Emergency Medicine

CHEST PAIN

56 General Medical Emergencies

2 Typical symptoms include leg pain, swelling, tenderness and redness or

discoloration.

3 Examination may reveal unilateral oedema, warmth, superficial venous

dilatation, increased limb girth or tenderness along the deep venous system.

(i) Unfortunately, a similar picture is seen in cellulitis, lymphoedema,

musculoskeletal injury and varicose vein insufficiency.

(ii) Homan’s sign of pain on forced ankle dorsiflexion is unreliable,

unhelpful and not recommended.

4 Ask about any associated features of a concomitant PE (see p. 51), particu-

larly in suspected proximal DVT above the knee.

5 Exactly as with PE, determine the clinical pre-test probability of a DVT now

before requesting diagnostic testing (see Table 2.5).

(i) A low pre-test probability on Wells’ criteria with a score ≤0 has

up to a 5% probability of DVT.

(ii) A moderate pre-test probability with a Wells’ score 1–2 has a 17%

probability of DVT, and a high pre-test probability with a Wells’

score ≥3 has up to a 53% probability of DVT.

Table 2.5 Estimation of the clinical pre-test probability for suspected deep venous

thrombosis (DVT)

Clinical feature Score

Active cancer (treatment ongoing or within 6 months or palliative) 1

Paralysis, paresis or recent plaster immobilization of the lower

extremities

1

Recently bedridden for ≥3 days, or major surgery within the previous

12 weeks

1

Localized tenderness along the distribution of the deep venous system 1

Entire leg swollen 1

Calf swelling >3 cm when compared with the asymptomatic leg

(at 10 cm below the tibial tuberosity)

1

Pitting oedema: confined to the symptomatic leg 1

Collateral superficial veins (non-varicose) 1

Previously documented deep venous thrombosis 1

Alternative diagnosis as likely or greater than that of deep

venous thrombosis

–2

In patients with symptoms in both legs, the more symptomatic leg is scored.

Low pre-test probability = score ≤ 0

Moderate pre-test probability = score 1–2

High pre-test probability = score ≥ 3

From Wells PS, Owen C, Doucette S et al. (2006) Does this patient have deep vein

thrombosis? J Amer Med Assoc 295:199–207.