Predicting pulmonary embolus in primary care

It is 4 30 pm, and your last patient of the day is a 42 year old woman in excellent health who awoke with pain located in the right infrascapular region that worsens with deep inspiration. She reports no dyspnea, cough, fever, or recent prolonged immobilization. Her vital signs and physical examination are normal. Your initial impression is that some type of musculoskeletal condition is causing her pain. Then you begin to wonder. Could this be a pulmonary embolus? Your gut says “no,” but your brain continues to dwell on this possibility. You contemplate your dilemma and consider two competing options: stick with your impression and treat the patient for presumed muscle pain or send her for an advanced imaging study to rule out a pulmonary embolus.

In a linked paper (doi:10.1136/bmj.h4438), Hendrickson and colleagues attempt to provide a third option for the physician in a primary care office setting.1 Their goal was to find a strategy using clinical decision rules that have been derived and validated in emergency department settings and that could be transported to the primary care setting and allow the safe discharge of a low risk …