A comprehensive clinical examination is the basis for selecting further diagnostic steps:
- General physical examination – including blood pressure, pulse, body weight, height; further:
- Inspection (viewing).
- Skin and mucous membranes [central cyanosis (bluish discoloration of skin and central mucous membranes, e.g., tongue)] (20 %)
- Signs of right heart failure (right-sided heart failure)?
- Abdomen (abdomen)
- Shape of the abdomen?
- Skin color? Skin texture?
- Efflorescences (skin changes)?
- Pulsations? Bowel movements?
- Visible vessels?
- Scars? Hernias (fractures)?
- Extremities (including measurement of the circumference of the lower leg on both sides; is there evidence of deep vein thrombosis)?
- Auscultation (listening) of the heart [emphasized 2nd heart sound (50%)]
- Auscultation of the lungs [tachypnea (> 20 breaths/min) (90% of cases); dyspnea (shortness of breath) (80-90% of cases); exacerbated breath sounds, moist rales (RGs); possibly: inspiratory (on inhalation) increased pleuritic pain/pulmonary irritation]
- Abdominal (stomach) examination [palpable pressure-sensitive liver?]
- Auscultation (listening) of the abdomen [vascular or stenotic sounds?, bowel sounds?]
- Percussion (tapping) of the abdomen.
- Meteorism (flatulence): hypersonoric tapping sound.
- Attenuation of tapping sound due to enlarged liver or spleen, tumor, urinary retention?
- Hepatomegaly (liver enlargement) and/or splenomegaly (spleen enlargement): estimate liver and spleen size.
- Inspection (viewing).
Caveat. (Caution) In 30-50% of cases of pulmonary embolism, there are no clinical signs! Square brackets [ ] indicate possible pathological (pathological) physical findings.
Wells Score
Wells score for determining the clinical probability of pulmonary embolism (LE) [original version].
| Symptoms | Points |
| Clinical signs or symptoms of deep vein thrombosis of the leg | 3 |
| Alternative diagnosis is less likely than pulmonary embolism | 3 |
| Heart rate > 100 | 1,5 |
| Immobilization or surgical procedure in the past four weeks | 1,5 |
| Previous deep vein thrombosis/pulmonary embolism | 1,5 |
| Coughing up blood (hemoptysis) | 1 |
| Tumor disease (under therapy, after therapy within the last 6 months, or palliative therapy) | 1 |
| Clinical probability of pulmonary embolism | |
| Low-risk group (cut-off of the sum value). | < 3 |
| Medium-risk group | 3,0-6,0 |
| High-risk group (cut-off of the sum value). | > 6 |
Wells score for estimating the clinical probability of pulmonary artery (LE) embolism (modified from).
| Criterion | Original version (points) | Simplified version( points) |
| Previous thromboembolism | 1,5 | 1 |
| Heart rate ≥ 100/minute | 1,5 | 1 |
| Surgery or immobilization within the last 4 weeks | 1,5 | 1 |
| Hemoptysis (coughing up blood) | 1 | 1 |
| Active cancer | 1 | 1 |
| Thrombosis sign | 3 | 1 |
| Alternative diagnoses less likely than LE | 3 | 1 |
| Clinical probability | ||
| 3-step score* | ||
| Low | 0-1 | – |
| Medium | 2-6 | – |
| High | ≥ 7 | – |
| Two-level score | ||
| LE unlikely | 0-4 | 0-1 |
| Probably | > 5 | ≥ 2 |
* LE probability:
- Low: 10%
- Medium: 30 %
- High: 70%
Geneva score for assessing the clinical probability of pulmonary embolism ( LE) (modified from and).
| Parameter | Original version | Simplified version |
| Age > 65 years | 1 | 1 |
| Previous LE or DVT (deep vein thrombosis). | 3 | 1 |
| Surgery or fracture (broken bone) in the last month | 2 | 1 |
| Active cancer | 2 | 1 |
| Unilateral leg pain | 3 | 1 |
| Hemoptysis (coughing up blood) | 2 | 1 |
| Heart rate 75-94/min | 3 | 1 |
| Heart rate ≥ 95/min | 5 | 2 |
| Pain on palpation and edema (water retention) on one leg | 4 | 1 |
| Clinical probability | ||
| 3-level score | ||
| Low | 0-3 | 0-1 |
| Intermediate | 4-10 | 2-4 |
| High | ≥ 11 | ≥ 5 |
| 2-level score | ||
| LE unlikely | 0-5 | 0-2 |
| LG probably | ≥ 6 | ≥ 3 |
