Approach to lower limb swelling Flashcards
History taking of lower limb swelling
A. Laterality: unilateral or bilateral?
B. Onset and duration
- Onset: sudden or gradual
- Duration and progression
- Variability: worse at end of day or start of the day?
C. Character and distribution
- Pitting or non-pitting?
- Abdominal swelling, or anasarca
D. Precipitating and relieving factors
- Fluid intake / restriction
- Prolonged ambulation
- Prolonged bedrest/supine
- Limb elevation
E. Associated symptoms
1. Pain - nature, severity, location
2. Erythema, warmth
3. Chest pain, SOB
4. Right heart failure: orthopnoea, PND, exertional dyspnoea
5. Urine output and colour - reduced/increased
6. Trauma
7. Thyroid disease
F. Medications
G. Social history
1. Immobility
2. Long travel
3. Occupation
4. Diet
Causes of unilateral lower limb swelling
- Deep vein thrombosis
- Anti-phospholipid syndrome
- Nephrotic syndrome
- IBD
- MPN
- Malignancy
- OCP use - Cellulitis
- Arthritis - inflammatory, infectious
- Gout, pseudogout
- Septic arthritis - Ruptured Baker’s cyst
- May-Thurner syndrome
- Lymphoedema
Causes of bilateral lower limb swelling
Often systemic or bilateral venous/lymphatic issues
- Heart failure
- Angina / MI
- Valvulopathies
- HOCM, cardiomyopathies, myopathies
- Arrhythmias
- Infective endocarditis
- Myocarditis, pericarditis (autoimmune)
- Thyroid: hypo/hyperthyroidism
- Anaemia - Nephrotic syndrome and/or CKD
- SLE, RA, Sjogren’s
- Hep B/C, HIV
- AA Amyloidosis
- Multiple myeloma, paraneoplastic, AL amyloidosis
- Infective endocarditis
- Diabetes mellitus
- Drugs - Cirrhosis and causes
- Protein-losing enteropathies
- Pulmonary hypertension
- Chronic venous insufficiency
- Meds: CCB, steroids, TCM
Pathophysiology of lower limb swelling
- Increased hydrostatic pressure
- Heart failure: RAAS and water retention
- Renal failure: impaired water and sodium excretion - Localised pressure increase
- DVT
- CVI - Arteriolar dilatation
- CCB
- Inflammation - Reduced oncotic pressure
- Cirrhosis, malnutrition
- Nephrotic syndrome
- Protein losing enteropathy
- Burns - Increased capillary permeability
- Sepsis, angioedema
- Cellulitis, burns, allergic reaction - Lymphoedema
- Obstructive - LN dissection, radiation, infection (elephantiasis)
- Lymphoma - Deposition
- Myxedema (GAG deposition in skin)
- Amyloidosis
LL swelling: heart failure
History and physical:
1. Orthopnoea, PND, SOB
2. Chest pain and anginal history
3. Palpitations and arrhythmias (AFib, tachy/bradyarrhythmias)
4. Murmurs
Investigations:
Echocardiogram
Management:
GDMTs
LL swelling: nephrotic syndrome and chronic kidney disease
History:
1. Frothy urine +/- haematuria
2. Reduced urine output
3. Abdominal distention, facial oedema
Etiologies:
Autoimmune: SLE, RA, Sjogren’s
Infections: Hep B/C, HIV, Infective Endocarditis (immune complex GN)
Malignancy/Paraprotein: Multiple Myeloma, AL/AA Amyloidosis, Paraneoplastic syndromes
Metabolic: Diabetes Mellitus
Drugs: NSAIDs, Penicillamine
LL swelling: multiple myeloma
History: (CKD + CRAB)
1. Frothy urine, reduced output, oedema
2. Hypercalcaemia
3. Renal impairment
4. Anaemia
5. Bone pain, fractures
5A. Spinal compression fracture
6. Hyperviscocity syndrome
Investigations:
1. BM plasma cells > 10%
2. Serum and urine protein electrophoresis with immunofixation
- FLC ratio > 100
3. PBF: Rouleaux formation
4. PET-CT and skeletal survey
6. RP and serum calcium
Management:
1. Chemotherapy: Dara-VTD
2. Autologous stem cell transplant
3. Maintenance: lenalidomide
4. Supportive: biphosphonates, denosumab, hyperCa management
LL swelling: amyloidosis
History and Physical:
1. Chronic disease
2. Multiorgan involvement
3. Maybe ballotable kidneys
Investigations:
1. Tissue biospy - Congo red stain: apple-green birefringence
2. Amyloid protein typing
3. Organ function assessment (nerves, cardiac, kidneys)
Management:
1. AL: treat plasma cell disorder
2. ATTR: tafamidis
3. AA: treat inflammation
4. Supportive
LL swelling: cirrhosis
History and physical:
1. Features of CLD and decompensation
Investigations:
1. Paracentesis
2. CT multiphase liver or US liver
Management:
1. Paracentesis with albumin replacement
2. High protein diet
3. Diuretics
LL swelling: DVT
History and physical:
1. Unilateral swelling, tenderness, warmth, erythema
2. Triggers: malignancy, OCP, immobility, Nephrotic, APS
Investigations:
1. US lower limb DVT
2. D-dimer
Management:
1. Anticoagulation
2. Thrombolysis, thrombectomy
3. IVC filter
LL swelling: cellulitis
History and physical:
1. Unilateral swelling, tenderness, warmth, erythema
2. Open wound / insect bites / skin lesion / recurrent scratching
Investigations:
1. Blood culture
Management:
1. Antibiotics
2. Break scratch-itch cycle
