Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Embolism, Pulmonary


Related Terms

  • PE
  • Pulmonary Apoplexy
  • Pulmonary Thromboembolism
  • Pulmonary Thrombosis
  • Venous Thromboembolism

Differential Diagnosis

Specialists

  • Cardiovascular Internist
  • Critical Care Internist
  • Internal Medicine Physician
  • Pulmonologist
  • Radiologist
  • Thoracic Surgeon

Comorbid Conditions

  • Heart disease
  • Obesity
  • Postphlebitic syndrome
  • Pulmonary disease

Factors Influencing Duration

Factors influencing the length of disability include advanced age, length of and response to anticoagulant therapy, underlying cause of the pulmonary embolus, degree of pulmonary dysfunction, and whether the individual required surgery.

Medical Codes

ICD-9-CM:
415.1 - Pulmonary Embolism
415.11 - Iatrogenic Pulmonary Embolism and Infarction
415.12 - Septic Pulmonary Embolism; Septic Embolism NOS
415.19 - Pulmonary Embolism, Other
673 - Obstetrical Pulmonary Embolism
673.0 - Obstetrical Pulmonary Embolism, Obstetrical Air Embolism
673.1 - Amniotic Fluid Embolism
673.2 - Obstetrical Blood-clot Embolism; Puerperal Pulmonary Embolism NOS
673.3 - Obstetrical Pyemic and Septic Embolism
673.8 - Obstetrical Pulmonary Embolism, Other; Fat Embolism
958.0 - Trauma Complications, Air Embolism
958.1 - Trauma Complications, Fat Embolism

Overview

Pulmonary embolism (PE) is a sudden blockage of the arterial circulation of the lungs. The blockage can occur in the main artery carrying blood from the heart to the lungs (pulmonary artery) or in the smaller arteries within the lung. In 90% of cases, the blockage arises from a blood clot originating in the veins of the legs (deep vein thrombosis [DVT]) that breaks loose, travels to the heart and lodges in the pulmonary artery (NHLBI). However, other substances can cause emboli in the pulmonary circulation. These include air from a central vein catheter, amniotic fluid dislodged in active labor, fat arising from long bone fractures, foreign bodies such as talc introduced during intravenous drug use, septic emboli as in acute endocarditis, or tumor cells.

In most cases, blockage is temporary and causes no symptoms. In others, the blockage can cause chest pain with shortness of breath (dyspnea), cough, and coughing up blood (hemoptysis). Other symptoms such as sweatiness, anxiety, fainting (syncope), and rapid heart rate (tachycardia) may occur. PE can cause permanent lung damage through the death of lung tissue (pulmonary infarction). A massive pulmonary embolism can put enormous stress on the right ventricle and halt the entire circulatory system, causing cardiopulmonary arrest and death.

Incidence and Prevalence: The incidence of PE is highest in women younger than 55 and in elderly men (Garg).

An estimated 650,000 cases of pulmonary embolism occur in the US each year, with an incidence of 100 cases per 100,000 population (Kamangar).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors for PE are similar to those for deep vein thrombosis (DVT), and include prolonged bed rest or inactivity, surgery, lower extremity or pelvic trauma, cast immobilization of a lower extremity, central vein intravenous lines (central vein catheters), severe burns, cancer, endocarditis, pregnancy and childbirth, stroke, congestive heart failure, chronic obstructive pulmonary disease (COPD), oral contraceptive or estrogen replacement use, frequent air travel, and obesity (Kamangar).
Individuals older than age 65 and those with prior DVT or PE are at increased risk (Kamangar), with the risk of PE doubling every 10 years after age 60 (NHLBI). PE incidence and mortality is highest in African-Americans, followed by whites (Kamangar). Overall, the mortality rate is 20% to 30% higher in men than in women (Kamangar).

Source: Medical Disability Advisor



Diagnosis

History: The individual usually experiences sudden dyspnea with chest pain that may radiate to the shoulder, jaw, neck, or arm. The chest pain may be described as worse with deep breathing (pleuritic). This may be combined with syncope, sweating, hemoptysis, a feeling of weakness, and anxiety. The individual may complain of a rapid or irregular heartbeat. The individual may report having had a surgical procedure within the past month or cancer treatment within the past 6 months (Kamangar).

Physical exam: Typical findings include dyspnea, rapid respiratory rate (tachypnea), and tachycardia (Kamangar). Some individuals may present with a low-grade fever, bluish skin (cyanosis), and wheezing. Listening to the chest may reveal abnormal lung sounds (rales) or an abnormal fourth heart sound. In cases of massive pulmonary embolism, the individual will display signs of shock (i.e., cold and clammy skin, weak pulse, low blood pressure).

Tests: Tests typically include chest x-ray, electrocardiogram (ECG), lung scan, and arterial blood gases. D-dimer blood tests are performed to measure clot-related substances in the blood, and serve as a rapid screening test. Lung scans (ventilation-perfusion lung scans) use a radioactive substance to examine the flow of blood and oxygen to the parts of the lungs. Color-flow Doppler ultrasounds of the legs may be used to diagnose blood clots in the leg veins. A pulmonary angiogram (computed tomography [CT] angiography) is the most definitive test to diagnose pulmonary emboli; it involves injecting dye into the blood vessels and then taking x-ray pictures of the lungs to examine pulmonary blood flow. A spiral CT scan or magnetic resonance imaging (MRI) may be ordered on occasion as a noninvasive alternative for diagnosis.

Source: Medical Disability Advisor



Treatment

Treatment of PE initially focuses on immediately relieving symptoms of the attack with a combination of oxygen, rapidly administered blood-thinning drugs (anticoagulants), morphine, and fluids. Anticoagulation therapy is used for at least 3 months following the initial PE, and longer than 6 months in individuals with recurrent DVT or PE (Kamangar). Anticoagulants should not be used on individuals susceptible to bleeding due to other medical conditions such as esophageal varices, ulcers, and liver or kidney disease. If the individual remains in critical condition following the embolism and has not responded well to emergency measures, blood clot dissolving drugs (thrombolytics) may be used.

Surgical removal of the embolus (pulmonary embolectomy) is an emergency procedure done as a last resort. Surgical ligation of the inferior vena cava (vena cava interruption) or insertion of an umbrella device into the inferior vena cava to block blood clots from traveling to the lungs is considered when recurrence of the disease is life-threatening in cases where the individual cannot tolerate anticoagulant therapy or has septic thrombophlebitis of pelvic origin.

Compression stockings (thrombo-embolism deterrent [TED] hose) with a compression gradient 30 to 40 mmHg may be used to decrease the risk of fluid pooling in the legs that may contribute to further blood clot formation. They are especially useful for individuals who had a precipitating DVT and may be used for as long as 2 years after an acute PE to reduce the risk of post-thrombotic syndrome and recurrent DVT (Kamangar).

Source: Medical Disability Advisor



Prognosis

Prognosis depends on the speed at which PE is diagnosed and treated. Of those individuals who develop PE, 10% die within the first hour and 30% will die subsequently from recurrent PE if it remains undiagnosed and untreated (Kamangar). After diagnosis and treatment, recurrence of PE is 17%, usually due to recurrent above-the-calf DVT (Kamangar). The outcome for survival is good if anticoagulant therapy is initiated rapidly, reducing the mortality rate to 5% (Kamangar). An estimated 650,000 fatalities occur in the US each year from PE (Sutherland).

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation of an individual with pulmonary embolism begins once the origin and reason for the blood clot is identified (e.g., surgery, immobilization, childbirth), and the situation is stabilized. The extent of rehabilitation will depend on the amount of damage resulting from the blood clot and whether surgery was required to remove the embolus. Early ambulation is encouraged. If walking is not an option, the physical therapist or other rehabilitation professional may assign leg exercises to reduce the risk of clot formation.

When surgery is required, early rehabilitative exercises are critical in preventing further emboli since blood clots in the leg veins are particularly common after any operation. Rehabilitation is more extensive if the individual must regain strength and mobility following surgical removal of the pulmonary embolus. Early rehabilitation primarily focuses on preventing any breathing difficulties and regaining upper extremity range of motion that may have been lost due to surgery on the chest. A physical therapist experienced in cardiac and pulmonary rehabilitation keeps a daily log of the individual's blood pressure, heart rate, and cardiac rhythm. As the individual progresses with breathing and relaxation techniques, active assisted range of motion and then active range of motion exercises for the upper and lower extremities are added. As endurance continues to improve without shortness of breath, strengthening exercises using light resistance and light aerobic activities such as brisk walking or low-resistance biking begin. The individual will progress to increased activities and exercises that simulate work.

Source: Medical Disability Advisor



Complications

Complications include lung collapse (atelectasis), pulmonary hypertension, fluid accumulation in the lung cavity (pleural effusion), shock due to low cardiac output, cardiopulmonary arrest, abnormal heart rhythms (arrhythmias), very low oxygen levels (hypoxemia), infection, and lung infarction. Death may occur.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Since pulmonary embolism usually is a result of a blood clot originating in the veins of the legs, it is vital for predisposed individuals to avoid sitting for prolonged periods. If long automobile or airplane trips are a part of job requirements, the individual should take periodic breaks from sitting to restore circulation.

The major concern while taking anticoagulant drugs is the increased risk of bleeding; therefore, the individual should avoid high-risk tasks such as heavy labor that may precipitate bleeding or tasks that may cause falls or cuts.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual have chest pain with dyspnea, cough, and hemoptysis? Is individual cyanotic?
  • Did individual have risk factors such as prolonged bed rest or inactivity, surgery, femur or pelvic trauma, cast immobilization of a lower extremity, central vein catheters, cancer, endocarditis, childbirth, stroke, congestive heart failure, frequent air travel, or obesity?
  • Did individual have proximal deep vein thrombosis?
  • On exam did individual have a tachycardia, chest pain, dyspnea, and syncope?
  • Did individual have abnormal lung or heart sounds?
  • Did the individual have clammy skin, weak pulse, and low blood pressure?
  • Has individual had a chest x-ray, ECG, lung scan, and arterial blood gases? D-dimer test?
  • Did individual have a pulmonary angiogram, CT scan or MRI?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Is individual being treated with oxygen, anticoagulants, morphine, and fluids?
  • Was it necessary to use thrombolytics?
  • Did it become necessary to perform surgery?

Regarding prognosis:

  • Is individual's employer able to accommodate any necessary restrictions?
  • Does individual have any conditions that may affect ability to recover?
  • Does individual have any complications such as atelectasis, pulmonary hypertension, arrhythmias, shock due to low cardiac output, cardiopulmonary arrest, infection, or lung infarction?

Source: Medical Disability Advisor



References

Cited

Garg, Kavita. "Acute Pulmonary Embolism (Helical CT)." eMedicine. Eds. Judith K. Amorosa, et al. 14 May. 2008. Medscape. 21 Sep. 2009 <http://emedicine.medscape.com/article/361131-overview>.

Kamangar, Nader, Mark S. McDonnell, and Sat Sharma. "Pulmonary Embolism." eMedicine. Eds. Gregory Tino, et al. 25 Aug. 2009. Medscape. 21 Sep. 2009 <http://emedicine.medscape.com/article/300901-overview>.

National Heart Lung and Blood Institute. "Pulmonary Embolism." National Heart Lung and Blood Institute. Jun. 2009. U.S. National Institutes of Health. 21 Sep. 2009 <http://www.nhlbi.nih.gov/health/dci/Diseases/pe/pe_what.html>.

Sutherland, Sara F. "Pulmonary Embolism." eMedicine. Eds. Michael S. Beeson, et al. 8 May. 2009. Medscape. 18 Sep. 2009 <http://emedicine.medscape.com/article/759765-overview>.

Source: Medical Disability Advisor






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