Clinical Presentation
DVT
The signs and symptoms suggestive of DVT include localized tenderness
along the distribution of the deep venous system, swelling on a unilateral or an
entire leg, swelling with a difference in calf or thigh
circumference; calf swelling >3 cm compared to an asymptomatic
leg (measured 10 cm below tibial tuberosity), pitting edema that is greater in the symptomatic leg, dilated collateral
superficial veins (non-varicose), erythema, warmth, and superficial
thrombophlebitis with a palpable cord over a superficial vein.
Phlegmasia alba dolens (pale, white, or milk leg) is the presence of
pallor in the edematous legs and is due to the interstitial tissue pressure
exceeding the capillary perfusion pressure. Additionally, it is caused by the
early compromise of arterial blood flow from extensive iliofemoral DVT. It is commonly seen in patients with thrombus in the major deep
veins.
Phlegmasia cerulea dolens (blue leg) happens when deoxygenated
hemoglobin in the stagnant veins causes a cyanotic hue in the leg. Advanced stages are seen in severe forms of iliocaval
or iliofemoral DVT causing total outflow obstruction with
rapid extension of thrombosis into all deep and superficial veins, including
collaterals over a few hours leading to sudden severe ischemic pain, massive
limb congestion, cyanosis, loss of function, tachycardia, and shock. This may lead to venous gangrene.
Pulmonary
Embolism
The suspicion of pulmonary embolism is usually
raised by the clinical symptoms. Clinical findings are non-specific and should
not be the only criteria to diagnose pulmonary embolism. Dyspnea, pleuritic
chest pain, syncope, and tachypnea (respiratory rate ≥20/minute) occur in most
cases of pulmonary embolism.
Dyspnea
is the most frequent symptom, while tachypnea is its most frequent sign. Other
signs and symptoms that may be present include tachycardia (heart rate >100
beats per minute [bpm]), cough and hemoptysis, fever, diaphoresis, non-pleuritic
chest pain, apprehension, decreased breath sounds, rales, increasing pulmonic
component of the second heart sound, wheezing, parasternal lift, hypotension, hypoxia, cyanosis, pleural
friction rub, and raised
jugular venous pressure. Pulmonary embolism should be suspected in cases of
postoperative hypoxemia.
Pleuritic chest pain with or without dyspnea is one
of the most frequent presentations of pulmonary embolism. It may suggest a
small embolism located distally near the pleura that also causes pleural
irritation.
Isolated dyspnea may occur
suddenly or progressively (over several weeks). It is usually due to a more
central pulmonary embolism (not affecting the pleura). It may be associated with
substernal angina-like chest pain that probably represents
RV ischemia. Worsening dyspnea may be the
only symptom that indicates pulmonary embolism in patients with pre-existing HF or pulmonary
disease.
Syncope or shock is the hallmark sign of central pulmonary
embolism and usually results in severe hemodynamic repercussions. The signs of
hemodynamic compromise and reduced heart flow are also usually present (eg
systemic arterial hypotension, oliguria, cold extremities, and/or clinical
signs of acute right HF).
Diagnosis or Diagnostic Criteria
Clinical findings are
important in the diagnosis of DVT but are poor predictors of
the presence or severity of thrombosis. Pretest probability is needed to guide
the diagnostic process.
| WELLS SCORE OF CLINICAL PRETEST PROBABILITY FOR DVT | |||
| Clinical Features | Points | Pretest Total Probability Points |
|
| Entire leg swollen | 1.0 | High risk≥3 Moderate risk1-2 Low risk≤0 If both legs are symptomatic, score the more severe side Simplified version*: DVT likely≥2 DVT unlikely<2 |
|
| Calf swollen by >3 cm compared to the asymptomatic side (measured 10 cm below tibial tuberosity) | 1.0 | ||
| Localized tenderness along the deep venous system distribution | 1.0 | ||
| Pitting edema (greater in the symptomatic leg) | 1.0 | ||
| Dilated collateral superficial veins (non-varicose) | 1.0 | ||
| Immobilization for >3 days or major surgery within 12 weeks | 1.0 | ||
| Paralysis, paresis, recent plaster immobilization of lower extremity | 1.0 | ||
| Previously documented DVT | 1.0 | ||
| Active cancer (ongoing treatment within the last 6 months or current palliative therapy) | 1.0 | ||
| Alternative diagnosis as likely or greater than that of DVT | -2.0 | ||
| Reference: Institute for Clinical Systems Improvement. Health care guideline: venous thromboembolism diagnosis and treatment. 13th ed. Jan 2013. *National Institute for Health and Care Excellence (NICE). Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. https://www.nice.org.uk. 26 Mar 2020. |
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Pretest Probability of Pulmonary
Embolism
All patients with possible pulmonary embolism should
have their clinical probability assessed and documented. Clinical probability
may be estimated empirically or explicitly by a prediction rule. There are 2
frequently used pretest probabilities of pulmonary embolism which are the
Geneva score (Europe) and Wells score (Canadian rule).
Geneva
Score
Geneva score requires arterial blood gas measurement
and a chest radiograph.
| GENEVA CLINICAL PREDICTION RULE FOR PULMONARY EMBOLISM | |||||
| Clinical Features | Points | Simplified Version | Pretest Total Probability Points |
Simplified Version | |
| Age >65 years | 1 | 1 | Based on likelihood of PE Pulmonary embolism likely≥6 Pulmonary embolism less likely0-5 According to risk groups High≥11 Intermediate4-10 Low0-3 |
≥3 0-2 ≥5 2-4 0-1 |
|
| Active cancer | 2 | 1 | |||
| Fracture or surgery within the past month | 2 | 1 | |||
| Heart rate 75-94 bpm ≥95 bpm |
3 5 |
1 2 |
|||
| Hemoptysis | 2 | 1 | |||
| Previous DVT or Pulmonary embolism | 3 | 1 | |||
| Unilateral edema and pain on lower-limb deep venous palpation | 4 | 1 | |||
| Unilateral pain in lower limb | 3 | 1 | |||
| References: 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J. 31 Aug 2019. Writing Committee Members; Creager MA, Barnes GD, Giri J, et al. 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN guideline for the evaluation and management of acute pulmonary embolism in adults: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2026 Mar 24;153(12):e977-e1051. |
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Wells Score
The Wells score requires that the patient has clinical
features suggestive of pulmonary embolism (eg breathlessness, and/or tachypnea
with or without pleuritic chest pain and/or hemoptysis), along with 2 other
features, the absence of another reasonable clinical explanation and the presence
of a major risk factor.
| WELLS SCORE OF CLINICAL PRETEST PROBABILITY FOR PULMONARY EMBOLISM | |||
| Clinical Features | Points | Simplified Version* | Pretest Total Probability Points |
| Clinical signs and symptoms of DVT | 3.0 | 1 | Based on likelihood of PE Pulmonary embolism likely>4 Pulmonary embolism less likely≤4 According to risk groups High>6 Intermediate2-6 Low<2 Simplified version*: Likely≥2 Unlikely<2 |
| Alternative diagnosis is less likely than Pulmonary embolism | 3.0 | 1 | |
| Heart rate ≥100 bpm | 1.5 | 1 | |
| Immobilization for ≥3 days or surgery within the past 4 weeks | 1.5 | 1 | |
| Previous DVT or pulmonary embolism | 1.5 | 1 | |
| Hemoptysis | 1.0 | 1 | |
| Malignancy (with treatment within the last 6 months or palliative) | 1.0 | 1 | |
| Reference: Writing Committee Members; Creager MA, Barnes GD, Giri J, et al.
2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN guideline for the evaluation
and management of acute pulmonary embolism in adults: a report of the American
College of Cardiology/American Heart Association Joint Committee on Clinical
Practice Guidelines. Circulation. 2026 Mar 24;153(12):e977-e1051. *2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J. 31 Aug 2019. |
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Pulmonary Embolism Rule-Out
Criteria (PERC)
PERC is used to identify groups at very low risk of pulmonary
embolism and to determine if additional investigations for pulmonary embolism are
warranted.
If the patient has answered yes to any of the following questions, the patient is PERC positive:
- Is the patient >49 years old?
- Is the patient’s heart rate >99 bpm?
- Is the patient’s pulse oximetry reading <95% while breathing room air?
- Does the patient have hemoptysis?
- Is the patient on exogenous Estrogen?
- Does the patient have prior diagnosis of VTE?
- Has the patient had surgery or trauma requiring hospitalization in the previous 4 weeks?
- Does the patient have unilateral leg swelling at the calves?
In low-risk, pulmonary embolism can be ruled out without imaging tests or D-dimer if PERC is negative (ie score of 0).