MDM - Deep Vein Thrombosis (DVT) Rule Out

[##]-year-old [male/female] with [right/left calf pain/swelling] with history and exam consistent with low risk for deep vein thrombosis and likely [muscle strain].

Initial consideration in this patient included deep vein thrombosis (DVT), muscle strain, edema, cellulitis, arterial occlusions, [differential diagnoses], and pulmonary embolism (PE) among others.

Patient presented with complaint of [leg swelling/calf pain] with [no] recent [flight/surgery/immobilization] within the past [days/weeks] prior to onset of symptoms.  Patient noted to have [low/moderate/high] risk Wells score for DVT at this time.  A D-dimer was obtained and noted to be [negative/positive].  [Bedside/Formal] ultrasound obtained of the [right/left/bilateral leg(s)] with no evidence of clot and completely compressible vessels at visulaized portions of the common femoral, greater saphenous, superficial femoral, deep femoral, or popliteal veins.  [We discussed limitations of bedside ultrasound evaluation, specifically limited ability to visualize the smaller vessels of the calf.]  Patient felt to be low risk at this time with no indication for initiation of anticoagulation.  Discussed need for follow up within 1-2 weeks for repeat evaluation with ultrasound for persistent symptoms, and the patient demonstrated understanding and agreement.  No report of chest pain, shortness of breath, or other symptoms or findings suggestive of PE at this time.  Patient noted to have [some/mild/significant] improvement after treatment with [specify] in the ED.

Prior to discharge, we discussed return precautions, specifically for evidence of chest pain or shortness of breath suggestive of PE, treatment [with specify interventions], and follow up with primary care doctor within [2-3 days/1 week] to arrange for repeat US for DVT, and the patient demonstrated understanding and agreement.