Case study: Serious Pathology - DVT
MDT Connect | Volume 1, Issue 3 | December 2024
CASE STUDY: SERIOUS PATHOLOGY - DEEP VEIN THROMBOSIS REQUIRING REFERRAL TO EMERGENCY DEPARTMENT
- Kavya Parekh, MSc, HCPC, MCSP
Differential diagnosis and clinical reasoning:
The patient’s subjective history of throbbing pain with swelling, past medical history of a DVT and breast cancer raised the suspicion of a DVT. Literature by McLendon et al. 2023 mentions that a previous DVT or history of cancer are risk factors of having a new thrombus formation. It also claims that breast cancer treated with chemotherapy has a 10% rate of clinically significant venous thromboembolism (VTE). Additionally, the fact that the patient has a sedentary job added to the suspicion quotient. Healy et al. 2010 suggests that prolonged work- and computer-related seated immobility increases the risk of VTE. To forge ahead to objective questioning, patient advised change in color of her limb, with entire leg swelling, warmer to touch and tender painful areas. Waheed et al. 2023 state that 70% of patients with a suspected DVT will report swelling in their legs and 50% will present with pain. When a DVT is suspected, risk stratification is crucial in deciding diagnostic and management options. This needs the use of Wells criteria to determine the grade of risk. Modi et al. 2016 mentions that the risk of developing DVT correlates linearly with Wells score, establishing it as a valid pretest tool for risk stratification.
After the subjective and objective assessment, there were a few possible causes of the patients’ symptoms especially that of swelling and red/purple skin. However, swelling and discoloration can also be present after a trauma to the leg. This patient lacked a history of such a trauma which was re-assuring to an exclusion of trauma based changes to the limb. Furthermore, some of these symptoms could have been of a baker’s cyst but the patient denied any knee joint pain or a specific area of swelling to the posterior knee. This helped rule out the possibility of a baker’s cyst. Cellulitis can be another possible differential in this case. Patient denied any recent fevers or feeling of any skin hardening which generally helps to differentiate between cellulitis and DVT. Nevertheless, Maze et al 2013 have suggested that it has been tricky for clinicians to fully differentiate these two conditions purely based on symptoms. There was no mention of superficial veins popping from under the skin when the patient was asked open ended questions which also added to help rule out thrombophlebitis. Waheed et al 2023 also mentions considering trauma, bakers’ cyst, thrombophlebitis, cellulitis as differential diagnosis while considering a diagnosis of a DVT. All of these were excluded as above. Based on the wells score of >3, there was a clear indication of a possible DVT. Complications such as post-phlebitic syndrome, pulmonary embolism, and death are common and very serious complications of DVT. Therefore, as per the National Institute for Clinical Excellence (NICE) guidelines, if a patient has a DVT score of more than or equal to 2, then they should receive a D-dimer test in the next 4 hours and a proximal leg vein ultrasound scan. Based on this reasoning, the patient was explained about the importance of visiting the emergency department as soon as possible.
References:
1. McLendon K, Goyal A, Attia M. Deep Venous Thrombosis Risk Factors. [Updated 2023 Mar 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470215/
2. Healy B, Levin E, Perrin K, Weatherall M, Beasley R. Prolonged work- and computer-related seated immobility and risk of venous thromboembolism. J R Soc Med. 2010 Nov;103(11):447-54. doi: 10.1258/jrsm.2010.100155. PMID: 21037335; PMCID: PMC2966881.
3. Waheed SM, Kudaravalli P, Hotwagner DT. Deep Vein Thrombosis. [Updated 2023 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507708/
4. Scarvelis D, Wells PS. Diagnosis and treatment of deep-vein thrombosis. CMAJ. 2006;175(9):1087–1092.
5. Modi S, Deisler R, Gozel K, Reicks P, Irwin E, Brunsvold M, Banton K, Beilman GJ. Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients. World J Emerg Surg. 2016 Jun 8;11:24. doi: 10.1186/s13017-016-0078-1. PMID: 27279896; PMCID: PMC4898382.
6. Maze MJ, Skea S, Pithie A, Metcalf S, Pearson JF, Chambers ST. Prevalence of concurrent deep vein thrombosis in patients with lower limb cellulitis: a prospective cohort study. BMC Infect Dis. 2013 Mar 19;13:141. doi: 10.1186/1471-2334-13-141. PMID: 23509908; PMCID: PMC3606326.
7. National Institute for Clinical Excellence (NICE) guidelines, 2020.
Meet a member - Dr Ruchi Jain, PT, Dip MDT
This month we meet Ruchi Jain, who has recently completed her Diploma MDT program. Congratulations on your success with the program!
Name: Ruchi Jain
Workplace: Recure Physiotherapy Clinic, Borivali
Tell us about your current work.
I have been into private practice in Mumbai since 2016, providing patient-centered care with a focus on holistic treatment and recovery.
What inspired you to pursue the McKenzie Method?
The logical, systematic, and evidence-based approach of Mechanical Diagnosis and Therapy (MDT) captivated me. Its accuracy and clarity in assessment have been game-changers in my clinical practice.
How has completing the Diploma in MDT influenced your practice?
Completing the diploma has significantly transformed my clinical approach, enhancing every aspect from patient education, assessment to diagnosis, treatment and prognosis. It has made me more confident and precise in handling a wide range of cases.
What advice would you give someone considering the Diploma in MDT program?
This program offers a comprehensive, evidence-informed framework that will elevate your practice and help you become the best version of yourself as a clinician.
What do you enjoy doing for fun or relaxation when you’re not working?
I unwind by watching movies and immersing myself in books, both of which fuel my creativity and provide a much-needed escape.
What’s your favorite quote, and why?
“The difference between who you are and who you want to be is what you do.”
– Bill Philips
This reminds me that actions, not intentions, define progress.
