Deep vein thrombosis: unstructured clinical assessment is not helpful in diagnosis.

Clinical bottom line (level 1a)

  1. In patients with suspected deep vein thrombosis, clinical assessment cannot accurately diagnose or exclude it- further investigations are required.
  2. In patients with suspected DVT, structured clinical assessment strongly influences the outcome of the diagnostic process
Anand et al: Journal of the American Medical Association 1998; 279 (14): 1094-1099
Expires February 2004

The study

Systematic review of all of
  • Patients: suspected deep vein thrombosis
  • Intervention: clinical assessment, ultrasonography compared with venography
  • Outcome: diagnosis


    • Articles found in English using MEDLINE, 1966 to April 1997 (search terms: thrombosis, physical examination, diagnostic tests, sensitivity, specificity, phlebography ) and bibliographic search

    Selection criteria: as above
    Appraisal criteria: graded methodologically (criteria referenced)
    Articles excluded if: none given

    Five studies were identified.
    There was no comment on heterogeneity.

    The evidence


    diagnostic test DVT no DVT LR+
    (95% CI)    		 LR-
    (95% CI)
    clinical assessment- O'Donnell et al 1.25
    (1.00 to 1.50)     		0.40
    (0.17 to 0.96)
    clinical asessment- Haeger et al 1.40
    (0.95 to 2.20)     		0.64
    (0.34 to 1.06)
    clinical assessment- Molley et al 2.10
    (1.30 to 3.50)     		0.55
    (0.36 to 0.80)
    clinical assessment- Landefeld et al 1.20
    (1.10 to 1.29)     		0.21
    (0.08 to 0.54)
    total

    • Clinical assessment included pain, tenderness, oedema, Homan's sign, swelling and erthythema.
    • The O'Donnell study involved 102 patients; Haegwe study 72; Molley study 100; Landefeld study 354 (this was a retrospective study).

    Comments

    1. The clinical predition guides described have only been tested where patients with previous VTE, suspected PE, current anticogulant therapy or patients who were pregnant were excluded
    2. The clinical prediction guides need further alidation outside their development centres

    Citation

    1. Anand SS, Wells PS, Hunt D, et al: Does this patient have deep vein thrombosis?. Journal of the American Medical Association 1998; 279 (14): 1094-1099
    Contributor: Chris Ball and Clare Wotton, January 1999
    Reviewer: Alex Gallas

    Clinical Question.
    Patient suspected deep vein thrombosis
    Intervention or Exposure clinical assessment
    Comparison venography
    Outcome diagnosis