Case report A family physician was asked to see at home an 89-year-old male patient with a medical history of hypertension and ischaemic heart disease. The patient presented with breathing difficulties and fatigability. Physical examination revealed normal body temperature, regular heart action at 68 beats/min, blood pressure 104/60 mmHg, vesicular pulmonary sounds and oedema of the lower limbs. Cardiac examination revealed a systo- lodiastolic murmur best heard over the apex. The patient was referred to a hospital with a diagnosis of worsening heart failure. During hospitalization the patient’s condition became worse. His dyspnoea was exacerbated and he developed a non-productive cough and chest pain. Oliguria was also observed. Diagnostic investigation revealed increasing levels of troponin and D-dimer. Evidence of renal failure was also found. A 4 mm ST segment depression in V3-V6 was detected by 12-lead ECG. Echocardiography revealed features of pulmonary hypertension, with dilation of the right ventricle, right atrium and pulmonary trunk. Pulmonary embolism was diagnosed, but because of the renal failure this diagnosis was not confirmed by angio-CT. The poor general condition of the patient disqualified him from invasive treatment in the haemodynamic unit. Over several days the patient’s condition deteriorated. Acute left ventricular insufficiency occurred and the renal failure was exacerbated. Intensive treatment was unsuccessful and the patient died several days after admission. Discussion Pulmonary embolism is a disease with a non- homogeneous clinical picture. The picture depends on the localization and size of the thrombus as well as the patient’s general condition. Many symptoms of PE are found in the literature but most of them are not typical, and this makes diagnosis difficult [7]. In “Prospective Investigation of Pulmonary Embolism Diagnosis II” (PIOPED II), 192 adults with Table I. Wells model for clinical diagnosis of PE Signs and symptoms Clinical signs and symptoms of DVT An 89-year-old patient with acquired murmur associated with pulmonary embolism acute PE, of whom 133 (69%) had no prior cardio- pulmonary disease, were compared with 632 pa- tients without PE [8]. The investigation revealed that symptoms such as dyspnoea (at rest not during exertion), cough, circulatory collapse, calf or thigh swelling and pain occurred more often in patients with PE. Orthopnoea, pleuritic pain, wheezing and haemoptysis were found to be not significant. Signs observed in PE were tachypnoea, tachycardia, increased P2 heart sound, right ventricular lift, jugular venous distention, pulmonary rales (crackles) and decreased breath sounds. There were also signs of deep vein thrombosis (DVT) of the calf or thigh such as oedema, erythema, tenderness or palpable cord. Other signs such as cyanosis, wheeze, rhonchi, or pleural friction rub were not significant. For the family physician it is important to estimate the risk of PE without using diagnostic tests. Wells et al. have created a model for clinical diagnosis of PE, which relies on a careful history and physical examination, and can be useful to a family physican [9, 10]. Wells’s model consists of seven signs and symptoms to be scored (Table I). Patients who scored more than 6 points were classified in the high risk group (probability of PE 37.5%). Patients with less than 2 points belonged to the low risk group (probability of PE 1.3%). A second decision model, for use in hospital, was developed by Wicki et al. [10]. This model does not rely on a judgment of whether an alternative diagnosis is less likely than PE and it uses information from a chest radiograph and arterial blood gas measurements. In this model assessment includes patient’s age, pulse rate, PaCO2, PaO2, chest radiograph, previous DVT or PE, and recent surgery. In a systematic review of hospital diagnostic tests for confirmation or exclusion of PE, a number of tests can be found for which the post-test probability is > 85% if positive. In patients with a moderate or high pre-test probability, spiral computed tomography gives a positive likelihood ratio of 24.1; with high pre-test probability, ventilation perfusion lung scan gives a positive Pulmonary embolism as likely or more likely than an alternative diagnosis Heart rate > 100 beats/min Immobilization (bed rest for at least 3 consecutive days) or surgery in the previous 4 weeks Previous objectively diagnosed DVT or PE Haemoptysis Malignancy (treatment that is ongoing, within the past 6 months, or palliative) Arch Med Sci 5, October / 2011 Points 3 3 1.5 1.5 1.5 1.0 1.0 903