11/13/24, 7\:01 PM Guide | DVT examination

DVT examination

Table of contents

Background

A deep vein thrombosis (DVT) refers to the formation of a thrombus within the deep venous system, most often occurring in
the veins of the leg but also in the pelvis and arm.
If this thrombus becomes dislodged, it becomes an embolus and can travel to the lungs causing a pulmonary embolism (PE).
PEs and DVTs are both types of venous thromboembolism (VTE).

Pathophysiology and risk factors

Factors that contribute to the development of VTE can be summarised using Virchow’s triad, which consists of\:
Hypercoagulability (a state in which blood coagulates quicker than usual). Examples include\:
Inherited thrombophilia (e.g. Factor V Leiden)
Pregnancy and oestrogen therapy
Malignancy
Infection and in
Dehydration
Nephrotic syndrome
Stasis (a state in which blood
Immobility (hospitalised patients, long
Varicose veins
Obesity
Endothelial injury (a state in which there has been damage to the vascular wall). Examples include\:
Physical trauma (including surgery)
Foreign devices (e.g. stents)
Hypertension
Bacterial infection

Clinical features of a DVT

Typical clinical features of a DVT include\:
Oedema
Pain (often cramping, may progress over several days)
Erythema & warmth
Peripheral venous distention
These signs are most often unilateral unless the DVT has occurred on both sides.
Red
A pulmonary embolism is a life-threatening complication of DVTs. The following clinical features are red
development of a PE\:
Sudden-onset shortness of breath
Tachycardia
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Haemoptysis
Chest pain (usually pleuritic)

Introduction

Wash your hands and don PPE if required.
Introduce yourself including your name and role.
Con
Brie
appropriate.
Gain consent to proceed with the examination and establish that the examination can be stopped at any point.
Adjust the head of the bed to a 45° angle and ask the patient to lay on the bed.
Adequately expose the patient’s lower limbs.
Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection

Risk factors

Perform a brief general inspection of the patient, looking for risk factors for venous thromboembolism such as\:
1,2
Age\: patients aged over 50 are at an increased risk
Sex\: incidence is similar between men and women, however, females have a higher risk during childbearing years and
males have a comparatively higher risk after the age of 45
Obesity\: is associated with decreased
Pregnancy\: is associated with up to a 5x increased risk, especially in the 3 rd
trimester
Immobility\: leads to venous stasis
Trauma\: direct damage to the endothelial vascular lining can trigger thrombosis, particularly if paired with immobility
Medication\: oral contraceptive pill, anticoagulants, chemotherapy

Clinical signs

Look for obvious clinical signs suggestive of venous thromboembolism including\:
Unilateral leg or arm swelling, pain or erythema (deep vein thrombosis)
Shortness of breath (pulmonary embolism)

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Medical equipment\: note any oxygen delivery devices and ECG leads.
Mobility aids\: items such as walking aids give an indication of the patient’s current mobility status.
Vital signs\: charts on which vital signs are recorded will give an indication of the patient’s current clinical status and how their
physiological parameters have changed over time.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications.

Pulse and blood pressure

Radial pulse
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Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle
longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm\:
Tachycardia (red
Thready pulse (may indicate dehydration, a risk factor for venous thromboembolism)
Bounding pulse (may indicate sepsis, a risk factor for venous thromboembolism)
Blood pressure
Oblood pressure guide for more details).
A comprehensive blood pressure assessment should also include lying and standing blood pressure.
In an OSCE station, you are unlikely to have to carry out a thorough blood pressure assessment due to time restraints, however,
you should demonstrate that you have an awareness of what this would involve.
Hypertension can be a response to signi
Hypotension may be a late and very concerning sign of a large or bilateral PE and should prompt consideration of
thrombolysis. It can also be an indicator of hypovolaemia secondary to dehydration.

Upper limbs

Inspection

the upper limbs.
Inspect the upper limbs for signs of a DVT. Unilateral engorgement of peripheral veins is a particularly useful clinical sign in
Ask the patient about any localised neck or shoulder pain.

Neck and chest

Inspection

The most important risk factor for upper limb DVT is the presence of a foreign body in the deep venous system.
3
On inspection, look for\:
Central venous catheters
Cardiac pacemakers\: usually marked by a scar inferior to the left clavicle and palpable on the thoracic wall
PICC lines\: especially the triple lumen subtype
Infection and introduction of chemotherapeutic agents through these devices increases the risk of upper limb DVT.
Superior vena cava (SVC) syndrome can be a result of malignant disease in the mediastinum obstructing the SVC and
resulting in engorgement of the upper extremity and neck veins. Malignancy is an important risk factor for upper limb DVTs.
Pemberton's sign
Pemberton’s sign may be elicited in patients with SVC syndrome\:
Ask the patient to raise their arms as high as possible
Observe for one minute
A positive sign is characterised by facial plethora and shortness of breath due to reduced venous return.
Thoracic outlet syndrome is a disorder in which the structures of the thoracic outlet (including veins supplying the upper limb
and neck) become compressed. This compression results in damage to the vascular walls and causes thrombosis. Causes of
thoracic outlet syndrome include trauma, cervical ribs and hypertrophic neck muscles.
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Leg inspection

Ask the patient to expose their legs fully (if not already exposed).
Inspect and compare the legs looking for
Erythema\: due to the pooling of blood in the lower extremity
Oedema\: caused by the blockage of venous return and therefore
forcing
Distended peripheral veins\: like in most other places in the body, there are collateral ways for blood to
are blocked. Peripheral veins act as a diversion around the blockage and may therefore appear distended.
Varicose veins\: although varicose veins are not directly related to DVTs they may indicate venous insu
for DVT)
Ulcers\: these also indicate venous insu
An example of a lower limb deep vein thrombosis [4]

Palpation

When performing palpation, both legs should be compared as DVTs are most likely to occur only on one side.

Temperature

Check the temperature of both legs by placing your hand along at least three sites moving proximally or distally.
Warmth is a common sign of DVT, but also of infection/in

Pitting oedema

Palpate the patient’s legs checking for pitting oedema. Press your thumb (as
prominences, moving from the medial malleolus proximally along the tibia (until no oedema is present).
Pitting oedema is observable as a marked imprint where pressure was applied, but it may not be very visible in less severe
cases. Gently feel over the pressure points for a slight dip.
Unilateral oedema should raise suspicion of a DVT. If the oedema is bilateral, alternative causes should be considered (e.g.
heart failure).

Tenderness

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Gently squeeze the calves moving proximally. Verbally con
expression for any signs of discomfort.

Measure

Using measuring tape, measure the circumference of each calf 10cm below the tibial tuberosity. If the di
the two is greater than 3cm, this is a clinically signi

Calculating the Wells score

If a DVT is suspected, a two-level Wells score for DVT is recommended. Remember, some patients can present
asymptomatically, so it is important to consider the history as well.
5,6
Table 1. The two-level Wells score for DVT
Clinical feature Points
Active cancer (currently receiving treatment or treatment within
6 months or palliative)
1
Paralysis, paresis or recent plaster immobilisation 1
Recently bedridden (3 days or more), or major surgery within
the last 3 months
1
Localised tenderness along the distribution of the deep venous
1
system
Entire leg swollen 1
Calf swelling at least 3cm larger than the asymptomatic side 1
Pitting oedema in the symptomatic leg 1
Collateral super
Previously documented DVT 1
An alternative diagnosis is at least as likely as DVT -2
* if both legs are symptomatic the more symptomatic leg should be used
Remember the rule of 3s\:
Bedridden for 3 days
Surgery in the last 3 months
Leg 3cm larger

Interpretation of the Wells score for DVT

Interpretation of the score\:
3
DVT likely\: _≥_2 points
DVT unlikely\: \<2 points
DVT likely (≥2 points)
If a DVT is likely, a proximal leg vein doppler ultrasound should be requested with the results available within four hours\:
If the ultrasound is positive\: treat the DVT with an anticoagulant.
If the ultrasound can’t be done within 4 hours\: D-dimer and o
If the ultrasound is negative\: check the D-dimer. If it is positive, repeat the scan in 6-8 days (stop interim coagulation if
started). If it is negative, another diagnosis should be considered and no anticoagulation given.
DVT unlikely (\<2 points)
If DVT is unlikely, o
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If the D-dimer is positive\: o
cannot be obtained within four hours. If the ultrasound is positive treat the DVT with an anticoagulant.
If the D-dimer results can’t be obtained within four hours\: o
If the D-Dimer is negative\: another diagnosis should be considered and no anticoagulation given.
Interpretation of the D-dimer test
The interpretation of a D-Dimer is only helpful if you know the Wells score (pre-test probability).
D-dimer is sensitive but not speci
venous thromboembolism.
7

Di

It is important to consider other di
peripheral pitting oedema should raise the suspicion for an alternative diagnosis (e.g. heart failure, liver failure or renal failure),
however, these conditions can co-exist with a DVT.

Acute limb ischaemia

Acute limb ischaemia occurs secondary to occlusion of the leg arteries. Like a DVT the symptoms are unilateral. A history of
peripheral arterial disease can be a helpful clue.
Remember the 6Ps of limb ischaemia\: pain, pallor, paralysis, paraesthesia, perishingly cold and pulseless.
8
On examination, a pulseless cool limb should point towards arterial rather than venous disease. For more information, see the
Geeky Medics guides to acute limb ischaemia and peripheral vascular examination.

Compartment syndrome

Compartment syndrome occurs when there is a pressure build-up in an anatomical compartment of the body that is
surrounded by fascia. When the pressure rises, it can stop blood
emergency.
The most common acute cause of compartment syndrome is trauma causing tissue swelling or bleeding into a compartment.
Compartment syndrome is a surgical emergency and requires immediate orthopaedic review.
9

Cellulitis

subcutaneous tissue.
Cellulitis is one of the most common and important mimics of DVTs. It is caused by bacterial infection of the dermis and
Erythema, swelling pain and warmth are common features and cellulitis usually only a
As opposed to DVTs, cellulitis can cause systemic symptoms such as fever, chills and nausea. On examination, there is often a
visible skin break where infectious organisms may have entered, and the skin may have developed blisters. Additionally, the
erythematous changes are usually well demarcated. The spread of the infection is often monitored by marking edges with a
pen.
Diabetic and immunocompromised patients as well as those with venous insu
cellulitis.
10
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An example of cellulitis marked with a pen [11]

Ruptured Baker’s cyst

A Baker’s cyst or popliteal cyst is caused by a cystic swelling of the gastrocnemio-semimembranosus bursa. It presents as a
palpable swelling in the popliteal fossa, often accompanied by sti
oedema due to compression of the popliteal vessels.
The rupture of a Baker’s cyst can present with an audible ‘pop’ and associated pain redness and warmth. Ultrasonography is
the key tool to distinguish Baker’s cysts from DVTs.
12
A ‘crescent sign’
, which is the appearance of bruising and swelling below the ankle, speci
may develop secondary to the rupture and can be an important
13

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
“ T o d a y I p e r f o r m e d a f o c u s e d D V T e x a m i n a t i o n o n a 5 9- y e a r-o l d g e n t l e m a n . O n g e n e r a l i n s p e c t i o n , c o m f o r t a b l e a t r e s t , a n d t h e r e w e r e n o o b j e c t s o r o b v i o u s r i s k f a c t o r s a s s o c i a t e d w i t h V T E .
”
t h e p a t i e n t a p p e a r e d
“ O n p e r i p h e r a l e x a m i n a t i o n o f t h e h a n d s , n o a c u t e s i g n s o f a p u l m o n a r y e m b o l i s m .
”
t h e r e w e r e n o o b v i o u s i d e n t i
“ G r o s s i n s p e c t i o n o f t h e l e g s r e v e a l e d n o o b v i o u s e r y t h e m a , s w e l l i n g o r s i g n s o f v e n o u s i n s u
”
“ P a l p a t i o n o f t h e l e g s r e v e a l e d n o w a r m t h o r t e n d e r n e s s a l o n g t h e d i s t r i b u t i o n o f t h e d e e p v e i n s . T h e c a l f c i r c u m f e r e n c e
w a s n o r m a l a n d e q u a l .
”
“ I n s u m m a r y , t h e r e a r e n o c l i n i c a l
”
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“ F o r c o m p l e t e n e s s , I w o u l d l i k e t o t a k e a f u l l h i s t o r y a n d c a l c u l a t e a W e l l s s c o r e a c c o r d i n g t o c l i n i c a l s u s p i c i o n a n d
p e r f o r m a v e n o u s D o p p l e r o r D-d i m e r t e s t gu i d e d b y t h e r e s u l t s .
”

Further assessments and investigations

Cardiovascular examination including measuring blood pressure\: to identify cardiovascular involvement including
hypotension.
Ankle-brachial pressure index (ABPI) measurement\: to assess arterial perfusion.
Peripheral arterial examination\: to assess for evidence of arterial disease.
Peripheral vascular examination\: to assess for evidence of venous disease.

Reviewer

Dr Leonidas Zachariades
Consultant in Acute Medicine

References

1. Heit J A., Spencer F A., White R H. The epidemiology of venous thromboembolism. 2016. Available from\: [LINK]
2. Motykie, G D et al. A Guide to Venous Thromboembolism Risk Factor Assessment. 2000. Available from\: [LINK]
3. Heil J et al. Deep Vein Thrombosis of the Upper Extremity\: A Systematic Review. 2017. Available from\: [LINK]
4. James Heilman MD. Lower Limb DVT. Licence\: [CC BY-SA 4.0]
5. NiCE Guidance. Venous thromboembolic diseases\: diagnosis, management and thrombophilia testing. Published 26 March
2020. Available from\: [LINK]
6. Wells P e t a l . Evaluation of D-Dimer in the Diagnosis of Suspected Deep-Vein Thrombosis. 2003. Available from\: [LINK]
7. Linkins L A, Takach Lapner S. Review of D-dimer testing\: Good, Bad, and Ugly. May 2017. Available from\: [LINK]
8. NICE Clinical Knowledge Summaries. Peripheral Arterial Disease - Features of acute limb ischaemia. Revised in July 2022.
Available from\: [LINK]
9. NHS. Compartment Syndrome. Revised in September 2019. Available from\: [LINK]
10. NICE Clinical Knowledge Summaries. Acute Cellulitis - Diagnosis. Revised in January 202. Available from\: [LINK]
11. Pshawnoah. Cellulitis marked with pen. Licence\: [CC BY-SA 3.0]
Source\: geekymedics.com
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