Increased criticism concerning the alleged misdiagnosis and overdiagnosis of deep vein thrombophlebitis (DVT) in the lower extremities, and of pulmo nary embolism, is being leveled at clinicians when unequivocal documentation by venography, lung scanning, and pulmonary angiography is lacking. The ex cessive adoption of this attitude by audit and utilization committees could prove dangerous for patients with these conditions, particularly when rigid cri teria intimidate the physician and override his clinical judgment and experi ence. The matter assumes added importance in view of the increasing magni tude of DVT and pulmonary embolism.
The following pertinent issues will be discussed:
1. Failure to consider DVT and pulmonary embolism in the appropriate clinical settings, especially when they are still minor and atypical.
2. Deficiencies in the physical examination.
3. Failure to recognize the inherent limitations of existing diagnostic meth ods.
4. The perpetuation of diagnostic bias and dogma by teachers and the liter ature.
5. Confusion introduced by coexisting disorders.
The combination of these insights, greater confidence in clinical skills, and newer noninvasive diagnostic methods promise to help resolve this heated con troversy.
Get full access to this article
View all access options for this article.
References
1.
Robin, E.D.: Overdiagnosis and over-treatment of pulmonary embolism: The emperor may have no clothes. Arch. Intern. Med., 87: 775, 1977.
2.
Robin, E.D.: Pulmonary embolism is over-diagnosed. Patient Care . April 30, 1979, pp. 110-130.
3.
Moser, K.M.: Pulmonary embolism: Where the problem is not. JAMA236: 1500, 1976.
4.
Dalen, J.E., Alpert, J.S.: Natural history of pulmonary embolism. Prog. Cardiovasc. Dis. , 17: 257, 1975.
5.
Gould, S.A., Kerstein, M.D.: The diagnosis and treatment of deep vein thrombophlebitis. Practical Cardiol., November 1978, pp. 85-95
6.
Le Quesne, L.P. : Diagnosis and prevention of postoperative deep-vein theombosis. Ann. Rev. Med., 26: 63, 1975.
7.
Roberts, H.J.: Difficult Diagnosis: A Guide to the Interpretation of Obscure Illness . Philadelphia, W. B. Saunders , 1958 .
8.
Beckering, R.E. , Jr., Titus, J.L.: Femoral-popliteal venous thrombosis and pulmonary embolism. Am. J. Clin. Pathol., 52: 530, 1969.
9.
Kistner, R.L. , Ball, J.J., Nordyke , R.A., et al.: Incidence of pulmonary embolism in the course of thrombophlebitis of the lower extremities . Am. J. Surg., 124: 169, 1972.
10.
Walker, M.G. : The natural history of thromboembolism. Br. J. Surg., 59: 753, 1972.
11.
Deykin, D., Fratantoni, J.C., Salzman, E.W., et al.: Treatment of venous thromboemboli disease. Panel Discussion . 57th Annual Session, American College of Physicians , Philadelphia, April 6, 1976.
12.
Joffe, S.N. : A reappraisal of the clinical diagnosis of postoperative deep vein thrombosis. Angiology, 26: 521, 1975.
13.
Roberts, H.J. : In defense of percussion. Dis. Chest., 49: 184, 1966.
14.
Prescott, S.M. , Pearl, J.E., Tikoff , G.: Pseudo-pseudothrombophlebitis. Ruptured popliteal cyst with deep venous thrombosis. N. Engl. J. Med., 299: 1192, 1978.
Strandness, D.E., Jr., Sumner, D.S.: Acute venous thrombosis: A case of progress and confusion. JAMA, 233: 46, 1975.
17.
Moser, K.M. , Longo, A.M., Ashburn , W.L., et al.: Spurious scintophotographic recurrence of pulmonary emboli. Am. J. Med., 55: 434, 1973.
18.
Greenspan, R.H.: Commentary in Patient Care . April 30, 1979, p. 124.
19.
Roberts, H.J. : The noninvasive diagnosis of deep venous disorders in the lower extremities: Clinical value of plethysmography combined with augmentation methods and a new scoring system. Angiology, 29: 275, 1978.
20.
Roberts, H.J. : Fatal hemoptysis in pulmonary embolism probably precipitated by pulmonary scanning. Angiology, 21: 270, 1970.
21.
Morris, G.K. , Mitchell, J.R.A.: Warfarin sodium in prevention of deep venous thrombosis and pulmonary embolism in patients with fractured neck of femur. Lancet, 2: 869, 1976.
22.
Wilson, J.E. , III: Commentary in Patient Care. April 30, 1979, p. 130.
23.
Strandness, E. : Invasive and noninvasive techniques in the detection and evaluation of the occluded vessel. American College of Angiology, 23rd Annual Meeting, Newport Beach, California, January 27, 1977.
24.
Young, J.R.: Axioms on thrombophlebitis and plebothrombosis. Hosp. Med. , October 1976, p. 6.
25.
Lemoine, J.: Personal communication, January 1977.
26.
Cugell, D.W. : Diagnostic criteria of pulmonary embolism. (Questions and answers). JAMA, 240: 1185, 1978 .
27.
Neuhaus, A., Bentz, R.R., Weg, J.G.: Pulmonary embolism in respiratory failure. Chest, 73: 460, 1978.
28.
Roberson, M.G. : Diagnostic criteria of pulmonary embolism. (Questions and answers). JAMA, 240: 1185, 1978 .
29.
Rafi, M.: Should pulmonary embolism treatment wait for test results? (Questions and answers). JAMA240: 1185, 1978.
30.
Moser, K.M. : Should pulmonary embolism treatment wait for test results? (Questions and answers). JAMA, 240: 1185, 1978.
31.
Personal Communication with Edwards Laboratories, November 1978.
32.
Mehlman—Powell 378 A 2d 1121.
33.
Barnes, R.W. , Collocitt, P.E., Mozersky , D.J., et al.: Nonivasive quantitation of maximum venous outflow in acute thrombophlebitis. Surgery, 72: 971, 1972.
34.
Hull, R., Van Aken, W.G., Hirsh, J., et al.: Impedance plethysmography using the occlusive cuff technique in the diagnosis of venous thrombosis. Circulation, 53: 696, 1976
35.
Wheeler, H.B. , Pearson, D., O'Connell , D., et al.: Impedance phlebography. Arch. Surg., 104: 164, 1972 .
36.
Barnes, R.W. , Wood, K.K., Hoak , J.C.: Fallibility of the clinical diagnosis of venous thrombosis. JAMA234: 605, 1975.
37.
Sigel, B., Felix, R., Jr., Popky, G.L., et al.: Diagnosis of lower limb venous thrombosis by Doppler ultrasound technique. Arch. Surg., 105: 175, 1972.
38.
Aaro, L.A., Juergens, J.L.: Thrombophlebitis associated with pregnancy. Am. J. Obstet. Gynecol., 109: 1128, 1971.
39.
Evarts, C.M. , Alfidi, R.J.: Thromboembolism after total hip reconstruction: Failure of low doses of heparin in prevention. JAMA, 225: 515, 1973.
Nichols, A.B. , Cochavi, S., Hales , C.A., et al.: Scintigraphic detection of pulmonary emboli by serial positron imaging of inhaled 15O-labeled carbon dioxide. N. Engl. J. Med., 299: 179, 1978 .
42.
Roberts, H.J. : On the unrecognized double-cross. J. Florida Med. Assoc., 46: 1087, 1960.
43.
Roberts, H.J. : Is Vasectomy Safe? West Palm Beach, SunshineAcademic Press, 1979.
44.
Roberts, H.J. : Delayed thrombophlebitis and systemic complications after vasectomy: Possible role of diabetogenic hyperinsulinism. J. Am. Geriatrics Soc., 16: 167, 1968.
45.
Roberts, H.J. : Vitamin E and thrombophlebitis. Lancet, 1:49, 1978.
46.
Roberts, H.J. : Thrombophlebitis associated with vitamin E therapy: With a commentary on other medical side effects. Angiology, 30: 169, 1979.
47.
Roberts, H.J. : Thrombophlebitis following liquid protein diets . N. Engl. J. Med, 298: 165, 1978.
48.
Roberts, H.J. : Thrombophlebitis following liquid protein diets . JAMA, 239: 722, 1978.
49.
Andrews, J.L. , Jr., Badger, T.L.: Lung sounds through the ages . JAMA, 241: 2625, 1979.
50.
Nichols, A.B. , Cochavi, S., Hales , C.A., et al.: Resolution rates of pulmonary embolism assessed by serial positron imaging with inhaled O-15-labeled carbon dioxide . J. Nucl. Med, 20: 281, 1979.
51.
Scott, J.: Why are we killing clinical medicine ?Medical World News , July 23, 1979, p. 6.
