CARDIOPULMO - Leg swelling

Question 1

Differential Diagnoses of Leg swelling

Answer 1

1. Chronic Venous Insufficiency* - PVD
2. Nephrotic Syndrome* - Kidney Problem
3. CHF cor Pulmonale* - Heart problem
4. Cellulitis + DM*
5. Heart problems
6. Kidney problems
7. Liver problems
8. Peripheral Vascular disease
9. DVT
10. Trauma

Leg and ankle swelling  
Probability diagnosis 
Physiological:
•dependency/gravitational
•prolonged sitting, standing, walking 
•hot weather
•pregnancy
•mechanical (e.g. constricting clothing)
Chronic venous insufficiency (varicose veins)
Congestive cardiac failure Drugs (e.g. calcium antagonists, NSAIDs)
Local trauma
Obesity

Serious disorders not to be missed  
Vascular:
•deep venous thrombosis (DVT)
•inferior vena cava thrombosis
•thrombophlebitis

Infection:
•cellulitis
•tropical infections (e.g. filariasis, hookworm)

Cancer:
•obstruction from pelvic cancer
•localised malignancy

Other:
•kidney disease (e.g. nephrotic syndrome)
•liver disease (e.g. cirrhosis)
•skin allergy (e.g. angioneurotic oedema)

Pitfalls (often missed) 
Idiopathic (periodic or cyclic) 
oedema
Protein-losing enteropathy (e.g. Crohn)
Lipoedema (fat and fluids) of legs
Lipidema (fat) of legs

Rarities:
•malnutrition
•lymphoedema: primary or secondary

Masquerades checklist
Diabetes
Drugs (multiple; see list)
Thyroid/endocrine (hypothyroidism, Cushing syndrome)

Question 2

Leg swelling - Key History

Answer 2

Key history

 Past history (esp. liver, heart, kidney disease), travel, drugs, occupation, recent trauma. 
Circumstances of swelling (e.g. prolonged walking, long journey).

Question 3

Leg swelling - Key PE

Answer 3

Key examination

•Cardiovascular, abdomen (signs of liver disease), legs including circulation, varicose veins and evidence DVT

Question 4

Leg swelling - Key Investigation

Answer 4

Key investigations 
Consider:
•urinalysis (?albumin)
•FBE
•ESR/CRP
•U&E
•KFTs
•serum albumin/LFTs
•TSH
•ultrasound (DVT screen)
•CXR
•pelvic ultrasound
•other radiographs (e.g. CT scan, venogram)

Question 5

Leg swelling - Diagnostic tips

Answer 5

Diagnostic tips
•Not all swollen legs require investigation.
•If the onset of oedema is acute (often <72 hours) suspect DVT.
•Pitting oedema is a feature of venous thrombosis or insufficiency, not lymphatic obstruction.
•The significance of leg swelling varies according to the age group, whether it is bilateral or unilateral and whether the onset is sudden or gradual.
•Drugs that can cause leg and ankle swelling include calcium antagonists, NSAIDs, corticosteroids, glitazones, beta blockers.