Deep vein thrombosis and pulmonary thromboembolism – presentation, investigation & therapy

Question 1

What are the common presenting symptoms of deep vein thrombosis (DVT)

Answer 1

🔹 Unilateral leg swelling
🔹 Calf pain/tenderness
🔹 Erythema and warmth
🔹 Dilated superficial veins
🔹 Homan’s sign (pain on dorsiflexion of foot – unreliable)

Question 2

What are the common presenting symptoms of pulmonary thromboembolism (PTE)?

Answer 2

🔹 Sudden onset dyspnea
🔹 Pleuritic chest pain
🔹 Haemoptysis (rare)
🔹 Tachypnea & tachycardia
🔹 Hypoxia & cyanosis (severe cases)
🔹 Syncope (if massive PE)

Question 3

What are the risk factors for DVT/PE? (Virchow’s Triad)

Answer 3

✅ Stasis: Immobility, surgery, prolonged travel
✅ Hypercoagulability: Cancer, pregnancy, thrombophilia, HRT/OCP use
✅ Endothelial injury: Trauma, recent surgery, smoking

Question 4

What is the first-line investigation for suspected DVT?

Answer 4

🩸 D-dimer test (high sensitivity, low specificity)
🖥 Compression ultrasound (USS) – diagnostic test of choice

Question 5

What is the first-line investigation for suspected PE?

Answer 5

📌 Wells Score for PE assessment
🩸 D-dimer (if low probability)
🖥 CT Pulmonary Angiography (CTPA) – gold standard
🖥 Ventilation-Perfusion (V/Q) scan – if CTPA contraindicated

Question 6

What is the initial management of DVT/PE?

Answer 6

💊 Immediate anticoagulation:

Low Molecular Weight Heparin (LMWH) e.g., Enoxaparin (if cancer)
DOACs (e.g., Rivaroxaban, Apixaban) – first-line for most patients
🔹 Oxygen if hypoxic
🔹 Haemodynamically unstable PE → Thrombolysis (Alteplase)

Question 7

What are the long-term anticoagulation options for DVT/PE?

Answer 7

1️⃣ DOACs (Rivaroxaban, Apixaban) – preferred
2️⃣ Warfarin (if contraindications to DOACs, e.g., severe renal disease)
3️⃣ LMWH (preferred in cancer patients)

🕐 Duration of anticoagulation:

Provoked DVT/PE: 3–6 months
Unprovoked or recurrent: Long-term (>6 months)

Question 8

What are the indications for IVC filter placement?

Answer 8

🔹 Contraindication to anticoagulation (e.g., active bleeding)
🔹 Recurrent PE despite adequate anticoagulation

Question 9

What are the complications of untreated DVT/PE?

Answer 9

🔴 DVT:

Post-thrombotic syndrome (chronic pain, swelling, ulcers)
Recurrent DVT
🔴 PE:

Right heart strain → Pulmonary hypertension
Shock & cardiac arrest (massive PE)

Question 10

Mnemonic for PE Symptoms: “P-E CLOTS”

Answer 10

✅ Pleuritic chest pain
✅ Elevated heart rate (tachycardia)
✅ Cough +/- haemoptysis
✅ Low oxygen saturation
✅ Onset sudden
✅ Tachypnea
✅ Syncope (if massive PE)