Anton Helman here for the EMCase's podcast. Welcome to Part 2 of pulmonary embolism challenges in diagnosis.

In Part 1, Eddie Langkerson Duet and I discussed how Ms. P.E. is almost always a failure to consider the diagnosis in the first place, rather than an erroneous workup,

that we do a ton of needless CTs with their inherent problems of

overdiagnosis and radiation risk, that you need to take a really good, detailed history

and realize that breathlessness and fatigue are the two most common symptoms, while chest pain

is only seen in about 5% of cases. And while there are dozens of PE risk factors, the really

important ones that should shift your probability of PE in particular are previous thromboembolic

events, recent immobilization, active cancer, estrogen use, and strong family history. We talked about

how patients who present with syncope and COPD should not routinely get

CTs to rule out PE despite the Italian studies that show a high rate of PEs in these patients.

We explained why you need to understand pretest probability and know the prevalence of PE in your

population, that tachycardia alone

should not automatically trigger the workup of PE, and that a normal heart rate should never

rule out PE. And for the decision tools, we suggested starting with Wells, and if it's less than

to, apply perk. If perk is negative, you're done.

If Wells is 2, 3, or 4, then consider a D-Dimer.

Over 4, get a CT.

And be sure to age-adjust your D-Dimer.

We covered the year's decision tool that uses two D-Darmer thresholds and agreed that it's

very promising but probably needs further validation in review.

And finally we discussed the value of chest x-ray ECG and Pocus in the workup of PE.

So that was part one.

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