Clinical features

• Pleuritic-type chest pain, dyspnoea, ± haemoptysis.

• The patient with a major embolus often prefers to lie flat. Dyspnoea improves due to increased venous return and right heart loading.

• Deterioration in gas exchange — may find a low PaO2 low or high PaCO2 and a metabolic acidosis. However, these .ndings are inconsistent and non-diagnostic.

• Cardiovascular features, e.g. tachycardia, low/high BP and collapse.

• CXR: may be normal but a massive embolus may produce fewer vascular markings (pulmonary oligaemia) in a hemithorax ± a bulging pulmonary hilum. A wedge-shaped peripheral pulmonary infarct may be seen after a few days following a smaller embolus.

• ECG: acute right ventricular strain, i.e. S1 Q3T3, tachycardia, right axis deviation, right bundle branch block, P pulmonale.

• Echocardiogram: may reveal evidence of pulmonary hypertension and acute right ventricular strain.

• D-dimers — though a raised level is non-diagnostic, a normal value carries a high probability of exclusion of a pulmonary embolus.

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