, Benjamin Hohlfelder2 and Samuel Z. Goldhaber3
(1)
Cardiovascular Division, Harvard Medical School Brigham and Women’s Hospital, Boston, Massachusetts, USA
(2)
Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, Massachusetts, USA
(3)
Thrombosis Research Group, Harvard Medical School Brigham and Women’s Hospital, Boston, Massachusetts, USA
Abstract
Diagnosis of deep vein thrombosis (DVT) requires a high index of suspicion, especially in patients with venous thromboembolism (VTE) risk factors. A strategy that combines an assessment of clinical probability of the diagnosis with use of D-dimer testing and imaging when appropriate maximizes diagnostic accuracy. Venous ultrasound is the imaging test of choice for most patients with suspected DVT.
Keywords
D-dimerDeep vein thrombosisDiagnosisUltrasoundSelf-Assessment Questions
1.
In which of the following patients would D-dimer testing for evaluation for suspected DVT be least likely to result in a false positive?
(a)
A 28-year-old man who presents to the Emergency Department with 2 days of right calf swelling, erythema, and tenderness
(b)
A 68-year-old woman who is 4 days status post left total knee replacement and reports left groin pain and thigh swelling
(c)
A 31-year-old woman who is 28 weeks pregnant and presents with asymmetric right ankle and calf edema
(d)
A 52-year-old man who is intubated in the Intensive Care Unit for treatment of acute respiratory distress syndrome (ARDS) in the setting of influenza infection who is noted to have left thigh and calf edema
2.
Which of the following patients would be categorized as having a high probability of acute DVT according to the modified Wells Criteria?
(a)
A 67-year-old man with heart failure who presents to his primary care physician with bilateral ankle pitting edema after missing a few days of his diuretic therapy
(b)
A 77-year-old man with prostate cancer status post prostatectomy 7 days prior who presents to the Emergency Department with complaint of left calf tenderness and swelling
(c)
A 22-year-old collegiate women’s basketball player who presents to the Student Health Center with right ankle pain and swelling and difficulty ambulating after a week of intensive pre-season practices
(d)
A 69-year-old woman with alcoholic cirrhosis found bed-bound in her apartment and admitted with ascites, encephalopathy, and bilateral entire leg edema
3.
In which of the following clinical scenarios would an alternative imaging technique such as CT, MR, or contract venography be appropriate?
(a)
Evaluation of suspected DVT in a patient with a right upper extremity indwelling peripherally-inserted central catheter (PICC) and acute swelling of the right forearm and hand
(b)
Evaluation of suspected DVT in a patient with left calf pain and swelling 1 week after left total knee replacement
(c)
Evaluation of suspected DVT in a patient with left lower extremity edema and pain, a modified Wells score of 4, and a negative venous ultrasound
(d)
Evaluation of suspected DVT in a patient with a history of PE status post insertion of an inferior vena cava filter who presents with right lower calf pain and ankle edema
Clinical Vignette
A 72-year-old man with a history of right lower extremity DVT following right ankle fracture 10 years prior and treated with anticoagulation for 6 months presented to the Emergency Department with sudden onset left leg discomfort and swelling. He had undergone cholecystectomy 2 weeks prior. Physical examination demonstrated slight redness, tenderness to palpation, and pitting edema of his left calf (Fig. 4.1). A venous ultrasound was performed and detected DVT in the left common femoral vein (Fig. 4.2).
Fig. 4.1
Physical examination demonstrating slight redness and asymmetric swelling in a 72-year-old man with prior right-sided deep vein thrombosis (DVT) who presented with acute onset left calf pain and edema
Fig. 4.2
Lower extremity venous ultrasound demonstrating a dilated and non-compressible left common femoral vein (CFV) (ovals) diagnostic of acute deep vein thrombosis (DVT) in a 72-year-old man with prior right-sided deep vein thrombosis (DVT) who presented with acute onset left calf pain and edema
Clinical Clues
Although it is most frequently observed in the lower extremities, DVT may also develop in the upper extremity veins in the setting of chronically indwelling central venous foreign bodies such as catheters or pacemakers, and syndromes of thoracic outlet obstruction [1, 2]. Patients with lower extremity DVT will commonly describe a cramping or pulling sensation of the lower calf that may worsen with ambulation. Warmth, edema, and tenderness of the lower extremity may be present on physical examination. Occasionally, a palpable cord or prominent venous collaterals may be appreciated. Importantly, some patients may not demonstrate any abnormalities on physical examination.
Alternative diagnoses to DVT include phlebitis without thrombosis, superficial vein thrombosis, venous insufficiency without acute thrombosis, post-thrombotic syndrome, ruptured Baker’s cyst, muscle or soft tissue injury, hematoma, cellulitis, lymphedema, and peripheral edema secondary to congestive heart failure, liver disease, renal failure, or nephrotic syndrome (Table 4.1).
Table 4.1
Alternative diagnoses to deep vein thrombosis (DVT)
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