I am going to have to apply Wells criteria if I am going to avoid sending this patient directly to CT. I quickly read the Wells criteria which are now conveniently on my screen along with their point values. I either print the list out or jot them down on my notepad for approximately the thousandth time (I always seem to forget to ask about hemoptysis and objectively measuring leg circumference unless I do this).

The macro reminds me yet again to carefully measure for objective leg swelling. Because the chair of my department humbled me once with a great pickup of a pulmonary embolism, I have adapted the practice of either using a tourniquet and a pen for extremity measuring and comparison or, preferably, I use an actual tape measure for determining accurate circumferences. In fact, I have no choice but to do this or else my macro will be incomplete, useless, and unfulfilled. Chekhov would not approve!

My Wells macro forces me to be deliberate and careful when I suspect PE. But mostly it forces me to follow through on my intentions, a hallmark of a decent writer: if you foreshadow, you must fulfill.

Another beauty of incomplete macros is that they can aid in my clinical decision-making by reminding me of known risk percentages associated with my findings that I have not yet memorized. Once I have easily and accurately documented the components of a clinical decision rule, the statistical probabilities associated with my findings are right in front of me.

My Wells score macro spits out the following. Total score: [blank]. For my patient, I fill in 1.5 points (for tachycardia). Next, I consult my list of known risks, which look like this: Risk: <2 points = low risk (mean probability = 3.4%), 2-6 points = moderate risk (mean probability = 27.8%), >6 points = high risk (78.4%). With 1.5 points, I know my patient is in the lowest risk category.

But given the overall pre-test scenario, I am likely going to have to get a D-dimer to reassure myself that the patient is not in a hypercoagulable state. But for now, I’ve avoided a CT because my suspicion is sufficiently low. Regardless of what happens, if I or anyone else were to look back at this case, my thought process and care would be clear to any reader.

My list of incomplete macros is ever growing. Sometimes, I make new ones at the end of shift, usually by cutting and pasting out of a note I have just written. I have an incomplete macro for “Red Flags of Headache (.RFHA). I have a macro for the differential diagnosis for each quadrant of the abdominal pain (.DdxRLQ, for example). I have a macro for the Clinical Institute Withdrawal Assessment scoring and treatment decision algorithm (.CIWA).