Clinical Documentation — Built for the pace of Australian general practice.
APP compliant transcription for Australian and New Zealand clinicians.
On examination this morning he was tachycardic at 104 beats per minute, febrile at 37.8 degrees, and hypoxic with saturations of 94% on room air. Auscultation revealed reduced air entry at the right base with corresponding dullness to percussion. There were no clinical signs of deep vein thrombosis on lower limb examination. Applying the Wells criteria, I calculate a score of 4, consistent with moderate probability of pulmonary embolism. Urgent CTPA has been requested and therapeutic enoxaparin commenced at weight-based dosing pending the result. I have notified both the respiratory and haematology teams and the patient will be admitted under general medicine for ongoing monitoring.