricular dysfunction in the presence of normal systemic blood pressure.
17. Which condition should be considered in the differential diagnosis of PE?
Acute cholecystitis
Tension pneumothorax
Pancreatitis
Acute myocardial infarction
Explanation: MI often presents similarly with chest pain and dyspnea; it is a critical differential diagnosis when PE is suspected.
18. Which symptom is more likely in PE than in acute coronary syndrome?
Retrosternal dull pain
Pleuritic chest pain with dyspnea
Left arm radiation
Exertional jaw pain
Explanation: Pleuritic chest pain that worsens with inspiration and is associated with dyspnea is more typical of PE.
19. Which is a late sign of massive pulmonary embolism?
Tachycardia
Restlessness
Mild hypoxia
Cyanosis
Explanation: Cyanosis indicates severe hypoxemia and is a late and ominous sign of significant circulatory compromise.
20. What is the clinical implication of a normal chest X-ray in a hypoxic patient with dyspnea?
Suggests pneumonia
Rules out PE
Raises suspicion for PE
Indicates asthma
Explanation: A normal chest X-ray in a hypoxic patient is a red flag for PE and supports pursuing further evaluation like CT pulmonary angiography.
| # | Clinical Feature | Pulmonary Embolism — Key Notes |
|---|---|---|
| 1 | Dyspnea | Most common presenting symptom (>80%) |
| 2 | Pleuritic chest pain | Especially in peripheral embolism and infarction |
| 3 | Tachypnea | Most frequent sign on physical exam |
| 4 | Tachycardia | Most common ECG finding |
| 5 | Hemoptysis | Suggests pulmonary infarction |
| 6 | Syncope | May indicate massive PE |
| 7 | Hypotension | Seen in massive or central PE |
| 8 | Loud P2 | Suggests pulmonary hypertension from right heart strain |
| 9 | Jugular venous distension | Indicates right ventricular dysfunction |
| 10 | Pleural rub | Seen in PE with infarction near pleura |
| 11 | Westermark’s sign | Focal oligemia on chest X-ray |
| 12 | Hampton’s hump | Wedge-shaped opacity suggesting infarction |
| 13 | S1Q3T3 pattern | Classic but uncommon ECG finding |
| 14 | Clear lung fields on CXR | Often seen despite severe dyspnea |
| 15 | Elevated D-dimer | Supports diagnosis, especially in low-risk cases |
| 16 | Right ventricular dysfunction | Seen on echocardiography in submassive/massive PE |
| 17 | Respiratory alkalosis | Common arterial blood gas abnormality |
| 18 | Chest pain worsened by inspiration | Typical of pleuritic origin |
| 19 | Normal chest X-ray in hypoxia | Raises strong suspicion for PE |
| 20 | Cyanosis | Late and serious sign of severe hypoxemia |
Short-Answer Questions on Clinical Features in Pulmonary Embolism
- What clinical symptom is most frequently reported in patients with pulmonary embolism, and why is it significant diagnostically?
Answer: Dyspnea; it’s the most common and often the earliest presenting symptom, occurring in over 80% of cases. - How does pleuritic chest pain help localize the embolus in pulmonary embolism?
Answer: It suggests a peripheral embolus irritating the pleural lining, often associated with pulmonary infarction. - What is the implication of a normal chest X-ray in a patient with unexplained hypoxia?
Answer: It raises suspicion for PE, particularly in the absence of pneumonia, heart failure, or other common causes. - Describe the typical findings on ECG in a patient with PE and their significance.
Answer: Sinus tachycardia is most common; S1Q3T3 pattern, right axis deviation, or RBBB may suggest right heart strain. - Why might hemoptysis occur in PE and what does it suggest anatomically?
Answer: Due to pulmonary infarction caused by distal emboli involving bronchial circulation. - Which auscultatory heart sound change is suggestive of pulmonary hypertension secondary to PE?
Answer: Loud P2 (pulmonary component of second heart sound). - What is Hampton’s Hump and what does it signify on imaging?
Answer: A wedge-shaped opacity on chest X-ray indicating pulmonary infarction. - How is jugular venous distention interpreted in the context of PE?
Answer: It suggests acute right heart strain, typically due to massive or submassive embolism. - Which clinical feature differentiates pulmonary embolism from myocardial infarction in acute chest pain?
Answer: Pleuritic pain with dyspnea and no ECG evidence of ischemia suggests PE over MI. - Why is elevated D-dimer an important laboratory finding in PE evaluation?
Answer: It’s sensitive but not specific; helps exclude PE in low-risk patients if normal.
| Feature | Pulmonary Embolism (PE) | Myocardial Infarction (MI) | Pneumothorax | Pneumonia |
|---|---|---|---|---|
| Chest Pain Type | Pleuritic, sharp, sudden | Pressure-like, crushing, radiates to arm/jaw | Sided, sharp, sudden onset | Pleuritic, gradual onset |
| Dyspnea | Severe, sudden | Moderate, exertional | Acute, often unilateral | Gradual, with fever/cough |
| Cough | Dry or hemoptysis | Usually absent | Absent | Productive, purulent |
| Fever | Mild or absent | Occasional low-grade | Absent | Common, high-grade |
| Onset | Sudden | Gradual or exertion-related | Sudden | Progressive over days |
| Vital Signs | Tachycardia, tachypnea, hypoxia | Brady/tachycardia, hypotension | Decreased breath sounds, tracheal shift (if tension) | Fever, tachycardia, hypoxia |
| ECG Findings | S1Q3T3, sinus tachycardia | ST elevation, Q waves | Usually normal | Normal or sinus tachycardia |
| Chest X-ray | Often normal, Westermark/Hampton signs | Normal or pulmonary edema | Absent lung markings on affected side | Infiltrates, consolidation |
| Risk Factors | DVT, immobilization, OCP, cancer | HTN, DM, smoking, family history | Trauma, spontaneous in tall thin males | Infection, COPD, immunosuppression |
| Confirmatory Test | CT Pulmonary Angiogram | Troponin + ECG | Chest X-ray | Sputum + CXR |
