What are the signs of Deep Vein Thrombosis (DVT)?

Signs and Symptoms of Deep Vein Thrombosis (DVT)

The classic signs of DVT include unilateral extremity swelling, pain, and erythema, which occur in approximately 80%, 75%, and 26% of cases respectively. 1

Lower Extremity DVT Signs and Symptoms

• Swelling of one extremity - Most common sign, typically unilateral
• Pain or tenderness - Often described as a heaviness, aching, or cramping sensation
• Erythema or warmth - Skin over the affected area may be red and warm to touch
• Unexplained persistent calf cramping - Particularly with activity or at night
• Palpable cord - Occasionally a firm, tender vein can be felt
• Increased venous distention - Visible dilated superficial veins
• Homan's sign - Pain in the calf upon dorsiflexion of the foot (though this is neither sensitive nor specific)

Upper Extremity DVT Signs and Symptoms

• Swelling in the face, neck, or supraclavicular space - Particularly with upper extremity or central venous thrombosis
• Catheter dysfunction - If a central venous catheter is present
• Arm or shoulder pain - Often unilateral
• Discoloration of the affected limb - Bluish or reddish hue

Special Considerations

Isolated Iliac Vein Thrombosis

Patients may present with:

• Swelling of the entire leg
• Flank, buttock, or back pain
• No evidence of DVT on standard proximal compression ultrasound 1

Asymptomatic DVT

• DVT may also be an incidental finding without classic symptoms
• Up to 34% of non-ambulatory patients with advanced cancer have asymptomatic DVT 1

Diagnostic Approach

Clinical symptoms alone are insufficient for diagnosis, as they lack specificity. The recommended diagnostic approach combines:

1. Clinical pretest probability assessment (Wells score)

   • Low probability: ~5% prevalence of DVT
   • Moderate probability: ~17% prevalence of DVT
   • High probability: ~53% prevalence of DVT 2

2. D-dimer testing

   • Highly sensitive but not specific
   • Useful for ruling out DVT in low-probability patients

3. Imaging

   • Compression ultrasound is the preferred initial imaging method
   • Two normal ultrasound examinations obtained 1 week apart can exclude progressive lower-extremity DVT 1

Warning Signs of Potential Complications

• Sudden shortness of breath - May indicate pulmonary embolism
• Chest pain - Particularly pleuritic pain that worsens with breathing
• Hemoptysis - Coughing up blood, suggesting possible pulmonary embolism
• Severe, persistent swelling - May indicate extensive thrombosis

Pitfalls in Diagnosis

• Clinical symptoms are not present in all cases of acute DVT
• The Wells score performs better for predicting proximal DVT than isolated distal DVT 2
• Wells score has limited utility in patients already receiving thromboprophylaxis 2
• D-dimer has limited utility in hospitalized patients, post-surgical patients, and pregnant patients due to high frequency of positive results 2
• Missed DVT can lead to pulmonary embolism with associated mortality rates of 25-30% 2

Early initiation of anticoagulation should be considered in patients with high clinical suspicion of DVT while awaiting results from imaging studies, provided there are no contraindications to anticoagulation 1.