ECHOES OF THE UNEXPECTED: SONOGRAPHIC DIAGNOSIS OF AN EXTENSIVE DVT WITHOUT CLASSIC SIGNS OR CLINICAL SUSPICION
By Alice Bevan, Somerset NHS Foundation Trust
40-year-old female, normally fit and well, presented acutely with worsening right-sided abdominal pain, referred for ultrasound assessment to look for renal colic, appendicitis or ovarian pathology.
Ultrasound findings showed normal pelvic and renal anatomy with no evidence of appendicitis. However, an incidental finding of a tubular structure in the pelvis with echogenic static contents led to sonographer-initiated assessment of the deep venous system, which revealed an extensive right-sided DVT involving the IVC.
The presence of IVC thrombus is a high risk for pulmonary embolism; results were issued urgently in written and verbal formats.
This was a very unusual presentation of a DVT without lower limb swelling, which led to urgent intervention and critical review of the patient’s underlying health status.
The diagnosis was confirmed with CT, ruling out any mass, malignancy, or physical cause. The patient commenced on intravenous heparin initially and converted to Rivaroxaban on discharge.
Subsequent haematology investigations led to a diagnosis of antiphospholipid syndrome with lupus anticoagulant positivity, a rare, complex autoimmune condition strongly associated with vascular thrombosis and pregnancy complications, requiring lifelong anticoagulation.
This case highlights the role of a sonographer in making critical clinical decisions and coordinating with the multidisciplinary team (MDT) to reduce diagnostic error. The unexpected clinical findings emphasised the need for careful attention to detail, flexibility in exploring beyond initial clinical presentation and effective communication.
This case illustrates the importance of a comprehensive approach to sonography where skills extend beyond scanning to include clinical reasoning, a core capability of advanced practice.
By combining critical thinking, sonographic skills, clinical examination and clinical reasoning, a sonographer who is integrated into the MDT is pivotal in identifying atypical presentations, leading to improved patient pathways and outcomes by reducing diagnostic error. This is directly translatable to the author’s future role as an advanced clinical practitioner.