SIU School of Medicine

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Department of Internal Medicine

Venous Thromboembolism DVT/PE

Prerequisites

Prior knowledge of the anatomy of the venous system, knee and ankle joint and popliteal fossa. Prior knowledge of the clotting cascade and thrombophilia, and the skill to perform a physical examination of the cardiorespiratory and musculoskeletal systems.

Knowledge

Students should be able to define, describe and discuss:

  • Inherited and acquired risk factors for developing venous thromboembolism
  • Presenting symptoms of DVT and pulmonary embolism
  • Standard treatment for venous thromboembolism.
  • The long term sequelae of DVT and pulmonary embolism

Skills

Students should demonstrate specific skills, including:

  • History-Taking Skills: Students should be able to obtain, document, and orally present an age-appropriate medical history that suggests the diagnosis of DVT or pulmonary embolus, including risk factors, leg pain and swelling, dyspnea, and pleuritic chest pain.
  • Physical Exam Skills: Students should be able to perform a physical examination which includes accurate identification of leg swelling, discoloration, and warmth; knee effusion, palpation for a Baker’s cyst, identification of pleural friction rubs, wheezes, rales, and signs of pneumothorax; and assessment of severity of dyspnea, including heart rate, respiratory rate, blood pressure and pulse oximetry.
  • Differential Diagnosis: Students should be able to generate a differential diagnosis for a patient suspected of having DVT, recognizing specific history and physical examination findings which suggest DVT or an alternative diagnosis such as ruptured Baker’s cyst, ruptured plantaris tendon, or cellulitis. Students should be able to generate a differential diagnosis for acute shortness of breath and/or pleuritic chest pain.
  • Diagnostic Studies: Students should be able to interpret a D-dimer and arterial blood gases and should understand the indications and limitations of diagnostic studies for DVT such as duplex scan and MR venogram, They should know the utility and limitation of ventilation perfusion (V/Q) lung scan, computerized tomography of the chest and the indications and risks of a pulmonary angiogram. Students should be able to recommend when each of these tests should be ordered.
  • Management Skills: Students should be able to
    • outline the acute and long-term treatment of isolated calf vein phlebitis, proximal DVT, superficial thrombophlebitis, and pulmonary embolism, including appropriate use and monitoring of heparin and warfarin.
    • explain the uses of unfractionated heparin, low molecular weight heparin and know of alternative agents to consider when a patient has a history of heparin-induced thrombocytopenia
    • describe the indications for DVT prophylaxis
    • describe the indications for placement of inferior vena cava filter
    • describe the indications and complications of thrombolytic therapy

Resources

  • 1. The Evaluation of Suspected Pulmonary Embolism, Peter F. Fedullo, M.D., and Victor F. Tapson, M.D., N Engl J Med 2003;349:1247-56.
  • 2. Clerkship Seminar – “Pulmonary Embolism”, Joseph Henkle, MD
  • 3. Internal Medicine Clerkship Guide, Paauw et al, Mosby 2003. 168-177 and 459-464.
  • 4. The Seventh ACCP Conference on Antithrombolic and Thrombolytic Therapy: Evidence Based Guidelines. Chest 2004; 126(3):
    Prevention of Venous Thromboembolism
  • 5. Anti-thrombotic Therapy for Venous Thromboembolism

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