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Physical examination findings in deep venous thrombosis
Abstract
DVT is a potentially serious disease and can serve as a marker for PE, an entity with even higher morbidity. Thus, it is critically important that emergency physicians consider this diagnosis in patients who present with suspicious symptoms. Recognition of alternative conditions, such as compartment syndrome, septic arthritis, and cellulitis, is also important for optimal care. Because physical examination is only 30% accurate for DVT, it serves to increase clinical suspicion in patients at risk but cannot be used to eliminate the possibility of thromboembolic disease. Because of this limitation, the diagnosis of DVT should be pursued using adjunctive testing in any patient with unexplained limb pain or swelling. Duplex sonography is currently the initial diagnostic study of choice for evaluation of DVT and, if test results are negative, it should be repeated serially if the clinical suspicion is high.
... Patients may also present with symptoms of PE: shortness of breath, tachypnea, pleuritic chest pain or hypoxemia. Extremity symptoms usually begin gradually and progress over days, whereas PE symptoms usually have sudden onset [7]. ...
... Superficial and collateral veins may be prominent. Homans' sign, pain in the posterior calf with passive dorsiflexion of the foot, has been shown to be unreliable in diagnosis, positive in 8-56% of patients with DVT, and greater than 50% of symptomatic patients without DVT [7,8]. Patients with major occlusion of the ileofemoral venous system may show a bluish discoloration of the leg, or, if tissue pressures exceed perfusion pressures, the leg may turn white. ...
... DVT can also cause fever, although it typically is low-grade. A ruptured Baker cyst can cause symptoms in distinguishable from DVT, including a positive Homans' sign [7,8]. A Baker cyst is a popliteal cyst filled with synovial fluid behind the knee. ...
Unilateral calf swelling and pain is not a common complaint in the pediatric emergency department. We present a case of a 17-year-old adolescent boy with no past medical history who presented with left leg swelling and pain while taking prednisone and isotretinoin. He was found to have an extensive occlusive thrombus throughout the deep venous system in his left leg. He was later diagnosed with May-Thurner syndrome, an anatomic variant in which the right iliac artery compresses the left iliac vein. We review the differential diagnosis, diagnostic workup, and initial ED management of deep venous thrombosis and provide a brief discussion of May-Thurner syndrome and the association of isotretinoin and vascular thrombi.
... According to Kennedy et al., 26 the evolution timeline of the illness is important because DVT usually starts gradually and progresses over several days. On the other hand, sudden onset pain is more consistent with muscle tear or musculoskeletal lesion. ...
The aim of this study is to reassess the diagnostic evaluation using duplex scanning in non-hospitalized patients, suspected of having deep vein thrombosis (DVT) of the lower limbs.
In a period of 4 years, 589 patients suspected of having DVT of the lower limbs were submitted to duplex scanning for diagnostic confirmation. The patient complaints were pain, edema or color alteration of the extremity, associated with a risk factor or not. The time span between the beginning of symptoms and the ultrasound was considered as well, with the examination being conducted only on the member that presented the signs or symptoms, or on both in case of suspicion of pulmonary embolism. This study features 203 male patients and 386 female patients, aged 19 to 93.
In Group I, of the 139 patients who displayed acute venous thrombosis (N=77), 55.4% had at least one associated risk factor; in Group II, of the 96 patients with chronic thrombosis (N=72), 75% had an associated risk factor that predominated the previous history of illness; and in Group III, in 354 patients without DVT, 161 of them (45.5%) featured some associated risk factor.
It was concluded that duplex scanning is a useful tool for offering a prompt and efficient diagnosis of venous thrombosis as well as displaying alterations in adjacent structures, thus facilitating the differential diagnostic with other conditions, although in many patients (32.7%) the examination was done unnecessarily, with irrelevant clinical signs and in the absence of any evident risk factor.
Prior to the advent of advanced imaging techniques, physicians devised a variety of physical examination maneuvers, described as signs of medical eponyms, as methods to detect lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) or venothromboembolism (VTE). Eponyms are present in the medical literature because they often reflect a simpler and concise way of describing a phenomenon. They are honorific terms ascribed to individuals for their accomplishments, which may include identifying such things as a disease, structure, sign, test, procedure, syndrome, maneuver, medical device, or surgical technique. Eponyms are derived from the name of a person, but not necessarily the first, who reported, described, or significantly contributed to the clinical understanding of the occurrence. The use of eponyms remains controversial and important questions have been raised regarding their appropriateness. Although there have been instances where eponyms were abandoned, the remainder are by and large embedded within the established and contemporary medical literature making their disappearance unlikely.
Preemptive heparinisation for clinically suspected DVT is perceived as safe practice with virtually no complications reported.5 However, this case highlights the risk of causing acute compartment syndrome when heparin is given for clinically-suspected DVT, when the actual diagnosis is a gastrocnemius tear.
Significant patient morbidity and mortality is associated with the development of venous thromboembolism (VTE) following orthopedic surgery. The majority of the literature supports proper prophylaxis following major orthopedic surgery involving hip and knee procedures. Foot and ankle surgery, however, is starkly contrasted because of the lack of recommendations. This article provides a comprehensive overview of the risk factors and incidence of VTE in foot and ankle surgery while also outlining the newest literature guidelines for prophylaxis.
As discussed in this review, DVT and PE are dangerous clinical diagnoses that can occur following foot and ankle surgery. The authors have provided a clinical protocol, a risk assessment tool, and treatment guidelines for this condition that can be applied to the everyday practice of foot and ankle surgeons. Unlike recommendations in previous studies, the authors believe that podiatric and orthopedic surgeons operating on the foot and ankle should evaluate each patient carefully and consider pharmacologic prophylaxis against DVT formation when significant risk factors are present.
For cellulitis that does not respond to conventional antimicrobial treatment, clinicians should consider, among other explanations, several noninfectious disorders that might masquerade as infectious cellulitis. Diseases that commonly masquerade as this condition include thrombophlebitis, contact dermatitis, insect stings, drug reactions, eosinophilic cellulitis (the Wells syndrome), gouty arthritis, carcinoma erysipelatoides, familial Mediterranean fever, and foreign-body reactions. Diseases that uncommonly masquerade as infectious cellulitis include urticaria, lymphedema, lupus erythematosus, sarcoidosis, lymphoma, leukemia, Paget disease, and panniculitis. Clinicians should do an initial diagnostic work-up directed by the findings from a detailed history and complete physical examination. In many cases, skin biopsy is the only tool that helps identify the correct diagnosis. Special tests may also be needed.
Venous thromboembolism (VTE) is the third most life-threatening cardiovascular disease in the USA, affecting a significant number of people each year. The treatment of VTE, encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), includes both medical and interventional therapies. The severity of the disease varies, with some patients requiring only outpatient medical management, while others may experience significant lifelong morbidity, limb loss, or death. This chapter discusses the pathophysiology of VTE and its historical origins and treatments. Clinical manifestations, diagnostic and treatment methods, and procedural techniques are reviewed.
The absence of a diagnostic test to determine actual or incipient thromboembolic disease makes an analysis of this condition basically unscientific and subject to much variation. However, the data from over 1,000 cases of thrombophlebitis in 2 general hospitals show much agreement on diagnosis, diagnostic errors, methods of management, and inadequacies of treatment. This is an analysis of the common problems in the diagnosis and treatment of thrombophlebitis, with suggestions for improvement.
Material
During the past 10 years, there were 608 cases of thrombophlebitis at University Hospital; at Mount Carmel Hospital there have been 409 cases in the past 14 years. These patients were treated by a large number of physicians, many of whom are on the staffs of both hospitals. There were 611 females and 406 males. Age and sex distribution were similar in the 2 hospitals. The age distributions are shown in Figure 1. A similar age range
Eighty-five patients suspected of having lower-extremity deep venous thrombosis (DVT) participated in a prospective study to test the diagnostic accuracy of four noninvasive techniques: Doppler ultrasonic flow study, electrical impedance plethysmography, the serial dilution protamine sulfate test, and an extensive physical examination. Ascending radiocontrast phlebography was the diagnostic standard of reference. We found that (1) when both Doppler and impedance examinations were positive, the diagnosis of DVT could be considered virtually certain; (2) impedance and Doppler examinations, when used in combination, were reliable screening tests capable of establishing or excluding the presence of thigh DVT; (3) physical examination and the serial dilution protamine sulfate test were unreliable screening techniques for DVT; (4) techniques other than the noninvasive methods investigated were needed to reliably detect or to exclude popliteal and calf DVT.
(Arch Intern Med 136:1091-1096, 1976)
• Serial impedance plethysmography has been shown to be a safe and effective alternative to venography in the management of patients with clinically suspected acute venous thrombosis. The rate of normalization of an initial abnormal impedance plethysmogram and, consequently, the usefulness of impedance plethysmography in the management of patients with recurrent symptoms is, however, unknown. In a prospective cohort follow-up study, 161 consecutive patients with proved venous thrombosis and abnormal impedance plethysmograms were studied for one year. After 3, 6, 9, and 12 months, the impedance plethysmograms had normalized in 67%, 85%, 92%, and 95% of the patients, respectively. Thirty-five patients (22%) returned with clinically suspected recurrent thrombosis, of whom 31 had normal impedance plethysmograms prior to their return. In 18 of these patients, repeated tests were normal; these patients did not undergo anticoagulant therapy, and follow-up disclosed no subsequent adverse consequences. In the other 13 patients, the test again became abnormal; 11 patients were shown by venograms to have recurrent deep-vein thrombosis. Consequently, 29 (83%) of the 35 patients in whom the suspicion of recurrent thrombosis arose could have been managed with impedance plethysmography alone without the necessity for venography or anticoagulant therapy. It is concluded that normalization of impedance plethysmography tests occurs in almost all patients within nine months, and that serial impedance plethysmography is useful for patient management in nearly 90% of patients presenting with recurrent symptoms.
(Arch Intern Med 1988;148:681-683)
Objective.
—To determine the frequency of pulmonary embolism in patients admitted for treatment of deep venous thrombosis.Design.
—An open, multicenter, dose-ranging study to assess the safety and pharmacokinetic characteristics of tissue-type plasminogen activator in deep venous thrombosis and pulmonary embolism. Perfusion and ventilation lung scans, chest roentgenograms, and venograms (in deep venous thrombosis) or pulmonary angiograms (in pulmonary embolism) were obtained before and 24 hours after inception of therapy. Heparin therapy was then administered.Settings.
—Five tertiary-care hospitals.Patients.
—All patients with suspected deep venous thrombosis or pulmonary embolism seen from August 1987 through November 1988 entered the study if they met inclusion criteria and if the diagnosis was confirmed by venogram (deep venous thrombosis) or pulmonary angiogram (pulmonary embolism).Interventions.
—All patients received tissue-type plasminogen activator followed by intravenous heparin therapy.Main Outcome Measures.
—The primary measure was the frequency of pulmonary embolism in patients with deep venous thrombosis who had no symptoms of pulmonary embolism. This was not the original purpose of the study but emerged as an important finding as the data were analyzed.Results.
—Nearly 40% of patients with deep venous thrombosis who had no symptoms of pulmonary embolism had evidence of pulmonary embolism based on ventilation-perfusion scan and chest roentgenogram findings.Conclusions.
—Because all of those considered to have embolism had so-called high-probability scan results, the frequency of embolism reported likely represents the minimum incidence of pulmonary embolism in patients with deep venous thrombosis who have no embolic symptoms. These data emphasize that venous thromboembolism is one disorder.(JAMA. 1994;271:223-225)