Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute onset of unilateral lower extremity pain, swelling, and erythema. Symptoms began [insert duration]. Patient reports [positive/negative] history of recent immobilization, long-distance travel, surgery, malignancy, or personal/family history of VTE. Denies chest pain, shortness of breath, or hemoptysis.
Clinical Examination Findings
Extremity examination reveals significant unilateral edema (circumference difference >3cm), localized tenderness along the deep venous system, and palpable cords. Homanโs sign is [positive/negative]. Skin is warm to touch with [erythema/cyanosis]. Distal pulses are intact (2+). No signs of superficial thrombophlebitis.
Treatment Protocol
Initiate therapeutic anticoagulation with [LMWH/DOAC] per protocol. Compression stockings (Class II) prescribed. Advise early ambulation as tolerated. Monitor for signs of bleeding or extension of thrombus. Follow-up Doppler ultrasound scheduled for [date].