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{{Deep vein thrombosis}}
{{Deep vein thrombosis}}
==Overview==
==Overview==
A proper history and physical exam is very important for establishing an accurate diagnosis of deep vein thrombosis (DVT) or venous thromboembolism ([[VTE]]). DVT can be either asymptomatic or associated with tenderness and swelling of the calf or [[thigh]].  One of the first steps in the management of [[DVT]] is the determination of the [[Pretest probability of DVT#Wells score|Wells score for DVT]]. Out of the 10 clinical questions in the score, 9 can be ascertained solely on the basis of history and physical exam. This underscores the importance of these variables. A high index of suspicion is also necessary to diagnose [[DVT]].
A proper history and physical exam is very important for establishing an accurate diagnosis of deep vein thrombosis (DVT). DVT can be either asymptomatic or associated with tenderness and swelling of the calf or [[thigh]].  One of the first steps in the management of [[DVT]] is the determination of the [[Pretest probability of DVT#Wells score|Wells score for DVT]], whose criteria can be ascertained solely on the basis of history and physical exam. A high index of suspicion is also necessary to diagnose [[DVT]].  DVT can be complicated by [[pulmonary embolism]] (PE); therefore, it is important to inquire about the symptoms of [[PE]] among patients suspected to have DVT.


==History==
==History==
Only 10-20% of VTE is clinically recognized, as depicted by the figure below
As depicted in the image below, the majority of patients with venous thromboembolism (VTE), that is [[DVT]], [[PE]], or both, are asymptomatic.


[[File:Challenge of Assessing VTE.JPG|300x400px|The challenge in diagnosis of VTE]]
[[File:Challenge of Assessing VTE.JPG|300x400px|The challenge in diagnosis of VTE]]


As VTE involves both DVT and PE, the patient can present with complaints of either of the disease.  
Since VTE involves both DVT and PE, the patient can present with complaints of either of the diseases. Therefore it is important to inquire about the symptoms of both diseases (the complete list of symptoms is discussed in the section [[Deep vein thrombosis history and symptoms#Symptoms|below]]).
*With PE, depending upon the severity of the disease, the patient experience
**[[Dyspnea|Shortness of breath]]
**[[Syncope|Loss of Consciousness]](in case of massive PE.)
*A smaller PE near the pleura can present with
**[[Chest pain|Pleuritic chest pain]]
**[[Cough]]
**[[Hemoptysis|Blood in sputum]].
*While with DVT, patient can complain of
**swelling of lower extremity which can be warm and tender.


In patients having known [[Deep vein thrombosis risk factors|risk factors]], a careful history should be taken. It must include the following:
If VTE is suspected or diagnosed, a complete history should be undertaken, including the following:
* History of any recent surgical procedure.
* '''Risk factors'''
* Use of [[hormonal contraception]], containing [[estrogen]].
** [[Chemotherapy]]<br>
* Recent, long-term flying.
** [[Chronic heart failure]]<br>
* History of a [[miscarriage]] (which can be a feature of thrombosis and several other disorders). 
** [[Respiratory failure]]<br>
* A family history can reveal a [[genetic disorder|hereditary]] factor in the development of DVT. A '''positive family history''' in one or more first-degree relatives under age 50 suggests the presence of a hereditary defect and/or an increased susceptibility for [[VTE]].<ref name="pmid19307525">{{cite journal| author=Bezemer ID, van der Meer FJ, Eikenboom JC, Rosendaal FR, Doggen CJ| title=The value of family history as a risk indicator for venous thrombosis. | journal=Arch Intern Med | year= 2009 | volume= 169 | issue= 6 | pages= 610-5 | pmid=19307525 | doi=10.1001/archinternmed.2008.589 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19307525  }} </ref>
** [[Hormone replacement therapy]]<br>
** [[Cancer]]<br>
** [[Oral contraceptive pills]] <br>
** [[Stroke]] <br>
** [[Pregnancy]] <br>
** [[Postpartum]] <br>
** Prior history of [[VTE]] <br>
** [[Thrombophilia]] <br>
** Advanced [[age]] <br>
** [[Laparoscopic surgery]] <br>
** Prepartum <br>
** [[Obesity]] <br>
** [[Varicose veins]]
* '''Triggers'''
** [[Bone fracture]] ([[hip]] or [[leg]]) <br>
** [[Hip replacement surgery]]<br>
** Knee replacement surgery<br>
** [[General surgery|Major general surgery]]<br>
** [[Trauma|Significant trauma]]<br>
** [[Spinal cord injury]]<br>
** Athroscopic knee surgery<br>
** [[Central venous line]]s<br>
** [[Chemotherapy]]<br>
** Bed rest for more than 3 days <br>
** Prolonged car or air travel <br>
** [[Laparoscopic surgery]] <br>
** Prepartum <br>
* '''Previous episode of [[VTE]]'''
** Age
** Location
* '''Past medical history'''
** Atherosclerosis
** Collagen vascular disease
** Heart failure
** Myeloproliferative disease
** Nephrotic syndrome
 
* '''History of [[thrombophilia]]'''
** Factor V Leiden mutation
** Prothrombin gene mutation G20210A
** Protein C or S deficiency
** Antithrombin (AT) deficiency
** Antiphospholipid syndrome (APS)
* '''Abortion'''
** Abortion at second or third trimester of pregnancy (suggestive of an inherited thrombophilia or APS)
* '''Drugs that may induce APS'''
** Hydralazine
** Phenothiazine
** Procainamide


==Symptoms==
==Symptoms==

Revision as of 13:06, 5 June 2014

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.; Assistant Editor(s)-In-Chief: Justine Cadet

Deep Vein Thrombosis Microchapters

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Assessment of Clinical Probability and Risk Scores

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History and Symptoms

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Overview

A proper history and physical exam is very important for establishing an accurate diagnosis of deep vein thrombosis (DVT). DVT can be either asymptomatic or associated with tenderness and swelling of the calf or thigh. One of the first steps in the management of DVT is the determination of the Wells score for DVT, whose criteria can be ascertained solely on the basis of history and physical exam. A high index of suspicion is also necessary to diagnose DVT. DVT can be complicated by pulmonary embolism (PE); therefore, it is important to inquire about the symptoms of PE among patients suspected to have DVT.

History

As depicted in the image below, the majority of patients with venous thromboembolism (VTE), that is DVT, PE, or both, are asymptomatic.

The challenge in diagnosis of VTE

Since VTE involves both DVT and PE, the patient can present with complaints of either of the diseases. Therefore it is important to inquire about the symptoms of both diseases (the complete list of symptoms is discussed in the section below).

If VTE is suspected or diagnosed, a complete history should be undertaken, including the following:

  • History of thrombophilia
    • Factor V Leiden mutation
    • Prothrombin gene mutation G20210A
    • Protein C or S deficiency
    • Antithrombin (AT) deficiency
    • Antiphospholipid syndrome (APS)
  • Abortion
    • Abortion at second or third trimester of pregnancy (suggestive of an inherited thrombophilia or APS)
  • Drugs that may induce APS
    • Hydralazine
    • Phenothiazine
    • Procainamide

Symptoms

Common Symptoms

The classical symptoms of DVT include:

However, sometimes there may be no symptoms referable to the location of the DVT.

There are several techniques done during a physical examination which can increase the detection of DVT. Some of these techniques are measuring the circumference of affected limb, measuring the circumference of the contra-lateral limb at a fixed point, and palpating the venous tract, which is often tender. Physical examination is unreliable for excluding the diagnosis of deep vein thrombosis and Homans sign is not recommended for this.

Less Common Symptoms

In phlegmasia alba dolens, the leg is pale and cold with a diminished arterial pulse.

In phlegmasia cerulea dolens, there is an acute and near-total venous occlusion of the entire extremity outflow, including the iliac and femoral veins. The leg is usually painful, cyanosed and edematous.

References

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