Pertinent negatives [ ← Pertinent negatives template ]
- No nausea or vomiting - No sweating - No palpitations - No syncope
- No SOB - No orthopnea - No PND - No ankle swelling
- No cough - No haemoptysis - No wheeze
- No calf pain/swelling - No DVT risk factors
- No dyspepsia or reflux - No abdominal pain - No neck / back pain
- No fever - No night sweats - No fatigue - No weight loss
- No shingles rash
- No anxiety / low mood
Further history [ ← Further history template ]
- Past Medical History - No significant past medical history
- Family History - No significant family history
- Medication history and allergies as documented in clinical notes
- Recreational drugs - Non-smoker - No alcohol - No recreational drugs
Examination [ ← Examination template | Telemedicine template ]
- Looks well, not distressed, not SOB, well-hydrated, alert and orientated, not confused
- HR = [ ] RR = [ ] Temp = [ ] BP = [ ] Sats = [ ]
- No jaundice /anaemia /clubbing /cyanosis /oedema /lymphadenopathy
- CVS: Normal pulse rhythm and character, JVP normal, HS I+II+0 no murmurs
- Calves soft non-tender no DVT, no SOA
- Chest: No respiratory distress, Good air entry, vesicular breath sounds, no crepitations /wheeze
- Abdo: Soft non-tender - No masses / LKKSB, BS normal
- Looks well, not distressed, not SOB, well-hydrated, alert and orientated, not confused
- HR = [ ] RR = [ ] Temp = [ ] BP = [ ] Sats = [ ]
- No jaundice /anaemia /clubbing /cyanosis /oedema /lymphadenopathy
- CVS: Normal pulse rhythm and character, JVP normal, HS I+II+0 no murmurs
- Chest: No respiratory distress, Good air entry, vesicular breath sounds, no crepitations /wheeze
- No / chest wall tenderness - reproduces pain exactly
- No shingles rash
- Abdo: Soft non-tender - No masses / LKKSB, BS normal
- Calves soft non-tender no DVT, no SOA
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*ECG:
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*Wells score & near patient D-dimer: [ ← Wells score: DVT | PE ]
