Deep vein thrombosis physical examination
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. 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. 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.