Deep vein thrombosis history and symptoms: Difference between revisions

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'''Editors-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]] '''Associate Editor-In-Chief''': [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]
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| [[File:Siren.gif|30px|link=Deep vein thrombosis resident survival guide]]|| <br> || <br>
| [[Deep vein thrombosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; {{AE}} {{CZ}} ; [[User:Kashish Goel|Kashish Goel, M.D.]]; [[User:Justine Cadet|Justine Cadet]]; {{Rim}}
{{Deep vein thrombosis}}
{{Deep vein thrombosis}}
==Overview==
==Overview==
In 25% of all hospitalized patients, there may be '''some''' form of DVT, which often remains clinically '''in-apparent''' (unless [[pulmonary embolism]] develops). There are several techniques during physical examination to increase the detection of 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 and Symptoms==
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]]
 
===Common Symptoms of DVT===
The classical symptoms of DVT include:
* [[Pain and nociception|Pain]] in the affected area
* [[Swelling]] of the affected area
* [[Erythema]] around the affected area
* [[Dilation]] of the surface veins and [[erythema]] of the overlying area
 
However, sometimes there may be no symptoms referable to the location of the DVT.
 
Shown below is a picture depicting unilateral swelling and redness in a leg affected with DVT.


==Symptoms==
[[image:Deep vein thrombosis Unilateral leg swelling and redness.jpg|left|thumb|250px|Unilateral swelling and redness in a leg affected with DVT By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=9444797]]
The classical symptoms of DVT include
*[[Pain and nociception|Pain]] in the affected area.
*[[Swelling]] of the affected area.
*Dilation of the surface veins and redness of the overlying area.


There may be no symptoms referable to the location of the DVT.  .
<br style="clear:left" />


There are several techniques during physical examination to increase the detection of DVT, such as measuring the circumference of the affected and the contra-lateral limb at a fixed point (to objective [[edema]]), and palpating the [[vein|venous]] tract, which is often tender.  Physical examination  is unreliable for excluding the diagnosis of deep vein thrombosis.
===Less Common Symptoms of DVT===
* In [[phlegmasia alba dolens]], the leg is pale and cold with a diminished arterial [[pulse]].  


In phlegmasia alba dolens, the leg is pale and cool with a diminished arterial pulse due to spasm. It usually results from acute occlusion of the iliac and femoral veins due to DVT.  
* In [[phlegmasia cerulea dolens]], there is an acute and near-total venous occlusion of the entire extremity outflow, including the [[iliac vein|iliac]] and [[femoral vein]]s. The leg is usually painful, [[cyanosis|cyanosed]] and [[edema|edematous]].


In phlegmasia cerulea dolens, there is an acute and nearly total venous occlusion of the entire extremity outflow, including the iliac and femoral veins. The leg is usually painful, cyanosed and oedematous. Venous gangrene may supervene.
===Symptoms of PE===
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.  Symptoms of PE include:
* [[Dyspnea]] (78–81%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref> <br>
* [[Pleuritic chest pain]] (39–56%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref>  <br>
* [[Fainting]] (22–26%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref> <br>
* [[Cough]] (20%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
* [[Substernal chest pain]] (12%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
* [[Hemoptysis]] (11%)<ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref><br>
* [[Wheezing]] <br>
* [[Cyanosis]] (11%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref> <br>
* [[Fever]] (7%)<ref name="pmid24182642">{{cite journal| author=Cohen AT, Dobromirski M, Gurwith MM| title=Managing pulmonary embolism from presentation to extended treatment. | journal=Thromb Res | year= 2014 | volume= 133 | issue= 2 | pages= 139-48 | pmid=24182642 | doi=10.1016/j.thromres.2013.09.040 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24182642  }} </ref> <br>
* Symptoms suggestive of [[shock]] (in case of massive PE)
** [[Altered mental status]]
** [[Cold extremities]]
** [[Cyanosis]]
** [[Oliguria]]


It is vital that the possibility of pulmonary embolism be included in the history, as this may warrant further investigation (''see'' [[pulmonary embolism]]).
===Complete History===
If VTE is suspected or diagnosed, a complete history should be elicited, including the following:
* '''Risk factors'''<ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>
** [[Chemotherapy]]<br>
** [[Chronic heart failure]]<br>
** [[Respiratory failure]]<br>
** [[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'''<ref name="pmid12814980">{{cite journal| author=Anderson FA, Spencer FA| title=Risk factors for venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I9-16 | pmid=12814980 | doi=10.1161/01.CIR.0000078469.07362.E6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814980  }} </ref><ref name="pmid18757870">{{cite journal| author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P et al.| title=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). | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 18 | pages= 2276-315 | pmid=18757870 | doi=10.1093/eurheartj/ehn310 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18757870  }} </ref>
** [[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 of diseases associated with hyperviscosity'''
** [[Atherosclerosis]]
** [[Collagen vascular disease]]
** [[Heart failure]]
** [[Myeloproliferative disease]]
** [[Nephrotic syndrome]]
** [[Autoimmune diseases]]
**[[Polycythemia vera]]
** [[Hyperhomocysteinemia]]
** [[Paroxysmal nocturnal hemoglobinuria]]
** [[Waldenstrom macroglobulinemia]]
** [[Multiple myeloma]]
* '''History of [[thrombophilia]]'''
** [[Factor V Leiden mutation]]
** [[Prothrombin gene mutation G20210A]]
** [[Protein C]] or [[Protein 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 increase the risk of VTE'''
** [[Hydralazine]]
** [[Phenothiazine]]
** [[Procainamide]]
** [[Tamoxifen]]
** [[Bevacizumab]]
** [[Glucocorticoids]]
* '''Family history (suggestive of [[inherited thrombophilia]])'''
** Deep vein thrombosis
** Pulmonary embolism
** Recurrent [[miscarriage]]
* '''Social history'''
** Heavy [[cigarette smoking]] (>25 cigarettes per day)
** [[Intravenous drug use]] (if injected directly in [[femoral vein]])
** [[Alcohol]]


A careful history should be taken, in patients having known [[Deep vein thrombosis risk factors|risk factors]], including
==References==
*Use of [[hormonal contraception]], containing [[estrogen]]
*recent long-haul flying,
*History of [[miscarriage]] (which is a feature of several disorders that can also cause thrombosis). 
A family history can reveal a [[genetic disorder|hereditary]] factor in the development of DVT.


<gallery>
{{reflist|2}}
Image:Extremities dvt.jpg|Deep venous thrombosis
Image:Extremities dvt2.jpg|Deep venous thrombosis
Image:Extremities dvt3.jpg|Deep venous thrombosis 
</gallery>


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Latest revision as of 19:45, 6 March 2018
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]

Deep Vein Thrombosis Microchapters

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Causes

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Epidemiology and Demographics

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Risk calculators and risk factors for Deep vein thrombosis history and symptoms

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 and Symptoms

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

Common Symptoms of DVT

The classical symptoms of DVT include:

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

Shown below is a picture depicting unilateral swelling and redness in a leg affected with DVT.

Unilateral swelling and redness in a leg affected with DVT By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=9444797


Less Common Symptoms of DVT

Symptoms of PE

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. Symptoms of PE include:

Complete History

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

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Cohen AT, Dobromirski M, Gurwith MM (2014). "Managing pulmonary embolism from presentation to extended treatment". Thromb Res. 133 (2): 139–48. doi:10.1016/j.thromres.2013.09.040. PMID 24182642.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 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.
  3. ↑ 3.0 3.1 Anderson FA, Spencer FA (2003). "Risk factors for venous thromboembolism". Circulation. 107 (23 Suppl 1): I9–16. doi:10.1161/01.CIR.0000078469.07362.E6. PMID 12814980.

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