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Deep Vein Thrombosis (DVT)

Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓

 

Doctor Instruction:


You are a doctor working in family medicine. Your next patient, Tom Hudson (61-year-old male) complaining of leg pain. Please take a history and carry out a relevant examination.



 

Patient History:


Tom Hudson, 61 y/o, recently retired – used to work as a business analyst.


You have been experiencing increasing leg pain for the past few days. The pain is located only at the left calf (only answer when specifically asked about the location). Pain is gradually getting worse and does not radiate to other parts of the body. Touching it makes it worse, and resting makes it better. The skin around the left calf feels hot and red; otherwise, no other skin changes. No previous injury towards calves.


There’s no coughing/ haemoptysis/ breathlessness. No fever/weight loss/ night sweats.


Ideas, Concerns, Expectations:

  • You think it might just be heart failure as you have been experiencing lower leg swelling for the past few years – which is why you are on furosemide. You can be concerned about the pain as there's limiting your rehab from your hip replacement which you had 1-2 weeks ago – you want to get better as soon as possible. You want to find out what is going on and have some painkillers.


Past Medical History:

  • Obesity, Diabetes Type 2, Hypertension, Heart Failure.

  • No previous malignancy with treatment within 6 months/ palliative.

  • No previous history of DVT/ PE.


Past Surgical History:

  • You just received a hip replacement 1-2 weeks ago, and due to pain, you have been quite immobile lately. Have been resting on a chair most of the time.


Drug History:

  • Metformin, Amlodipine, Multi-vitamins, Atorvastatin, Furosemide

  • Allergic to penicillin (anaphylactic reaction)


Family History:

  • Nil


Social History:

  • Do not smoke (used to smoke 10 cigarettes a day for 15 years)

  • Drink a beer every night with dinner

  • Live with wife

  • Retired - used to work as a business analyst.


 

Examination Findings:

  • Left calf erythema and warmth to touch

  • Distension of superficial veins and tenderness on palpitation of the left calf

  • Mild pitting oedema and swelling on both calves

  • The left calf swelling is worse than the right

  • Chest clear on auscultation


 

Differentials:

  1. Deep Vein Thrombosis

  2. Cellulitis

  3. Superficial thrombophlebitis

  4. Heart Failure

  5. Trauma including calf muscle haematoma, calf muscle tear/ Achilles' tendon tear


 

Investigations:


Bedside:

  • Observations

  • ECG (sinus tachycardia / S1 Q3 T3 changes in PE)

  • Calculate Well's Score for DVT


Bloods:

  • Anticoagulation screen

  • Routine blood tests: FBC, Bone profile LFTs, U&Es, CRP (infections/renal function for scans and treatment)

  • Consider D-Dimer

  • Consider Antiphospholipid antibodies (if unprovoked)


Imaging:

  • USS scan (if Well’s score at least 2 points and is within 4 hours from onset)

  • CXR/ CT pulmonary angiogram (if suspecting pulmonary embolism)


 

Management:

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