“No DVT” is not a Diagnosis, Discharge Diagnoses in Patients Investigated for Deep Venous Thrombosis
S. Gilmartin, C. McInerney, V. Varley, B. McNicholl
Galway University Hospital, Galway, Ireland
Patient’s regularly present to the emergency department seeking the exclusion of DVT for calf pain or swelling. Lower limb deep venous thrombosis (DVT) occurs in 84 people per 100,000 of the general population1. One previous Irish study found that only 12.4% of people who undergo a venous ultrasound doppler will have a positive scan for deep venous thrombosis2. This leaves up to 87.6% of patients who have attended an emergency department with symptoms and signs suspicious for DVT left seeking an alternative diagnosis. No study has previously looked at this cohort of patients and described their diagnoses and management.
A retrospective review was performed on two hundred and eleven lower limb VUS doppler scans performed on 203 patients following referral from the emergency department. Thirty (14.2%) scans were positive for DVT, with fifteen (7.1%) of these being proximal thromboses. One hundred and eighty one (86.8%) of the venous ultrasound doppler scans were negative for DVT. Scans were repeated on 8 patients due to high clinical suspicion and high d-dimer. None of these patients had a subsequent DVT. Four of the scans had no corresponding clinical documentation available. This left a final study population of 169.
Seventy seven patients (45.6%) received no diagnosis or a diagnosis of ‘No DVT’. Twenty four (14.2%) patients were diagnosed with cellulitis, twenty (11.8%) patients received a musculoskeletal diagnosis and twelve (7.1%) received a diagnosis of thrombophlebitis or chronic venous changes. Other diagnoses included sciatica, lymphedema and post op swelling.
Venous thromboembolism and DVT itself causes much anxiety in both patients and clinicians. This is due to the potential morbidity and mortality caused by DVT, with mortality rates ranging from 9.4-10.5% if left untreated3,4. As a result of this, patients and medical practitioners tend to adopt a binary approach to diagnosing DVT. Practitioners are often satisfied providing patients with the reassurance they do not have a venous clot and do not seek to establish a definitive diagnosis or plan for the patient’s symptoms. This is despite the fact that many of the alternative diagnoses listed above have the potential to cause ongoing morbidity for patients.
This study has shown that 45.6% of patients who have a negative VUS Doppler scan do not receive an alternative diagnosis. We intend to incorporate a section in our DVT pathway whereby a reasonable alternate diagnosis should be recorded in the event that the patient has a negative VUS Doppler. We plan to perform further research looking at the long term outcomes of patients who receive no diagnosis or a diagnosis of ‘No DVT’ on discharge.
We need to move away from the “No DVT” school of thought in order to provide appropriate diagnosis and management plans for our patients.
Emergency Medicine Spr
Galway University Hospital
1 Anderson FAJ, Wheeler HB, Goldberg RJ, Hosmer DW, Patwardhan NA, Jovanovic B. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. 1991 May;151(5):933–8.
2 Lillis D, Lloyd C, O’Kelly P, Kelada S, Kelly S, Gilligan P. DVT Presentations To An Emergency Department: A Study Of Guideline Based Care And Decision Making. Ir Med J. 2016;109:354.
3 Cushman M, Tsai A, Heckbert SR, White R, Rosamund W, Enright P. Incidence rates, case fatality, and recurrence rates of deep vein thrombosis and pulmonary embolus: the Longitudinal Investigation of Thromboembolism Etiology (LITE). Thromb Haemost. 2001;86(1).
4 Murin S, Romano PS, White RH. Comparison of outcomes after hospitalization for deep venous thrombosis or pulmonary embolism. Thromb Haemost. 2002 Sep;88(3):407–14.