PE
Age: years old
Gender:
HISTORY:
Presents with a - history of sudden onset of
Symptoms include:
, , , ,
,
Worsening factors:
Alleviating factors: ,
Contributing factors:
no history of: , , , ,
no use of: , ,
no family history of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Chest: on
Breasts: , ,
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: pulmonary embolism, musculoskeletal pain, right heart strain, chronic thromboembolic pulmonary hypertension, pneumonia, heart failure, acute coronary syndrome, pericarditis, tamponade, pulmonary hypertension, asthma exacerbation, COPD exacerbation, pleural effusion, pneumothorax, rib fracture, costochondritis, anxiety/panic disorder
PLAN:
Investigations:
- Blood work: , , , , ,
- Chest X-ray
- CT pulmonary angiogram
- V/Q scan
- ECG
- Echocardiogram
- Lower limb venous doppler ultrasound
- Cardiac monitoring
Treatments:
-
- if signs of massive PE
- Oxygen to maintain SpO2 > 92%
Further care:
- Referral to pulmonologist
- Referral to hematologist
- Referral to internist
- Investigation of underlying cause (maligancy, thrombophilia)
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as chest pain, shortness of breath, or fainting
- Referral to ER if severe chest pain, severe shortness of breath, or fainting occurs
HISTORY: EXAM: ASSESSMENT: PLAN: