What should be included in the History of Present Illness (HPI) for a Pulmonary Embolism (PE) workup in an inpatient?

History of Present Illness for Inpatient PE Workup

When documenting the HPI for a suspected PE in an inpatient, focus on the four cardinal presenting symptoms—sudden onset dyspnea, chest pain (especially pleuritic), syncope/presyncope, and hemoptysis—as at least one of these is present in 94% of PE cases. 1

Essential Symptom Documentation

Primary Presenting Symptoms (in order of frequency)

• Sudden onset dyspnea: Present in 78-81% of PE patients; document onset timing, severity, and whether it occurred at rest or with exertion 2, 1
• Chest pain: Present in 39-56% of cases; specifically characterize as pleuritic (sharp, worse with breathing) or substernal; document radiation pattern 2, 1
• Syncope or presyncope: Occurs in 22-26% of patients; document whether true loss of consciousness occurred and any prodromal symptoms 2, 1
• Hemoptysis: Present in 5-7% of cases; document volume and character 2, 1

Additional Symptoms to Document

• Cough: Present in approximately 20% of PE patients 2
• Tachypnea: Document respiratory rate, as many patients have rate >20/min even without subjective dyspnea 2
• Apprehension or anxiety: Noted in PE presentations 2

Critical caveat: 12% of patients with pulmonary infarction syndrome have neither dyspnea nor tachypnea, and isolated symptoms can occur, so absence of classic symptoms does not exclude PE 3. Only 1% of PE patients are completely asymptomatic at diagnosis 1.

Risk Factor Assessment

Major Risk Factors (score +1 if present)

Document presence or absence of each 2, 4:

• Recent immobilization or major surgery (within past 4 weeks)
• Recent lower limb trauma and/or surgery
• Clinical signs of deep vein thrombosis (unilateral leg swelling, pain, warmth)
• Previous proven DVT or PE
• Active malignancy (particularly important in inpatients, as cancer-associated VTE has different management implications) 2
• Pregnancy or postpartum status
• Major medical illness (heart failure, respiratory disease, inflammatory conditions)

Additional Risk Factors

• Estrogen use (oral contraceptives, hormone replacement therapy) 2
• Age (risk increases significantly after age 40) 2
• Recent hospitalization for other conditions 2

Important note for inpatients: The inpatient setting itself represents a risk factor, and many hospitalized patients will have multiple comorbidities that elevate D-dimer levels independent of PE (infection, inflammation, recent surgery), making clinical probability assessment even more critical 2.

Hemodynamic Status Documentation

Vital Signs at Presentation

Document all of the following to stratify risk 2, 4:

• Blood pressure: Systolic BP <90 mm Hg indicates high-risk (massive) PE requiring immediate intervention 2
• Heart rate: Tachycardia >110 bpm suggests hemodynamic compromise 4
• Oxygen saturation: <90% on room air indicates significant PE 4
• Respiratory rate: >20/min is common even in stable PE 2

Signs of Right Ventricular Dysfunction

• Elevated jugular venous pressure 4
• Right ventricular gallop (S3 or S4) 4
• Signs of shock: Cool extremities, altered mental status, oliguria 2

Timing and Onset Characteristics

• Acute vs. subacute presentation: Document whether symptoms developed suddenly (minutes to hours) or gradually (days to weeks) 1
• Relationship to activity: Note if symptoms occurred at rest, with minimal exertion, or only with significant activity 1
• Progression: Document whether symptoms are stable, worsening, or improving 2

Differential Diagnosis Considerations

Document symptoms that might suggest alternative diagnoses 2:

• Cardiac: Crushing chest pain radiating to arm/jaw (ACS), positional chest pain (pericarditis)
• Pulmonary: Productive cough with fever (pneumonia), wheezing (asthma/COPD exacerbation)
• Other: Unilateral leg swelling alone may represent isolated DVT without PE 1

Key pitfall: In hospitalized patients, PE is frequently missed in those with severe underlying cardiorespiratory disease, elderly patients, and those presenting with isolated dyspnea without other symptoms 2. Maintain high clinical suspicion even when alternative diagnoses seem more likely.

Clinical Probability Assessment

Document your clinical gestalt or apply a validated prediction rule 2:

• Wells Criteria or Revised Geneva Score can be calculated from HPI elements 2
• Classify as low, intermediate, or high probability to guide subsequent testing 2
• Note that clinical gestalt by experienced clinicians performs similarly to structured tools 2

Special consideration for inpatients: D-dimer has lower specificity in hospitalized patients due to comorbidities, but a normal D-dimer combined with low clinical probability can still safely exclude PE in approximately 10% of inpatients (compared to 36% of emergency department patients) 2. However, most hospitalized surgical patients will have at least intermediate probability, limiting the utility of D-dimer testing 2.