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October 28, 1992

The Rational Clinical Examination-Reply

Author Affiliations

McMaster University Hamilton, Ontario
American Medical Association Chicago, Ill

JAMA. 1992;268(16):2165. doi:10.1001/jama.1992.03490160034011

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In Reply.  —Concerning Dr Devitt's patient with a history and physical examination strongly suggesting deep-vein thrombosis and pulmonary embolism, both of us (as well as the chief of one of our hospital's thromboembolism service) would have started heparin "on spec" at the conclusion of our examination. However, given the imperfect specificity of her symptoms and signs (which will be the topic of a later overview in this series) and in light of the risks of anticoagulation and of labeling her a vasculopath, we also would have ordered one of the noninvasive tests for deep-vein thrombosis. If that initial investigation was positive, we would have stopped testing, continued her heparin, and prepared to switch her treatment over to long-term therapy with warfarin sodium. Only if noninvasive testing for deep-vein thrombosis was negative would we have proceeded to lung scanning or invasive testing. Finally, if we found the above course of action