How to successfully screen for a DVT…

A few days ago, I received a call from a patient whom  another clinician and myself have been treating for pes anserine bursitis.  The patient reported that she went home from PT and noticed increased discomfort in her lower leg.   I asked what her symptoms were and she reported the following: Bruising over a small portion of the inside of her calf, a swollen vein (she has + hx of varicose veins) and discomfort over the vein.  She denied swelling, a history of DVTs or pain with dorsiflexion. I explained that it sounded like phlebitis vs. a true blood clot but for her to go to the ER if she is concerned about a clot.  Instead, she came into my facility.

In situations like the one that I just experienced, it is vital that we as direct access practitioners understand when it is crucial for us to refer patients and when we can recognize that something less serious may be occurring.   I screened her leg and used the clinical prediction rule for a DVT and determined it was likely phlebitis.  I also contacted her physician with the findings and he agreed with the assessment.  Below I have provided the clinical prediction rule for screening a DVT.

Wells Clinical Prediction Rule for DVT:

1. Active Cancer (treatment ongoing or within previous 6 months)
2. Paralysis, paresis or recent plaster immobilization of the LE
3. Recently bedridden for 3 days or more, or major surgery within the previous 12 weeks requiring anesthesia
4. Localized tenderness along the distribution of the deep venous system
5. Entire leg swelling
6. Calf Swelling at least 3cm larger than asymptomatic leg (measured 10cm below tibial tub)
7. Pitting Edema confined in symptomatic leg
8. Collateral superficial veins (nonvaricose)
9. Previous DVT
10. Subtract 2 if there is an alternative diagnosis at least as likely as a DVT

High Probability if score > 3

Moderate if score is 1-2

Low if score is 0

Bottom Line: With our profession gaining increased autonomy, it is vital that we understand how to screen for serious pathology and when to refer.

Citation:  Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretrest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350:1795-1798.