Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with [duration] of [pleuritic chest pain/dyspnea/cough]. Wells score is [score], indicating low clinical probability of PE. Patient denies syncope, hemoptysis, or signs of DVT. No history of recent surgery, immobilization, or malignancy. Vitals are stable with O2 saturation >94% on room air.
Clinical Examination Findings
General: Patient is in no acute distress, alert and oriented x3. Cardiovascular: Regular rate and rhythm, S1/S2 normal, no murmurs, rubs, or gallops. Pulmonary: Lungs clear to auscultation bilaterally, no wheezing or crackles. Extremities: No unilateral leg swelling, tenderness, or erythema. Homanโs sign negative.
Treatment Protocol
Low clinical probability confirmed via PERC criteria (all criteria negative). D-dimer ordered to rule out PE. Patient advised to monitor for worsening dyspnea, chest pain, or syncope. Follow-up in [timeframe] if symptoms persist.