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'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org]; '''Associate Editor(s)-In-Chief:''' {{CZ}} ; [[User:Kashish Goel|Kashish Goel, M.D.]]; '''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]]
{| class="infobox" style="float:right;"
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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''']]
|}
'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[User:Kashish Goel|Kashish Goel, M.D.]]; [[User:Justine Cadet|Justine Cadet]]; {{Rim}}


{{Deep vein thrombosis}}
{{Deep vein thrombosis}}
==Overview==
==Overview==
Physical exam 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 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.


==Vitals==
== Physical Examination ==
Temperature, blood pressure, heart rate and respiratory rate may all be within normal range.
=== 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%)<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>
**[[Tachypnea]] (70%)<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>
** [[Low grade fever]]


==Extremities==
=== Extremities ===
The most significant part of physical exam in a patient with suspected [[DVT]] is measurement of the size of both legs at same point (usually measured vertically from the knee joint), to assess for difference. If a difference is detected and there is suspicion of DVT, further tests should be conducted. It may also reveal:
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:
* Palpable cord (reflecting a thrombosed vein)
* Unilateral calf or thigh tenderness
* Calf or thigh pain
* Unilateral calf or thigh [[pitting edema]]
* Unilateral edema or swelling with a difference in calf diameters, warmth, tenderness and erythema.
* Unilateral calf or thigh swelling
* Superficial venous dilation.
* 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 [[vein thrombosis|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]])
* [[Cyanosis|Cyanotic]] and cold skin, lips, nail bed (suggestive of [[cardiogenic shock]])


'''[[Homans test]]''' is mainly of historical perspective. It is said to positive when passive dorsiflexion of the ankle (knee in flexed position) elicits sharp pain in the calf. However, the test has very poor positive or negative predictive value. Previous studies have shown that Homans test was present  only in 30% of the patients with positive [[DVT]].
===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:
* [[Rales]]
* [[Crackles]]
* [[Pleural friction rub]]


'''Pratt's sign''': Squeezing of posterior calf elicits pain, is also not recommended.<ref name="pmid16403932">{{cite journal| author=Wells PS, Owen C, Doucette S, Fergusson D, Tran H| title=Does this patient have deep vein thrombosis? |journal=JAMA | year= 2006 |volume= 295 | issue= 2 | pages= 199-207 | pmid=16403932 | doi=10.1001/jama.295.2.199 | pmc=|url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16403932  }}[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16813372 Review in: ACP J Club. 2006 Jul-Aug;145(1):24]  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17213132 Review in: Evid Based Med. 2006 Aug;11(4):119] </ref>
==References==
==References==
{{reflist|2}}  
{{reflist|2}}  


[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Hematology]]
[[Category:Hematology]]
[[Category:Pulmonology]]
[[Category:Angiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Mature chapter]]
[[Category:Vascular surgery]]
[[Category:Up-To-Date]]
[[Category:Cardiovascular diseases]]


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{{WH}}
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Latest revision as of 12:01, 13 July 2014
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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Patient Information

Overview

Classification

Pathophysiology

Causes

Differentiating Deep vein thrombosis from other Diseases

Epidemiology and Demographics

Risk Factors

Triggers

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Diagnosis

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Assessment of Clinical Probability and Risk Scores

Assessment of Probability of Subsequent VTE and Risk Scores

History and Symptoms

Physical Examination

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Ultrasound

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MRI

Other Imaging Findings

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Upper extremity DVT

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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

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

Abdomen

Heart

Among patients with DVT complicated by PE, the following might be present:

Lungs

Among patients with DVT complicated by PE, the following might be present:

References

  1. ↑ 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.

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