template to assist in the discharge documentation of suspected PE SSU admits
see also:
example notations to copy and paste
No definitive cause for this patient's chest pain was found at this presentation. In particular, there was no evidence to support diagnoses such as aortic dissection, pulmonary embolism, acute coronary syndrome warranting emergent angiography, pericarditis, pneumonia, pneumothorax, shingles, or extra-thoracic causes such as biliary colic.
The patient was admitted to the ED observation unit for investigation of possible pulmonary embolus based upon:
PERC rule being positive / negative:
patient < 50yrs age
heart rate < 100
no unexplained hypoxia (ie. SaO2 > 95% on room air)
no PH DVT or PE
no haemoptysis
no calf swelling
no proven DVT
not on exogenous oestrogen Rx such as OCP or HRT
no recent general anaesthetic or trauma in past 4wks
Wells score of …. (4 or higher, or 2-3 plus +ve PERC or D-Dimer, is an indication for scanning)
3pts = clinical signs and symptoms of DVT (minimum of leg-swelling and pain with palpation of the deep veins)
3pts = an alternative diagnosis is less likely than PE (ie. clinician gestalt for PE is >10% probability)
1.5pts = heart rate greater than 100 beats/min
1.5pts = immobilisation (complete bedrest for ≥ 3 days in the 4 weeks before presentation) or surgery in the previous 4 weeks
1.5pts = previous objectively diagnosed DVT or PE
1.0pts = haemoptysis
1.0pts = malignancy (receiving treatment, treated in the last 6 months or receiving palliative care)
CXR was normal
ECG showed SR no acute ischaemic changes
D-Dimer was ….
Based upon the above, it was decided that imaging was warranted and thus a CTPA V/Q scan was done and this showed ….