title: Alternative diagnoses in patients in whom the GP considered the diagnosis of pulmonary embolism.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.affiliation: 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.
authors.forename: Petra M G
authors.initials: PM
authors.lastname: Erkens
authors.affiliation: Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam and.
authors.forename: Wim A M
authors.initials: WA
authors.lastname: Lucassen
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Geert-Jan
authors.initials: GJ
authors.lastname: Geersing
authors.affiliation: Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam and.
authors.forename: Henk C P M
authors.initials: HC
authors.lastname: van Weert
authors.affiliation: Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam and.
authors.forename: Marlous
authors.initials: M
authors.lastname: Kuijs-Augustijn
authors.affiliation: Department of Family Medicine, School for Public Health and Primary Care (CAPHRI).
authors.forename: Marloes
authors.initials: M
authors.lastname: van Heugten
authors.affiliation: Department of Family Medicine, School for Public Health and Primary Care (CAPHRI).
authors.forename: Lonneke
authors.initials: L
authors.lastname: Rietjens
authors.affiliation: Department of Internal Medicine, Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM) and.
authors.forename: Hugo
authors.initials: H
authors.lastname: ten Cate
authors.affiliation: Department of Clinical Epidemiology, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht.
authors.forename: Martin H
authors.initials: MH
authors.lastname: Prins
authors.affiliation: Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam and.
authors.forename: Harry R
authors.initials: HR
authors.lastname: Büller
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Arno W
authors.initials: AW
authors.lastname: Hoes
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Karel G M
authors.initials: KG
authors.lastname: Moons
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Ruud
authors.initials: R
authors.lastname: Oudega
authors.affiliation: Department of Family Medicine, School for Public Health and Primary Care (CAPHRI).
authors.forename: Henri E J H
authors.initials: HE
authors.lastname: Stoffers
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000933:Antifibrinolytic Agents; D015415:Biomarkers / Q000097:blood; D002637:Chest Pain / Q000175:diagnosis / Q000209:etiology; D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data*; D003937:Diagnosis, Differential; D004417:Dyspnea / Q000175:diagnosis / Q000209:etiology; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products; D058006:General Practice / Q000379:methods / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D011014:Pneumonia / Q000175:diagnosis*; D019095:Point-of-Care Systems / Q000706:statistics & numerical data; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000097:blood / Q000175:diagnosis*; D012140:Respiratory Tract Diseases / Q000175:diagnosis / Q000503:physiopathology; D055815:Young Adult
chemical_list: D000933:Antifibrinolytic Agents; D015415:Biomarkers; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D
keywords: Bacterial pneumonia; chest pain/dyspnoea; diagnostic decision making; differential diagnoses; primary care; pulmonary embolism