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Alternative diagnoses in patients in whom the GP considered the diagnosis of pulmonary embolism.
Fam Pract. 2014 Dec; 31(6):670-7.FP

Abstract

INTRODUCTION

Pulmonary embolism (PE) often presents with nonspecific symptoms and may be an easily missed diagnosis. When the differential diagnosis includes PE, an empirical list of frequently occurring alternative diagnoses could support the GP in diagnostic decision making.

OBJECTIVES

To identify common alternative diagnoses in patients in whom the GP suspected PE but in whom PE could be ruled out. To investigate how the Wells clinical decision rule for PE combined with a point-of-care d-dimer test is associated with these alternative diagnoses.

METHODS

Secondary analysis of the Amsterdam Maastricht Utrecht Study on thrombo-Embolism (Amuse-2) study, which validated the Wells PE rule combined with point-of-care d-dimer testing in primary care. All 598 patients had been referred to and diagnosed in secondary care. All diagnostic information was retrieved from the GPs' medical records.

RESULTS

In 516 patients without PE, the most frequent alternative diagnoses were nonspecific thoracic pain/dyspnoea (42.6%), pneumonia (13.0%), myalgia (11.8%), asthma/chronic obstructive pulmonary disease (4.8%), panic disorder/hyperventilation (4.1%) and respiratory tract infection (2.3%). Pneumonia occurred almost as frequent as PE. Patients without PE with either a positive Wells rule (>4) or a positive d-dimer test, were more often (odds ratio = 2.1) diagnosed with a clinically relevant disease than patients with a negative Wells rule and negative d-dimer test.

CONCLUSION

In primary care patients suspected of PE, the most common clinically relevant diagnosis other than PE was pneumonia. A positive Wells rule or a positive d-dimer test are not only positively associated with PE, but also with a high probability of other clinically relevant disease.

Authors+Show Affiliations

Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Department of Internal Medicine, Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM) and Department of Clinical Epidemiology, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht, petra.erkens@maastrichtuniversity.nl.Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam and.Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam and.Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam and.Department of Family Medicine, School for Public Health and Primary Care (CAPHRI).Department of Family Medicine, School for Public Health and Primary Care (CAPHRI).Department of Internal Medicine, Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM) and.Department of Clinical Epidemiology, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht.Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam and.Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.Department of Family Medicine, School for Public Health and Primary Care (CAPHRI).

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

25216665

Citation

Erkens, Petra M G., et al. "Alternative Diagnoses in Patients in Whom the GP Considered the Diagnosis of Pulmonary Embolism." Family Practice, vol. 31, no. 6, 2014, pp. 670-7.
Erkens PM, Lucassen WA, Geersing GJ, et al. Alternative diagnoses in patients in whom the GP considered the diagnosis of pulmonary embolism. Fam Pract. 2014;31(6):670-7.
Erkens, P. M., Lucassen, W. A., Geersing, G. J., van Weert, H. C., Kuijs-Augustijn, M., van Heugten, M., Rietjens, L., ten Cate, H., Prins, M. H., Büller, H. R., Hoes, A. W., Moons, K. G., Oudega, R., & Stoffers, H. E. (2014). Alternative diagnoses in patients in whom the GP considered the diagnosis of pulmonary embolism. Family Practice, 31(6), 670-7. https://doi.org/10.1093/fampra/cmu055
Erkens PM, et al. Alternative Diagnoses in Patients in Whom the GP Considered the Diagnosis of Pulmonary Embolism. Fam Pract. 2014;31(6):670-7. PubMed PMID: 25216665.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Alternative diagnoses in patients in whom the GP considered the diagnosis of pulmonary embolism. AU - Erkens,Petra M G, AU - Lucassen,Wim A M, AU - Geersing,Geert-Jan, AU - van Weert,Henk C P M, AU - Kuijs-Augustijn,Marlous, AU - van Heugten,Marloes, AU - Rietjens,Lonneke, AU - ten Cate,Hugo, AU - Prins,Martin H, AU - Büller,Harry R, AU - Hoes,Arno W, AU - Moons,Karel G M, AU - Oudega,Ruud, AU - Stoffers,Henri E J H, Y1 - 2014/09/12/ PY - 2014/9/14/entrez PY - 2014/9/14/pubmed PY - 2015/7/16/medline KW - Bacterial pneumonia KW - chest pain/dyspnoea KW - diagnostic decision making KW - differential diagnoses KW - primary care KW - pulmonary embolism SP - 670 EP - 7 JF - Family practice JO - Fam Pract VL - 31 IS - 6 N2 - INTRODUCTION: Pulmonary embolism (PE) often presents with nonspecific symptoms and may be an easily missed diagnosis. When the differential diagnosis includes PE, an empirical list of frequently occurring alternative diagnoses could support the GP in diagnostic decision making. OBJECTIVES: To identify common alternative diagnoses in patients in whom the GP suspected PE but in whom PE could be ruled out. To investigate how the Wells clinical decision rule for PE combined with a point-of-care d-dimer test is associated with these alternative diagnoses. METHODS: Secondary analysis of the Amsterdam Maastricht Utrecht Study on thrombo-Embolism (Amuse-2) study, which validated the Wells PE rule combined with point-of-care d-dimer testing in primary care. All 598 patients had been referred to and diagnosed in secondary care. All diagnostic information was retrieved from the GPs' medical records. RESULTS: In 516 patients without PE, the most frequent alternative diagnoses were nonspecific thoracic pain/dyspnoea (42.6%), pneumonia (13.0%), myalgia (11.8%), asthma/chronic obstructive pulmonary disease (4.8%), panic disorder/hyperventilation (4.1%) and respiratory tract infection (2.3%). Pneumonia occurred almost as frequent as PE. Patients without PE with either a positive Wells rule (>4) or a positive d-dimer test, were more often (odds ratio = 2.1) diagnosed with a clinically relevant disease than patients with a negative Wells rule and negative d-dimer test. CONCLUSION: In primary care patients suspected of PE, the most common clinically relevant diagnosis other than PE was pneumonia. A positive Wells rule or a positive d-dimer test are not only positively associated with PE, but also with a high probability of other clinically relevant disease. SN - 1460-2229 UR - https://www.unboundmedicine.com/medline/citation/25216665/Alternative_diagnoses_in_patients_in_whom_the_GP_considered_the_diagnosis_of_pulmonary_embolism_ L2 - https://academic.oup.com/fampra/article-lookup/doi/10.1093/fampra/cmu055 DB - PRIME DP - Unbound Medicine ER -