Pulmonary Embolism & Pleural Disease
Use probability-based testing and distinguish thromboembolic and pleural emergencies from less urgent disease.
Quick revision ↓ Medical Dictionary
01Estimate embolic probability
Pulmonary embolism can cause acute dyspnoea, pleuritic pain, haemoptysis, tachycardia or collapse. Review recent surgery, immobility, cancer, prior thrombosis and other risk factors. The absence of leg swelling does not exclude PE. Assess haemodynamic stability first, then use a validated clinical probability pathway suited to the setting. A normal oxygen saturation or chest radiograph cannot independently rule out the diagnosis.
02Use tests in sequence
D-dimer is useful for exclusion in appropriate lower-probability pathways but is nonspecific and often raised in infection, malignancy and other conditions. Higher probability usually requires definitive imaging rather than using a negative low-sensitivity strategy for reassurance. Imaging choice considers renal function, contrast issues, pregnancy and local expertise. If testing is delayed, clinicians assess interim anticoagulation against bleeding risk through the approved pathway.
03Treat according to risk
Confirmed PE requires anticoagulation when suitable, with selection informed by kidney function, interactions, pregnancy, cancer and bleeding risk. Haemodynamic instability demands urgent specialist escalation and consideration of reperfusion options. Stable low-risk patients may qualify for outpatient care only after structured clinical and social assessment. Duration is reviewed according to provoking factors, recurrence risk and bleeding risk rather than assumed lifelong for every patient.
04Assess pleural fluid
A pleural effusion can reflect heart failure, infection, malignancy or other disease. Ultrasound helps define fluid and guide safe procedures. When sampling is indicated, examine protein and LDH relationships, cell profile, microbiology and cytology as appropriate. A suspected infected effusion requires attention to drainage and source control; antibiotics alone may be insufficient. Never perform an invasive pleural procedure without competence, supervision and the safety pathway.
05Recognise pneumothorax
Sudden unilateral pleuritic pain and breathlessness suggest pneumothorax, but severity depends on physiology and underlying lung disease. A tension presentation with severe compromise is a clinical emergency and should not wait for confirmatory imaging. Stable cases need imaging and management based on symptoms, risk and local specialist guidance. Distinguish a simple radiological finding from a deteriorating patient requiring immediate action.
High-Yield Revision
- D-dimer must be interpreted within a probability pathway.
- Instability changes the urgency of suspected PE.
- Suspected tension pneumothorax should not wait for an X-ray.
Common Pitfalls
- A positive D-dimer does not confirm PE.
- Do not perform pleural procedures without the required supervision and safety checks.
References & Further Reading
Read the relevant guideline sections alongside these original clinical teaching cases. Local pathways, available services and individual patient factors determine care.
Reference review: 27 September 2026. Consult current local protocols for prescribing, procedures and escalation.