D-DIMER Mandatory Request Information Please print, complete and send with sample
Patient name:
Date of birth:
Patient Number:
Consultant/GP:
/
A low D-dimer is useful in the exclusion of VTE when the Wells score is low. Testing in the management of VTE should be according to NICE clinical guideline 144. To ensure that only appropriate tests are performed, this form must be completed and sent to the laboratory with every D-Dimer request.
Requests received without this form will not be tested.
1. The test has low specificity for VTE and is raised in conditions such as inflammatory diseases, infection, cancer, pregnancy and increasing age. Therefore, in majority of inpatients, this test will not be helpful.
2. If DVT Wells Score is 2 or PE Wells Score is 4.5, do not order the test initially, as the result will not affect management of the patient. These patients should all undergo imaging to confirm VTE.
3. Only request D Dimer with a likely DVT Wells score if the initial proximal ultrasound scan is negative (reference: DVT Diagnosis algorithm 1).Please indicate if initial ultrasound scan is:
Positive Negative
Suspected (tick one box please): DVT PE DIC
Complete the appropriate Wells score for DVT or PE below:
Two-level DVT Wells Score Points / Two-level PE Wells Score Points
Active cancer in last 6 months / 1 / / Signs and symptoms of DVT. Minimum of leg swelling and tender deep veins / 3.0 /
Paralysis or recent POP immobilisation / 1 / / Alternative diagnosis is less likely than PE / 3.0 /
Recently bedridden >3 days or major surgery in last 12 weeks / 1 / / Heart rate >100 bpm / 1.5 /
Tenderness along deep venous system / 1 / / Immobilisation > 3 days or surgery in previous 4 weeks / 1.5 /
Entire leg (thigh and calf) swollen / 1 / / Previous DVT/PE / 1.5 /
Calf circumference >3 cm difference / 1 / / Haemoptysis / 1.0 /
Pitting oedema confined to symptomatic leg / 1 / / Active cancer (treatment within last 6 months, ongoing or palliative) / 1.0 /
Dilated collateral (non-varicose) superficial veins in symptomatic leg only / 1 /
Previously documented DVT / 1 /
Another diagnosis at least as likely as DVT / –2 /
Clinical probability simplified score / Clinical probability simplified score
DVT ‘likely’ 2 points or more: DDimer not indicated / PE ‘likely’ – 4.5 points or more: DDimer not indicated
DVT ‘unlikely’ less than 2 points / PE ‘unlikely – 4 points or less
Name: Signature:
Consultant/GP: Bleep number:
Date: Time of sample:
Diagnostic investigations for deep vein thrombosis
Document title: DDimer Mandatory Request Information / Page 1 of 3
WARNING: This document is only controlled if viewed electronically from its original location if the hard copy is validated / Date of issue: Dec 2015
Approved by: Consultant Haematologist / Master copy registered on Pathology Qpulse database