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Pulmonary Embolism History-Taking



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    • Diagnosis - provoked or unprovoked PE, preceding DVT
    • Management - anticoagulation
    • Complications - infarction, right heart failure, pulmonary hypertension
    • Risk Factors for Pulmonary Embolism

    • Genetic Predisposition

    • Inherited hypercoagulability - protein C or S deficiency, factor V Leiden, prothrombin gene mutation, sickle cell disease, hyperhomocysteinaemia, antithrombin III deficiency
    • Family history of VTE
    • Patient  Factors

    • Advanced age
    • Past history of VTE
    • Acquired hypercoagulability - antiphospholipid syndrome, hyperviscosity, PNH, TTP, HITS
    • May-Thurner syndrome (anatomical variant where the right common iliac artery overlies and compresses the left common iliac vein)
    • Malignancy
    • Hormonal therapy - oestrogen-containing oral contraceptives, hormone replacement, SERMs
    • Venous pathology - varicose veins, superficial vein thrombosis
    • Environmental Triggers

    • Trauma
    • Surgery - particularly hip / knee surgery or major surgery
    • Pregnancy / peripartum period
    • Continuous immobilisation >72 hours - bedrest, neurologic pathology, cast
    • Hospital or nursing home admission
    • Long-distance travel (air, land or sea)


    • Complications of Pulmonary Embolism

    • Disease-Related

    • Pulmonary infarction
    • Right heart failure
    • Chronic thromboembolic pulmonary hypertension (CTEPH)
    • Treatment-Related

    • Major bleeding


    • Management Options

    • Thrombolysis (haemodynamically unstable patients)
    • Anticoagulation - heparin, low molecular weight heparin, warfarin, dabigatran, rivaroxaban, apixaban
    • Pearls: Choice of Anticoagulant

    • Heparin infusion - short-term, for bridging or in the perioperative period. APTT must be monitored regularly as per local protocol.
    • Low molecular weight heparin (e.g. enoxaparin) - first line for patients with active malignancy; also used for bridging. Contraindicated if CrCl <30.
    • Warfarin - must be bridged. INR must be monitored. Can be used in renal failure. Inferior to enoxaparin in active malignancy.
    • Dabigatran - contraindicated if CrCl <30.
    • Rivaroxaban - contraindicated if CrCl <30, severe liver disease, on protease inhibitors / azoles, pregnancy / breastfeeding. Potential role in active malignancy.
    • Apixaban - contraindicated if CrCl <25, severe liver disease, on protease inhibitors / azoles, pregnancy / breastfeeding.
    • Contraindications to Anticoagulation

    • Absolute - active bleeding, major trauma, platelets <50, bleeding diathesis, perioperative
    • Relative - past incompressible bleed, intracranial or spinal tumour, platelets <100, large AAA, high falls risk
    • Duration of Anticoagulation

    • Provoked VTE (transient risk factors) - 3 months then reassess based on risk of recurrence and bleeding
    • First unprovoked VTE - 3 months then continue depending on risk of recurrence and bleeding
    • Recurrent unprovoked VTE - long-term anticoagulation
    • Thrombophilia - consider long-term anticoagulation
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Ainslie G. Assessment of cough. Continuing Medical Education. 2009 Mar 19;27(2):68.
 Antoniou KM, Margaritopoulos GA, Tomassetti S, Bonella F, Costabel U, Poletti V. Interstitial lung disease. European Respiratory Review. 2014 Mar 1;23(131):40-54. Badran M, Ayas N, Laher I. Cardiovascular complications of sleep apnea: role of oxidative stress. Oxidative medicine and cellular longevity. 2014;2014. Beasley R, Semprini A, Mitchell EA. Risk factors for asthma: is prevention possible?. The Lancet. 2015 Sep 12;386(9998):1075-85. Braman SS, Davis SM. Wheezing in the elderly. Asthma and other causes. Clinics in geriatric medicine. 1986 May;2(2):269-83. Cano-Jiménez E, Hernández González F, Peloche G. Comorbidities and Complications in Idiopathic Pulmonary Fibrosis. Medical Sciences. 2018 Sep;6(3):71. Committee on Rating of Mental and Physical Impairment. The Respiratory System. JAMA. 1965 Nov; 194(8): 919-932. Cushman M. Epidemiology and risk factors for venous thrombosis. InSeminars in hematology 2007 Apr 1 (Vol. 44, No. 2, pp. 62-69). WB Saunders. del Giudice MM, Allegorico A, Parisi G, Galdo F, Alterio E, Coronella A, Campana G, Indolfi C, Valenti N, Di Prisco S, Caggiano S. Risk factors for asthma. InItalian journal of pediatrics 2014 Dec (Vol. 40, No. 1, p. A77). BioMed Central. Feierabend R. Hoarseness in adults. Am Fam Physician. 2009;80:363. Gordon BR. Asthma History and Presentation. Otolaryngeal Clin N Am. 2008; 41: 375-385. Harding SM. Complications and consequences of obstructive sleep apnea. Current opinion in pulmonary medicine. 2000 Nov 1;6(6):485-9. Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'fallon WM, Melton LJ. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Archives of internal medicine. 2000 Mar 27;160(6):809-15. Ho WK. Deep vein thrombosis: risks and diagnosis. Australian family physician. 2010 Jul;39(7):468. Holzinger F, Beck S, Dini L, Stöter C, Heintze C. The diagnosis and treatment of acute cough in adults. Deutsches Ärzteblatt international. 2014;111:356. Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006;129:1S-23S. Kilgore D, Najm W. Common Respiratory Diseases. Prim Care Clin Office Pract. 2010; 37: 297-324. Krieger BP. When wheezing may not mean asthma: other common and uncommon causes to consider. Postgraduate medicine. 2002 Aug 1;112(2):101-11. Mannino DM, Buist AS. Global burden of COPD: risk factors, prevalence, and future trends. The Lancet. 2007 Sep 1;370(9589):765-73. Mathews KP. Respiratory Atopic Disease. JAMA. 1982 Nov; 248(20): 2587-2610. Molina JR, Yang P, Cassivi SD, Schild SE, Adjei AA. Non-small cell lung cancer: epidemiology, risk factors, treatment, and survivorship. InMayo Clinic Proceedings 2008 May 1 (Vol. 83, No. 5, pp. 584-594). Elsevier. O'Donnell AE. Bronchiectasis. Chest. 2008 Oct 1;134(4):815-23. Osann KE. Lung Cancer in Women: The Importance of Smoking, Family History of Cancer, and Medical History of Respiratory Disease. Cancer Research. 1991 Sep; 51: 4893-4897. Papiris S, Kotanidou A, Malagari K, Roussos C. Clinical review: severe asthma. Critical Care. 2001 Feb;6(1):30. Prakash UBS. Uncommon Causes of Cough. Chest. 2006;129:206S. Pratter MR. Overview of common causes of chronic cough: ACCP evidence-based clinical practice guidelines. CHEST Journal. 2006 Jan 1;129(1_suppl):59S-62S. Samama MM. An epidemiologic study of risk factors for deep vein thrombosis in medical outpatients: the Sirius study. Archives of internal medicine. 2000 Dec 11;160(22):3415-20. Sethi GR, Batra V. Bronchiectasis: causes and management. The Indian Journal of Pediatrics. 2000 Feb 1;67(2):133-9. Travis, W.D., Costabel, U., Hansell, D.M., King Jr, T.E., Lynch, D.A., Nicholson, A.G., Ryerson, C.J., Ryu, J.H., Selman, M., Wells, A.U. and Behr, J., 2013. An official American Thoracic Society/European Respiratory Society statement: update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. American journal of respiratory and critical care medicine, 188(6), pp.733-748. Troy L, Corte T. Interstitial lung disease in 2015: where are we now?. Australian family physician. 2015 Aug;44(8):546. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. Jama. 2004 Apr 28;291(16):2013-6.