Controversies and Enigmas in Thrombophlebitis and Pulmonary Embolism

Increased criticism concerning the alleged misdiagnosis and overdiagnosis of deep vein thrombophlebitis (DVT) in the lower extremities, and of pulmonary embolism is being leveled at clinicians when unequivocal documentation by venography, lung scanning, and pulmonary angiography is lacking. The excessive adoption of this attitude by audit and utilization committees could prove dangerous for patients with these conditions, particularly when rigid criteria intimidate the physician and override his clinical judgment and experience. The matter assumes added importance in view of the increasing magnitude 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 methods. 4. The perpetuation of diagnostic bias and dogma by teachers and the literature. 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 controversy.