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The patient’s history reveals any predisposing conditions for pulmonary embolism. The following diagnostic tests are also helpful:
❑ Chest X-ray helps to rule out other pulmonary diseases; it also shows areas of atelectasis, an elevated diaphragm, pleural effusion, a prominent pulmonary artery and, occasionally, the characteristic wedge-shaped infiltrate suggestive of pulmonary infarction.
❑ Spiral computed tomography scan may identify a thrombus in the pulmonary vasculature.
❑ Lung scan shows perfusion defects in areas beyond occluded vessels; however, it doesn’t rule out microemboli.
❑ Pulmonary angiography is the most definitive test but requires a skilled angiographer and radiologic equipment; it also poses some risk to the patient. Its use depends on the uncertainty of the diagnosis and the need to avoid unnecessary anticoagulant therapy in high-risk patients.
❑ Electrocardiography (ECG) is inconclusive but helps distinguish pulmonary embolism from myocardial infarction. In extensive embolism, the ECG may show right-axis deviation; right bundle-branch block; tall, peaked P waves; ST-segment depression and T-wave inversions (indicating right heart strain); and supraventricular tachyarrhythmias.
❑ Auscultation occasionally reveals a right-sided ventricular S3 gallop and increased intensity of the pulmonic component of S2. Also, crackles and a pleural rub may be heard at the site of embolism.
❑ Arterial blood gas (ABG) analysis showing decreased partial pressures of arterial oxygen and carbon dioxide are characteristic but don’t always occur.
If pleural effusion is present, thoracentesis may rule out empyema, which indicates pneumonia.
CLINICAL TIP: When the patient’s condition is stabilized, a thorough diagnostic evaluation for hematologic hypercoagulability should be performed.
Source: Handbook of Diseases, 2003
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