Deep Vein Thrombosis GP Referral Form



Deep Vein Thrombosis GP Referral Form

• Obvious other differential diagnoses to have been excluded as per aide memoire below

and

• Well’s Score to be available at the time of discussion with the admitting team.

The differential diagnoses considered today following history and examination were

|Differential diagnoses considered |Clinical impression |

| |Yes No Maybe |

|Calf muscle strains/tears/haematomas | | | |

|Ruptured Baker’s cyst | | | |

|Cellulitis | | | |

|Superficial thrombophlebitis | | | |

|Worsening of chronic leg swelling/oedema, often bilateral | | | |

|Abscess | | | |

|Arterial compromise | | | |

|Possibility of bony injury | | | |

|Osteomyelitis | | | |

|Acute spontaneous compartment syndrome (rare) | | | |

Well’s Clinical Probability Score

|After History & Examination |Circle as appropriate |Points-2 to +8 |

|Malignancy, including treatment up to 6 months before |Y/N |+1 |

|Leg trauma OR surgery OR immobilisation in POP cast |Y/N |+1 |

|Bedridden for more than 3 days OR surgery within last 4 weeks |Y/N |+1 |

|Tenderness along the line of femoral or popliteal veins - not just calf |Y/N |+1 |

|tenderness | | |

|Entire swollen leg |Y/N |+1 |

|Calf circumference more than 3cm larger - measure 10cm below tibial tuberosity |Y/N |+1 |

|Pitting oedema |Y/N |+1 |

|Dilated collateral superficial veins (non-varicose) |Y/N |+1 |

|Alternative diagnosis as, or more likely than DVT |Y/N |- 2 |

| |Total | |

 

Clinical probability of DVT

| |Total Points |

|Low |-2,-1 or 0 |

|Intermediate |+1 or +2 |

|High |+3 or more |

Patient Information

|Date | |

|Time | |

|Patient Name | |

|Patient DOB | |

|Patient Address | |

|Patient CHI | |

|Brief History of Presenting Complaint including any risk factors for| |

|abnormal thrombotic events | |

|PMHx | |

|Current Medications | |

|Allergies | |

|IF required could this patient manage warfarin therapy safely? | |

|Name of referring GP (block capitals): |Signature: |

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