Diagnostic Checklist

  1. Apply Clinical Evaluation Model
Clinical Parameter Score
Active cancer (treatment ongoing or within previous 6 months or palliative) 1
Paralysis, paresis, or recent plaster immobilization of the lower extremities 1
Recently bedridden for >3 days or major surgery within 4 weeks 1
Localized tenderness along the distribution of the deep venous system 1
Entire leg swelling 1
Calf swelling by >3 cm when compared with the asymptomatic leg (measured 10 cm below the tibial tuberosity)† 1
Pitting edema (greater in the symptomatic leg) 1
Collateral superficial veins (nonvaricose) 1
Alternative diagnosis as likely or greater than that of deep vein thrombosis -2
† in patients with symptoms in both legs, the more symptomatic leg was used

  1. Total Score Assigned Probability
 High Medium Low
  > or equal to 3 1-2 < or equal to 0
 

  1. Results of Doppler Ultrasonography
      Normal
      Abnormal

  2. If ultrasonogram results are not diagnostic and/or the case is high risk, consider venogram
      Venogram Results
        Normal
        Abnormal

  1. Ruled Out DVT
      Yes
      No

  2. If DVT is not ruled out, proceed to Patient Inclusion/ Contraindication Checklist

Physician Signature/Date

 

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