Maciej Godycki-Ćwirko, Agnieszka Bratkowska likelihood ratio of 18.3, and leg vein ultrasound gives a positive likelihood ratio of 16.2. There are also tests for which the post-test probability is < 5% if negative. In patients with a low or moderate pre-test probability, negative spiral computed tomography plus a negative leg vein ultrasound gives a negative likelihood ratio of 0.04; normal or near normal lung scan has a negative likelihood ratio of 0.05 and a D-dimer < 500 μg/l by quantitative enzyme-linked immuno- sorbent assay has a negative likelihood ratio of 0.08. To make a diagnosis, one should also estimate risk factors associated with an increased risk of venous thromboembolism. Possible risk factors that should be considered in the presenting patient are varicose veins, overweight, ischaemic heart disease (risk of PE but not DVT) and heart failure (risk of PE but not DVT). Other possible risk factors noted in the literature are fractures, surgery, cancer, oral corticosteroid use, opposed hormone therapy, oral contraceptives, cerebrovascular disease (risk of PE but not DVT) and inflammatory bowel disease. In the case reported here, the patient had no symptoms typical for PE when first examined by the family physician. He reported dyspnoea and fatigability. Physical examination revealed low blood pressure and non-significant lower limb oedema. The heart murmur was the main symptom in this case. This clinical picture might suggest exa- cerbation of cardiac failure. During hospitalization new symptoms such as chest pain and cough occurred and the dyspnoea was exacerbated. The heart murmur observed in this patient was probably the result of right cardiac overload caused by growing pulmonary vascular resistance. We may suspect that in this patient a massive embolus occurred, leading to haemodynamic disorder, without pulmonary infarction, and therefore without cough, pleural pain or haemoptysis. This hypothesis was not confirmed by angio-CT. In the case of the 89-year-old patient that is reported here, differential diagnosis was particularly difficult because of non-specific presentation. In the elderly we can often find coexisting diseases that can cause similar symptoms and their treatment can change PE progress. Cardiopulmo- nary conditions may mimic PE and age may influence the diagnostic tests for PE. Fewer than 20% of elderly have the classic triad of dyspnoea, chest pain and haemoptysis. They often present confusing symptoms such as unexplained fewer or arrhythmias, shortness of breath, heart failure, wheezing, cardiovascular collapse with hypotension and syncope. The most common symptom in the elderly is tachypnoea. Pulmonary embolism is often underdiagnosed in the elderly, although its incidence increases steadily with age. We conclude that this problem is not sufficiently described in the literature. We should be aware that in many cases symptoms supposed to be found in PE do not occur at all. It is possible to make a diagnostic mistake when ruling out PE in a patient without typical symptoms. Acknowledgments The authors wish to thank Professor Carl Whitehouse for reviewing the manuscript. R e f e r e n c e s 1. Kamangar N. Pulmonary embolism. Accessed on emedi- cine Jan 14, 2010. 2. Dallen JE, Alpert JS. Natural history of pulmonary embolism. Prog Cardiovasc 1975; 17: 257-70. 3. Horlander KT, Mannino DM. Embolism mortality in the United States. Arch Intern Med 2003; 163: 1711-7. 4. Huerta C, Johansson S, Wallander MA, Garcia Rodriquez LA. Risk factors and short-term mortality of venous thromboembolism diagnosed in the primary care setting in the UK. Arch Intern Med 2007; 167: 953-43. 5. Ceccarelli E, Masotti L, Barabesi L, Forconi S, Cappeli R. Pulmonary embolism in very old patients. Aging Clin Exp Res 2003; 15: 7-122. 6. Ceccarelli E, Masotti L Forconi S, Cappeli R. Diagnostic and therapeutic features of pulmonary embolism in elderly patients. Ital Heart J Suppl 2003; 9: 745-54. 7. Evans W. The less common forms of pulmonary hypertension. Br Heart J 1959; 21: 97-217. 8. Stein PD, Beemath A, Matta F, et al. Clinical characteristics of patients with acute pulmonary embolism. Am J Med 2007; 120: 871-9. 9. Ebell MH. Suspected pulmonary embolism: evidence- based diagnostic testing. Am Fam Physician 2004; 69: 599-601. 10. Ebell MH. Suspected pulmonary embolism: evidence- based clinical assessment. Am Fam Physician 2004; 69: 367-9. 904 Arch Med Sci 5, October / 2011