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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