Deep Vein Thrombosis

History Taking

1. DEEP VEIN THROMBOSIS History Taking

2. Do you have any pain or tender spots in your legs ? Have you noticed any new swelling in your legs ? Does the pain or swelling get worse when you stand, sit, or walk? Classical symptoms of DVT include swelling, pain, warmth, and redness in the involved leg

3. 4) Have you ever had a blood clot? People who had a history of previous DVT or PE (Pulmonary Embolism) are more likely to develop recurrent DVT and PE.

4. 5) What medications are you taking ? Patient who are on oral contraceptive pill and hormone replacement therapy which contain estrogen Oestrogen causes the blood to clot slightly more easily, so your risk of getting DVT is slightly increased. First generation OCCP - lynestrenol . Second generation pills - levonorgestrel or, less often, norgestrel . Third generation pills - desogestrel or gestodene .

5. 6) Have you had surgery recently ? As a patient, the risk of developing DVT depends on the type of treatment they are having. Patient may be at higher risk of DVT if any of the following apply: Having an operation that takes longer than 90 minutes, or 60 minutes if the operation is on the leg, hip or abdomen. Having an operation for an inflammatory or abdominal condition such as appendicitis. Confined to a bed, unable to walk, or spending a large part of the day in a bed or chair for at least three days .

6. 7) Do any of your relatives have blood clotting problems? The risk of DVT is increased if patient have an inherited condition that causes the blood to clot more easily than normal. These conditions include: Cancer . Heart and lung disease I nfectious diseases such as hepatitis Inflammatory conditions such as rheumatoid arthritis T hrombophilia (a genetic condition that makes your blood more likely to clot) and Hughes syndrome (when your blood becomes abnormally "sticky")

7. 8) Have you been on any long trips recently? If patient are immobile (unable to move) for a long period of time, such as during a long journey, their blood flow can slow down considerably. Reduced blood flow to vein increase likelihood of blood cells sticking together which causes clotting.

8. 9) Have you had any recent injuries ? Having a recent minor leg injury, was found to be associated with a threefold increase in the risk of serious blood clots, such as deep vein leg clots and pulmonary embolism (clots that travel to the lung ). Example : Paralysis from a spinal cord injury Broken hip or leg Fracture

9. 10) Do you have varicose veins? Varicose veins, because they occur in superficial veins, are not generally linked to a serious condition called deep vein thrombosis (DVT). However, with severe varicose veins, there is a small increased chance of developing DVT .

10. PHYSICAL EXAMINATION

11. Homan’s sign Homans's sign is often used in the diagnosis of deep venous thrombosis of the leg . A positive Homans's sign is thought to be associated with the presence of thrombosis . However , Homans's sign has a very poor predictive value for the presence or absence of deep vein thrombosis, like any other symptom or clinical sign of this disease . Other isolated clinical findings such as calf tenderness, swelling, and redness have been shown not to have diagnostic value for detecting DVT .

12. To assess Homan’s sign, the patient’s knee is in an extended position and the examiner forcefully dorsiflexes the patient’s ankle A positive sign is indicated when pain in the popliteal region and the calf is elicited as the foot is dorsiflexed . A negative Homan’s sign, on the other hand, doesn’t automatically conclude an absence of DVT. Thrombosis that develops in the thigh and pelvic veins are often difficult to detect and patients can often remain asymptomatic Homan’s test still remains an important tool for use in the health care setting. Thus, it can be to our advantage to apply Homan’s test in conjunction with other detected clinical symptoms correlated with DVT such as: unexplained fever or tachycardia, muscle pain, tenderness, swelling, temperature change and venous dilation

13. Wells Rule To rule out DVT The Wells Rule was used by the examining GP to assess likelihood of DVT. Patients with a high likelihood (Wells score >1) were referred straight for ultrasound.

14. Clinical Decision Rule Developed by Wells and Colleagues29. Riddle D L , and Wells P S PHYS THER 2004;84:729-735 Physical Therapy

15. Score interpretation: ≤0 = probability of proximal lower-extremity deep vein thrombosis (PDVT) of 3 %, 1 or 2=probability of PDVT of 17% ≥ 3=probability of PDVT of 75 % Tenderness along the deep venous system is assessed by firm palpation in the center of the posterior calf, the popliteal space, and along the area of the femoral vein in the anterior thigh and groin. Most common alternative diagnoses are cellulitis, calf strain, and postoperative swelling.