Deep vein thrombosis physical examination
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Resident Survival Guide |
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Kashish Goel, M.D.; Justine Cadet; Rim Halaby, M.D. [3]
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Overview
The physical examination may be completely normal in patients with DVT. A high degree of suspicion is necessary for early identification of venous thrombosis, as sometimes these patients are admitted with a different complaint and a thorough physical exam gives a clue to the diagnosis. The typical symptoms of DVT include unilateral calf or thigh tenderness, swelling, and/or erythema. Since DVT can be complicated by pulmonary embolism (PE), the physical exam should include assessment of the signs of PE, such as tachypnea and tachycardia among others.
Physical Examination
Vitals
- Temperature, blood pressure, heart rate and respiratory rate may all be within normal range in DVT.
- Among patients with DVT complicated by PE, the following might be present:
- Blood pressure lower than baseline, suggestive of cardiogenic shock (associated with tachycardia and end organ hypoperfusion)
- Tachycardia (26%)[1]
- Tachypnea (70%)[1]
- Low grade fever
Extremities
One of the most significant part of the physical exam in a patient with a suspected DVT is the measurement of the size of both legs at the same point (usually measured vertically from the knee joint), to assess for differences. If a difference is detected, and there is suspicion of DVT, further tests should be conducted. The complete exam of the extremities should include the assessment of all the following:
- Unilateral calf or thigh tenderness
- Unilateral calf or thigh pitting edema
- Unilateral calf or thigh swelling
- Difference in calf diameters > 3 cm (the calf circumference is measured 10 cm below the tibial tuberosity)
- Difference in thigh diameters (the thigh circumference is measured 10-15 cm above the patella)
- Unilateral calf or thigh warmth
- Unilateral calf or thigh erythema
- Palpable cord (a thickened palpable vein suggestive of thrombosed vein)
- Dilatation of unilateral collateral superficial veins
- Localized tenderness upon palpation of the deep veins
- Posterior calf
- Popliteal fossa
- Inner anterior thigh
Skin
- Generalized edema (suggestive of right heart failure, or nephrotic syndrome)
- Cyanotic and cold skin, lips, nail bed (suggestive of cardiogenic shock)
Abdomen
- Ascites (suggestive of Budd Chiari syndrome, that is hepatic vein thrombosis)
- Hepatomegaly (suggestive of Budd Chiari syndrome, that is hepatic vein thrombosis)
Heart
Among patients with DVT complicated by PE, the following might be present:
- Cardiac murmur
- Graham-Steell murmur (suggestive of pulmonary regurgitation)
- Accentuated P2
- S3 or S4 gallop (suggestive of RV dysfunction)
- Jugular venous distention (suggestive of right heart failure)
Lungs
Among patients with DVT complicated by PE, the following might be present:
References
- ↑ 1.0 1.1 Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P; et al. (2008). "Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)". Eur Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870.