Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Suspected deep vein thrombosis (DVT)
Confirmed DVT – follow-up visit
Evaluation for complications of DVT (e.g., pulmonary embolism – PE)
II. History of Present Illness:
New DVT:
Sudden onset of unilateral leg pain, swelling, tenderness, redness (symptoms may be absent or atypical)
Risk factors for DVT (recent surgery, prolonged immobilization, medical conditions, medications)
Follow-up visit:
Improvement or worsening of symptoms since diagnosis
Adherence to anticoagulation therapy (blood thinners)
Any new symptoms suggestive of PE (chest pain, shortness of breath, coughing)
III. Past Medical History:
Underlying medical conditions (cancer, chronic inflammatory diseases)
Previous history of DVT or PE
Risk factors for DVT (surgery, prolonged immobilization, obesity, varicose veins)
Current medications (hormonal therapy, birth control pills)
IV. Social History:
Smoking history
Recent travel (increased risk for DVT)
V. Physical Exam:
Vital signs (BP, HR, RR, Temp) – may be elevated with PE
Lower extremity exam:
Signs of DVT (unilateral leg swelling, tenderness, redness, positive Homans’ sign)
Comparison of both legs for asymmetry
VI. Diagnostic Studies (consider as appropriate):
Doppler ultrasound: Gold standard for diagnosing DVT, evaluates blood flow and identifies blood clots in deep veins.
Venography (may be done in specific cases): X-ray imaging of veins with contrast dye to visualize blood flow and identify clots.
D-dimer test: Rapid blood test to rule out DVT (negative test result makes DVT unlikely, but positive test requires further evaluation with ultrasound).
VII. Assessment:
Suspected or confirmed DVT based on clinical presentation, risk factors, and imaging studies (if performed).
Location and extent of the clot (proximal DVT in the thigh is more serious than distal DVT in the calf).
Severity of symptoms and potential for complications (PE).
VIII. Plan:
Treatment for DVT aims to prevent further clot formation and reduce the risk of PE:
Anticoagulation therapy: Blood thinners (warfarin, heparin, direct oral anticoagulants) are mainstay of treatment.
Compression stockings: Improve circulation and reduce leg swelling.
Early ambulation: Promote blood flow and reduce clot formation.
Thrombolysis or thrombectomy (clot removal): May be considered in some high-risk cases with large clots.
Evaluation for PE if clinically suspected (chest X-ray, CT scan with contrast)
IX. Prognosis:
Discuss the prognosis based on the location and extent of the clot, presence of complications, and adherence to treatment.
The importance of long-term anticoagulation therapy to prevent recurrent DVT may be needed.
X. Notes:
Include any additional observations or concerns, such as patient’s understanding of the diagnosis and treatment plan, potential side effects of medications, the need for regular follow-up appointments, and fall prevention measures to avoid future injuries.
XI. Resources:
Consider providing patient education materials on deep vein thrombosis from reputable sources (e.g., National Heart, Lung, and Blood Institute (NHLBI), American College of Chest Physicians (ACCP)).