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]

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.

• 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

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

• Generalized edema (suggestive of right heart failure, or nephrotic syndrome)
• Cyanotic and cold skin, lips, nail bed (suggestive of cardiogenic shock)

• Ascites (suggestive of Budd Chiari syndrome, that is hepatic vein thrombosis)
• Hepatomegaly (suggestive of Budd Chiari syndrome, that is hepatic vein thrombosis)

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)

Among patients with DVT complicated by PE, the following might be present:

• Rales
• Crackles
• Pleural friction rub

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