What are the clinical signs of Deep Vein Thrombosis (DVT) that indicate a patient does not have one?

From the Guidelines

A patient likely does not have a DVT if they lack symptoms such as swelling, pain, or tenderness in one leg, warmth, and redness or discoloration of the skin, as these are common clinical signs associated with DVT 1. When evaluating a patient for DVT, it is essential to consider the clinical presentation, risk factors, and physical examination findings. The absence of risk factors such as recent surgery, prolonged immobility, pregnancy, hormonal contraceptive use, cancer, or family history of blood clotting disorders decreases the likelihood of DVT. Some key points to consider when assessing a patient for DVT include:

• Swelling in one leg, particularly the calf
• Pain or tenderness in the affected area that worsens when standing or walking
• Warmth in the affected leg
• Redness or discoloration of the skin
• Recent surgery or prolonged immobility
• Pregnancy or hormonal contraceptive use
• Cancer or family history of blood clotting disorders The Wells score, a clinical prediction rule, can also help assess DVT probability; a low score (less than 2) indicates a low risk 1. Normal physical examination findings, including absence of calf tenderness, swelling difference between legs, and collateral superficial veins, suggest against DVT. If symptoms are bilateral rather than unilateral, or if pain improves rather than worsens with walking, these also point away from DVT. It is crucial to note that approximately one-third of patients with DVT do not have any symptoms, and the clinical diagnosis of DVT using clinical risk-stratification scores alone has been less than ideal 1. Therefore, imaging is frequently required to definitively exclude DVT and properly document the extent of venous thrombosis, which is critical for proper therapeutic management of DVT.

From the Research

Clinical Signs of DVT

The clinical signs of Deep Vein Thrombosis (DVT) include:

• Pain in the affected limb
• Swelling in the affected limb
• Erythema (redness) in the affected limb
• Dilated veins in the affected limb 2

Assessment of DVT

To assess DVT, a multifaceted approach is required, including:

• Clinical assessment
• Evaluation of pre-test probability
• Objective diagnostic testing 2 The pre-test probability of DVT can be assessed using a clinical decision rule, which stratifies DVT into "unlikely" or "likely" 2

Excluding DVT

If DVT is "unlikely", a D-dimer test can be used to exclude DVT. If the D-dimer level is normal, DVT can be excluded 2 If the D-dimer level is increased, compression ultrasound can be used to confirm or exclude DVT 2

Why a Patient May Not Have DVT

A patient may not have DVT if:

• They do not have any of the common symptoms or signs of DVT, such as pain, swelling, erythema, or dilated veins in the affected limb 2
• Their pre-test probability of DVT is "unlikely" and their D-dimer level is normal 2
• Compression ultrasound does not show any evidence of DVT 2