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10: DEEP VEIN THROMBOSIS

Thomas S. Zeller, MPT; Mila Marhovich, DPT; Eric Shamus, PhD, DPT, PT, CSCS

CONDITION/DISORDER SYNONYMS

  • Blood clot

  • Deep vein thrombophlebitis

  • Venous thrombosis

  • Venous thromboembolism

ICD-9-CM CODES1

  • 453.4 Acute venous embolism and thrombosis of deep vessels of the lower extremity

  • 453.5 Chronic venous embolism and thrombosis of deep vessels of lower extremity

ICD-10-CM CODES2

  • I74.9 Embolism and thrombosis of unspecified artery

  • I82.4 Acute embolism and thrombosis of deep veins of lower extremity

  • I82.90 Acute embolism and thrombosis of unspecified vein

FIGURE 10-1

Algorithm for diagnosis of deep venous thrombosis (DVT) in pregnancy with D-dimer as the first decision node. LMWH, low-molecular-weight heparin. (From Tintinalli JE, Stapczynski J, John Ma O, Cline D, Cydulka R, Meckler G Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)

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FIGURE 10-2

Superficial phlebitis and deep venous thrombosis. A. A linear painful erythematous cord extending from the popliteal fossa to the mid-calf in a 35-year-old man who had moderate varicosities. Phlebitis occurred after a 15-hour flight. B. The leg is swollen, pale, with a blotchy cyanotic discoloration, and is painful. The episode occurred after abdominal surgery (the circular marks are from a compression bandage). (From Wolff K, Johnson RA. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 6th ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)

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PREFERRED PRACTICE PATTERN

  • Pattern 6A: Primary Prevention/Risk Reduction for Cardiovascular/Pulmonary Disorders3

PATIENT PRESENTATION

A 42-year-old diabetic woman complains of soreness of the left leg. She is moderately obese and has been recovering from surgical removal of her gallbladder (cholecystectomy) performed 2 weeks ago. On examination, she has obvious swelling in the left lower leg and some tenderness of the calf that increases when the calf is gently squeezed. There is no redness of the leg, and she is afebrile (without fever). 4

KEY FEATURES

Description

  • Clot formation and acute inflammation of deep vein

  • Associated with Virchow’s triad:5

    • Decreased rate of blood flow (venous stasis)

    • Damage to blood vessel

    • Hypercoagulation

  • Most commonly occurs in lower extremity (LE)

  • Pulmonary embolism (PE) occurs when blood clot breaks off and settles in lung

Essentials of Diagnosis

  • Clinical decision rule for outpatients suspected of having a proximal deep vein thrombosis (DVT)6

  • History: Family history, recent trauma, cancer, oral contraceptives

  • Subjective report of pain

  • Visual examination

  • Reproduction of symptoms with dorsiflexion of the ankle (Homan’s sign) and palpation5

  • Diagnostic ultrasound of affected veins

  • Ankle-brachial index

  • D-dimer test

  • Well’s score or criteria: Possible scores range from −2 to 9

    • Active cancer (treatment within last 6 ...

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