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Calf pain & suspected DVT
Two-level Wells, D-dimer, scan within 4 h or anticoagulate.
Typical consult⏱ 25 min
Investigations🔬 D-dimer ± ultrasound per Wells
Usual outcome💊 Interim apixaban if scan delayed
0–5Red flags + history5–12Examine12–17Decide17–24Treat + explain24–30Safety-net + document
1Rule out first — red flags
| If you find… | …then |
|---|---|
| Breathlessness, pleuritic pain, tachycardia, hypoxia | Suspected PE — PE pathway |
| Massive swelling, blue/white limb | Phlegmasia — vascular emergency |
| Hot swollen calf with fever | Cellulitis or septic joint (also consider Baker’s cyst rupture) |
| Active bleeding or high bleeding risk | Caution with anticoagulation — senior |
2Focused history
3Focused examination
4Decide — investigate only if it changes the plan
Two-level DVT Wells score
- Active cancer (+1)
- Paralysis or recent plaster immobilisation of the leg (+1)
- Bedridden > 3 days or major surgery within 12 weeks (+1)
- Tenderness along the deep veins (+1)
- Entire leg swollen (+1)
- Calf > 3 cm larger than the other side (+1)
- Pitting oedema in the symptomatic leg (+1)
- Collateral superficial veins (+1)
- Previous DVT (+1)
- Alternative diagnosis at least as likely (−2)
≥ 2 = DVT likely → proximal leg ultrasound within 4 h (or D-dimer + interim anticoagulation + scan within 24 h). ≤ 1 = unlikely → D-dimer; if positive → ultrasound within 4 h (or interim anticoagulation + scan within 24 h).
| Investigation | Only if… |
|---|---|
| D-dimer | DVT unlikely (Wells ≤ 1), or likely with scan delayed |
| Proximal leg vein ultrasound | DVT likely, or positive D-dimer |
| FBC, U&E, LFT, clotting | Before starting anticoagulation |
5Treat & send home
Management & advice
- Explain the plan and the scan appointment
- If DVT excluded: consider other causes; if Wells likely with negative scan, repeat scan in 6–8 days per NICE
- If confirmed: anticoagulation for at least 3 months; look for provoking factors
Refer / follow-up
- Confirmed DVT → anticoagulation / DVT clinic follow-up per local pathway
- Suspected PE → ED / ambulatory PE pathway
℞
Discharge prescription (TTO)Typical adult doses — check the BNF/BNFc, allergies, renal function, pregnancy and interactions.
| Drug | Dose | Duration / notes |
|---|---|---|
| Interim / treatment: apixaban | 10 mg twice a day for 7 days, then 5 mg twice a day | Check renal function, weight, interactions, bleeding risk |
| Alternative: rivaroxaban | 15 mg twice a day for 21 days, then 20 mg once a day (with food) | As above |
| Paracetamol | 1 g every 4–6 hours, max 4 g in 24 h (reduce if under 50 kg or liver risk) | As needed |
6Safety-net
Say it like this
We need to rule out a blood clot in your leg. Your scan is booked for [time/date]. Until then, take this blood thinner exactly as prescribed. Call 999 straight away if you get sudden breathlessness, chest pain, or cough up blood. Come back if you notice any bleeding that won’t stop, or black stools.
Come back / call 111 — or 999 if severe — if:
- Sudden breathlessness, chest pain or coughing up blood — call 999
- Bleeding that won’t stop, black stools, blood in urine (on anticoagulants)
- Leg becomes very swollen, cold or discoloured
7Patient leaflets — scan & go
Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.
8Document
Calf pain & suspected DVT — clinic note
A structure to document efficiently. It is not a completeness check — use your trust’s system and your clinical judgement.
URGENT CARE — CALF PAIN & SUSPECTED DVT
PRESENTING COMPLAINT:
HISTORY
Onset, swelling, pain:
Risk factors: surgery/immobility, cancer, previous VTE, pregnancy/postpartum, combined pill/HRT, long travel:
Breathlessness, chest pain, haemoptysis:
Bleeding risk, renal function, weight, current medicines:
RED FLAGS (record present / absent)
[ ] Breathlessness, pleuritic pain, tachycardia, hypoxia
[ ] Massive swelling, blue/white limb
[ ] Hot swollen calf with fever
[ ] Active bleeding or high bleeding risk
PMH:
DRUG HISTORY:
ALLERGIES:
SOCIAL (job / who is at home / driving):
OBSERVATIONS: RR SpO2 HR BP Temp (NEWS2 )
EXAMINATION
Obs incl. SpO₂:
Measure calf circumference 10 cm below tibial tuberosity (both legs):
Pitting oedema, tenderness along deep veins, collateral veins:
Alternative causes: cellulitis, ruptured Baker’s cyst, muscle injury:
DECISION RULE — Two-level DVT Wells score: result ______
INVESTIGATIONS: none required / D-dimer, Proximal leg vein ultrasound, FBC, U&E, LFT, clotting — result:
IMPRESSION:
PLAN
Treatment / TTO (drug, dose, duration):
Advice given:
Leaflet given (QR / printed): DVT (deep vein thrombosis)
Follow-up / referral:
SAFETY-NETTING (told to return / call 111 / 999 if):
- Sudden breathlessness, chest pain or coughing up blood — call 999
- Bleeding that won’t stop, black stools, blood in urine (on anticoagulants)
- Leg becomes very swollen, cold or discoloured
Patient understands and agrees with the plan: Y / N
Seen by: Grade: Date/Time:
✓Guidelines
Doses are typical adult doses drawn from the guidance above. Always check the current BNF/BNFc and your local antimicrobial policy.
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