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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]; '''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==
The actual physical signs of venous thrombosis can be quite unreliable. There may be pain and tenderness in the thigh along the course of the major veins
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.


==Appearance of the Patient==
== 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%)<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]]


[[Obesity]] may be present.
=== Extremities ===
The patient may complain of pain.
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 [[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


==Physical examination==
===Skin===
Physical examination may reveal
* Generalized [[edema]] (suggestive of [[right heart failure]], or [[nephrotic syndrome]])
*Palpable cord (reflecting a thrombosed vein)  
* [[Cyanosis|Cyanotic]] and cold skin, lips, nail bed (suggestive of [[cardiogenic shock]])
*Calf or thigh pain
*Unilateral edema or swelling with a difference in calf diameters, warmth, tenderness and erythema.
*Superficial venous dilation.


==Test==
===Abdomen===
*[[Homan's test]]: is said to be present when passive dorsiflexion of the ankle by the examiner elicits sharp pain in the calf.. A '''positive Homans''' sign does not positively diagnose DVT (poor positive predictive value), and a '''negative Homans''' sign does not rule out the DVT diagnosis (poor negative predictive value).
* [[Ascites]] (suggestive of [[Budd Chiari syndrome]], that is [[hepatic vein thrombosis]])
*Pratt's sign: Squeezing of posterior calf elicits pain
* [[Hepatomegaly]] (suggestive of [[Budd Chiari syndrome]], that is hepatic vein thrombosis)
However, these [[medical sign]]s do not perform well and are not included in [[clinical prediction rule]]s that combine best findings in order to diagnose DVT.<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>


===Screening for malignancy===
===Heart===
Venous thromboembolism may be the first manifestation of an underlying malignancy. However, a detailed and routine search for an occult malignancy is neither mandatory nor cost effective.<ref name="pmid16954002">{{cite journal| author=Oudega R, Moons KG, Karel Nieuwenhuis H, van Nierop FL, Hoes AW| title=Deep vein thrombosis in primary care: possible malignancy? | journal=Br J Gen Pract | year= 2006 | volume= 56 | issue= 530 | pages= 693-6 | pmid=16954002 | doi= | pmc=PMC1876636 | url= }} </ref>
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]])


The following test should be considered:
===Lungs===
 
Among patients with [[DVT]] complicated by [[PE]], the following might be present:
'''In Males'''
* [[Rales]]
*Rectal Examination
* [[Crackles]]
*[[Fecal occult blood]] testing (FOBT) must be performed.
* [[Pleural friction rub]]
 
'''In Females'''
*Pelvic examinations to rule out any mass/malignancy.


==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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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]

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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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