DVT / PE

Differentials

• Muscle strain/tear

• Achilles tendinopathy

• Cellulitis

• Calf haematoma

• Baker’s cyst (popliteal cyst) mimicking DVT

History Questions

• DVT: Trauma, recent immobilisation (surgery, long-haul travel), oral contraceptive use, smoking, pregnancy, cancer history

• PE: Chest pain, shortness of breath, tachycardia, hypotension

Exam Findings

• Localised calf tenderness

• Calf swelling >3 cm compared to the asymptomatic side

• Pitting oedema confined to symptomatic limb

• Collateral superficial veins visible

• Homan’s sign (pain on foot dorsiflexion) — low specificity but often mentioned

• Entire limb swelling, erythema/warmth

Investigations

• Bloods: UEC (renal function), APTT/INR, D-dimer (if low pre-test probability), FBC, LFTs, β-hCG

• Imaging:

  • DVT: Compression ultrasound (CUS)

  • PE: CT Pulmonary Angiogram (CTPA); Ventilation-perfusion (V/Q) scan in pregnancy or if CTPA contraindicated

Management

• Anticoagulation:

  • Rivaroxaban: 15 mg BD for 3 weeks, then 20 mg OD

  • Apixaban: 10 mg BD for 1 week, then 5 mg BD

  • LMWH (e.g. enoxaparin): Use in pregnancy or remote settings until definitive imaging confirms diagnosis

• Other Measures:

  • Compression bandage/stocking to reduce swelling

  • Analgesia (e.g. NSAIDs or paracetamol)

  • Encourage mobilisation

Duration of Treatment

• Provoked distal DVT: 6 weeks

• All other DVTs (including proximal) & PE: 3 months

• Extended duration (>3 months) for unprovoked events or high recurrence risk

Additional Considerations

• Avoid DOACs in pregnancy; use LMWH instead

• Consider antiphospholipid syndrome testing in recurrent unprovoked VTE

• Monitor for post-thrombotic syndrome (persistent swelling, pain, skin changes in the affected limb)

Key Notes

• Cancer-associated thrombosis often requires extended LMWH or a DOAC (under specialist guidance)

• Use Wells or Geneva score to stratify pre-test probability of DVT or PE

• Early mobilisation, adequate hydration to prevent clot extension