Deep vein thrombosis history and symptoms

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]

Overview

A proper history and physical exam is very important for establishing an accurate diagnosis of deep vein thrombosis (DVT). DVT can be either asymptomatic or associated with tenderness and swelling of the calf or thigh. One of the first steps in the management of DVT is the determination of the Wells score for DVT, whose criteria can be ascertained solely on the basis of history and physical exam. A high index of suspicion is also necessary to diagnose DVT. DVT can be complicated by pulmonary embolism (PE); therefore, it is important to inquire about the symptoms of PE among patients suspected to have DVT.

History and Symptoms

As depicted in the image below, the majority of patients with venous thromboembolism (VTE), that is DVT, PE, or both, are asymptomatic.

Common Symptoms of DVT

The classical symptoms of DVT include:

Pain in the affected area
Swelling of the affected area
Erythema around the affected area
Dilation of the surface veins and erythema of the overlying area

However, sometimes there may be no symptoms referable to the location of the DVT.

Shown below is a picture depicting unilateral swelling and redness in a leg affected with DVT.

Unilateral swelling and redness in a leg affected with DVT By James Heilman, MD – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=9444797

Less Common Symptoms of DVT

In phlegmasia alba dolens, the leg is pale and cold with a diminished arterial pulse.

In phlegmasia cerulea dolens, there is an acute and near-total venous occlusion of the entire extremity outflow, including the iliac and femoral veins. The leg is usually painful, cyanosed and edematous.

Symptoms of PE

Since VTE involves both DVT and PE, the patient can present with complaints of either of the diseases. Therefore it is important to inquire about the symptoms of both diseases. Symptoms of PE include:

Dyspnea (78–81%)^[1]
Pleuritic chest pain (39–56%)^[1]
Fainting (22–26%)^[1]
Cough (20%)^[2]
Substernal chest pain (12%)^[2]
Hemoptysis (11%)^[2]
Wheezing
Cyanosis (11%)^[1]
Fever (7%)^[1]
Symptoms suggestive of shock (in case of massive PE)

Complete History

If VTE is suspected or diagnosed, a complete history should be elicited, including the following:

Risk factors^[3]^[2]
- Chemotherapy
- Chronic heart failure
- Respiratory failure
- Hormone replacement therapy
- Cancer
- Oral contraceptive pills
- Stroke
- Pregnancy
- Postpartum
- Prior history of VTE
- Thrombophilia
- Advanced age
- Laparoscopic surgery
- Prepartum
- Obesity
- Varicose veins
Triggers^[3]^[2]
- Bone fracture (hip or leg)
- Hip replacement surgery
- Knee replacement surgery
- Major general surgery
- Significant trauma
- Spinal cord injury
- Athroscopic knee surgery
- Central venous lines
- Chemotherapy
- Bed rest for more than 3 days
- Prolonged car or air travel
- Laparoscopic surgery
- Prepartum
Previous episode of VTE
- Age
- Location
Past medical history of diseases associated with hyperviscosity
History of thrombophilia
- Factor V Leiden mutation
- Prothrombin gene mutation G20210A
- Protein C or Protein S deficiency
- Antithrombin (AT) deficiency
- Antiphospholipid syndrome (APS)
Abortion
- Abortion at second or third trimester of pregnancy (suggestive of an inherited thrombophilia or APS)
Drugs that may increase the risk of VTE
Family history (suggestive of inherited thrombophilia)
- Deep vein thrombosis
- Pulmonary embolism
- Recurrent miscarriage
Social history
- Heavy cigarette smoking (>25 cigarettes per day)
- Intravenous drug use (if injected directly in femoral vein)
- Alcohol

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 ^1.4 Cohen AT, Dobromirski M, Gurwith MM (2014). “Managing pulmonary embolism from presentation to extended treatment”. Thromb Res. 133 (2): 139–48. doi:10.1016/j.thromres.2013.09.040. PMID 24182642.
↑ ^2.0 ^2.1 ^2.2 ^2.3 ^2.4 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.
↑ ^3.0 ^3.1 Anderson FA, Spencer FA (2003). “Risk factors for venous thromboembolism”. Circulation. 107 (23 Suppl 1): I9–16. doi:10.1161/01.CIR.0000078469.07362.E6. PMID 12814980.

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[pmid24182642-1] 1.0 ^1.1 ^1.2 ^1.3 ^1.4 Cohen AT, Dobromirski M, Gurwith MM (2014). “Managing pulmonary embolism from presentation to extended treatment”. Thromb Res. 133 (2): 139–48. doi:10.1016/j.thromres.2013.09.040. PMID 24182642.

[pmid18757870-2] 2.0 ^2.1 ^2.2 ^2.3 ^2.4 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.

[pmid12814980-3] 3.0 ^3.1 Anderson FA, Spencer FA (2003). “Risk factors for venous thromboembolism”. Circulation. 107 (23 Suppl 1): I9–16. doi:10.1161/01.CIR.0000078469.07362.E6. PMID 12814980.

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