This document provides information about assessing a patient for deep vein thrombosis (DVT). It lists questions to ask the patient about risk factors for DVT like recent surgery, estrogen use, family history of clotting issues, and immobility from travel or injury. It describes performing a physical exam including Homan's sign and using the Wells Rule clinical decision tool to evaluate the likelihood of DVT based on symptoms and risk factors. A positive Homan's sign or Wells Rule score over 1 would indicate higher risk of DVT warranting ultrasound referral.

1. DEEP VEIN THROMBOSIS
History Taking

2. 1) Do you have any pain or tender spots in your
legs?
2) Have you noticed any new swelling in your
legs?
3) 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:
1. Having an operation that takes longer than 90 minutes, or 60 minutes if
the operation is on the leg, hip or abdomen.
2. Having an operation for an inflammatory or abdominal condition such as
appendicitis.
3. 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:
1.
Cancer.
2.
Heart and lung disease
3.
Infectious diseases such as hepatitis
4.
Inflammatory conditions such as rheumatoid arthritis
5.
Thrombophilia (a genetic condition that makes your blood more likely to
clot) and
6.
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 :
1.
Paralysis from a spinal cord injury
2.
Broken hip or leg
3.
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:
1.
≤0 =probability of proximal lower-extremity deep vein thrombosis
(PDVT) of 3%,
2.
1 or 2=probability of PDVT of 17%
3.
≥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.