The Wells Score Field Is Where the Clinical Reasoning Starts
Most CTPA study records are designed around the scan. This one is designed around the clinical reasoning that preceded the scan — and that distinction changes what the data is worth. The Wells score field sits upstream of the CTPA indication, which is where it belongs. When you retrospectively audit a cohort of CTPA-negative patients, the Wells distribution tells you whether pre-test probability was appropriately applied or whether low-probability patients were being scanned reflexively because the D-Dimer came back elevated and nobody wanted to miss a PE.
That audit is only possible if the Wells score is captured at the point of decision, not reconstructed from notes weeks later.
From Presenting Complaint to Outcome: The Full Clinical Arc
The template is structured to follow the actual clinical pathway for PE workup, and the fields are specific enough to be analytically useful rather than just documentarily complete.
Presenting Complaint captures eleven symptoms as a multichoice: breathlessness, chest pain, syncope, hemoptysis, leg pain/swelling, palpitation, orthopnea, giddiness, fever, incidentally found PE in CT abdomen, and post-COVID screening. That last two entries matter. Incidentally found PE in CT abdomen is a distinct epidemiological category — these patients often have lower clot burden, less hemodynamic compromise, and different anticoagulation decisions than symptomatic PE. Capturing it separately means you can pull that subset for analysis rather than having it dilute your symptomatic cohort.
Co-morbidities covers twenty-two risk factors including prothrombotic state, prior DVT, recent surgery or trauma, malignancy, CKD, CLD, PAH, pregnancy/postnatal, OCP use, recent COVID-19, and immobilization. The multichoice structure means a patient with IHD, COPD, and recent COVID-19 gets all three flagged — not collapsed into an "other" free text field where they'll never be searchable. At 300 records, you can filter for PE patients with concurrent malignancy who required thrombolysis and look at their outcomes.
Clinical signs is the most granular acute assessment field, capturing cyanosis, tachycardia, hypotension, tachypnea, desaturation, raised JVP, S3/S4, loud P2, wide split S2, and bilateral leg examination findings. Loud P2 and wide split S2 together suggest acute RV pressure overload — the hemodynamic signature of massive or submassive PE. Logging these as discrete fields rather than free-text exam findings allows pattern analysis: how often did classic auscultatory signs correlate with RA/RV dilatation on echo?
The Diagnostic Cascade: ECG, ABG, Echo, Radiology
The ECG field captures S1Q3T3, RBBB, RAD, non-specific ST-T changes, arrhythmias, and T-wave inversions in V1/V5/V6. The pattern is nonspecific in isolation, but in the context of a high Wells score and elevated D-Dimer, RBBB with sinus tachycardia tells a story. The field captures the pattern, not an interpretation, which is the correct approach for a research-grade dataset.
ABG — PO2, PCO2, pH, and metabolic acidosis secondary to shock — is a free text field, which accommodates the variability of how ABG results are documented. Echo findings include RA/RV dilatation, McConnell's sign (global RV hyperkinesia excluding apex), TR/PR, PAH, intracardiac thrombus, and LV dysfunction. These are the echo parameters that determine whether PE is hemodynamically significant and drive the thrombolysis decision.
CTPA finding is binary: PE or no PE. That simplicity is correct at the top level. The nuance lives in CTPA report, the free text field where clot burden, laterality, segmental versus subsegmental extension, and concurrent findings get documented. The binary field enables fast filtering; the report field enables depth.
Outcome Variables That Close the Loop
Three sentences: Treatment given — thrombolysis or anticoagulation — maps directly to PE severity classification. Mechanical ventilation distinguishes no support, NIV, and invasive ventilation, which is the field that separates intermediate-risk from high-risk PE in any outcomes analysis. Final outcome — discharge or death — is the terminal variable that makes everything upstream meaningful for mortality risk stratification.