Leg swelling

  • 2 Nov, 2020
  • Reading time:1 mins read
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FieldsCellulitis DVT Heart Failure Varicose Eczema Nephrotic Syndrome 
Age Typically >45 years Typically > 45, Increase with age Increases with Age Over 50 All ages - often presents in children 
Gender M = F M = F M > F F > M M > F 
Typical Presentation A 50 year old woman with type 2 diabetes and chronic liver disease visits her GP with a swollen, painful leg. On examination, it is erythematous and very warm. She has a fever and slight tachycardia. An elderly man who has recently had a hip replacement with a family history of thrombophilia develops a tender, red, swollen calf. O/E he has putting oedema and a fever. A 69 year old man with a family history of heart disease and hypertension develops swollen legs and increasing intolerance to exercise. He has found that he is being increasingly woken in the night due to difficulty breathing. O/E he has peripheral oedema, crackles in both lung bases and an S3 heart sound. A 65 year old woman with known venous insufficiency presents to her GP with an itchy, swollen leg which has developed following a traumatic injury several months ago. On examination it is reddish-brown, scaly and oedematous, particularly around the ankle. A 45 year old man with a history of sarcoidosis and diabetes mellitus develops swelling of his face and legs. He has also noticed that his urine is foamy. On examination he has mild ascites and basal crackles in his lungs 
Other Symptoms ● Swollen leg ● Bright red - well defined border ● Really warm ● Tenderness ● Almost NEVER bilateral - be wary of anyone presenting with 'Bilateral Cellulitis' it is much more likely varicose eczema or something other than cellulitis ● Red, swollen leg (particularly calf) ● Tenderness ● Swollen leg ● Fatigue ● Lethargy ● Exercise intolerance ● SOB ● Weight loss ● Wheeze ● Swollen leg ● Pruritis ● Oedema ● Often, chronically swollen legs made worse by an acute episode ● Swollen leg ● Facial swelling (may complain of itchy swollen eyes) ● Foamy urine 
Pain Onset: Sub-acute Onset: Sub-acute Onset: sub-acute to chronic Onset: Chronic. Usually not particuarly painful ● HX renal impairment ● Minimal change disease ● Focal segmental glomerulosclerosis ● Membranous nephropathy ● Hepatitis B ● SLE ● Diabetes Mellitus ● Sarcoidosis ● Syphilis ● Malginancy ● HIV ● Obesity ● Hypertensive nephrosclerosis ● Hodgkin’s lymphoma ● Recently started NSAID therapy 
Signs ● Malaise ● Chills ● Fever ● Lymphangitis spread (red lines streaking away from area of infection ● Pain disproportionate to appearance ● Violaceous bullae ● Cutaneous haemorrhage ● Skin sloughing ● Skin anaesthesia ● Tachypnoea ● Tachycardia ● Hypotension ● Pitting oedema ● Warm, tender, erythematous leg ● Fever ● Horman’s sign ● Leg swelling >3cms compared to unaffected leg ● Check for signs of PE ● Peripheral oedema ● Orthopnoea ● Paroxysmal nocturnal dyspnea ● Ascites ● Elevated JVP ● Pulsus alternans ● Hypotension ● Tachycardia ● Heaves ● Displaced apex beat ● Gallop rhythm (S3 sound) ● Bilateral crepitations ● Cachexia ● Hepatic tenderness ● Reddish-brown skin discolouration ● Scaling and eczematous patches ● Hyperpigmentation ● Atrophic patches ● Peripheral pitting oedema, especially around the eyes and limbs ● Genital oedema ● Ascites ● Hypertension ● Basal lung crackles 
Past Medical History ● General debility ● Immunocompromise ● HX infection ● Diabetes mellitus ● Cancer ● Venous stasis ● Chronic liver disease ● Peripheral arterial disease ● CKD ● FH thrombosis ● Recent stasis/ immobility (in hospital/ long flight) ● Dehydration ● pregnancy ● combined oral contraceptive pill ● Obesity ● Varicose veins ● Recent surgery ● previous DVT/ embolism ● Trauma ● Infection ● Malignancy ● Congestive heart failure ● Recent MI ● Thrombophilia ● Protein C deficiency ● Antithrombin deficiency ● Hypertension ● Coronary artery disease ● Smoker ● Arrhythmia ● Valvular disease ● Hx of MI/ myocardial ischaemia ● Obesity ● Excessive alcohol consumption ● Cocaine use ● Chemotherapeutic drugs (beta blockers) ● Thyrotoxicosis/ myxedema ●Cardiomyopathy ● Anaemia ● Pulmonary hypertension ● Pericardial disease ● Family history ● Acquired venous deficiency ● Surgery ● Trauma ● Thrombosis ● HX DVT ● Previous HX oedematous legs ● Congestive heart failure ● HTN ● DH amlodipine ● Hypoalbuminaemia <30g/L ● Hypercholesterolaemia ● U&E ● ESR ● CRP ● Complement ● Anti-GMB, ANA, ANCA ● Anaemia 
Bloods ● Blood cultures ● CBC with differential – left shift ● Creatinine high ● Bicarbonate low ● Creatine phosphokinase high ● CRP high ● D-dimer: a negative test rules out DVT ● Anaemia ● Hyponatraemia ● Hypo/hyperkalaemia ● Abnormal LFTs ● Abnormal RFTs ● TFT to rule out thyrotoxicosis/ myxedema ● None specific unless venous thrombosis as comorbidity ● Hypoalbuminaemia <30g/L ● Hypercholesterolaemia ● U&E ● ESR ● CRP ● Complement ● Anti-GMB, ANA, ANCA ● Anaemia 
Imaging ● US to detect occult abscesses and direct care ● CT if concerned about necrotising fasciitis ● Venography to visualise blocked vein ● Doppler USS (higher sensitivity above knee than below knee) ● CXR: cardiomegaly +/- pleural effusions ● Echocardiogram to confirm ● Angiography to assess extent of IHD ● Doppler US may reveal deep venous circulation abnormality ● Renal USS 
Additional Investigations ● US-guided aspiration has diagnostic and therapeutic indications ● Leg measurement 10cm below tibial tuberosity: difference between legs >3cm significant for DVT ● Bleeding time ● Coagulation time ● Prothrombin time ● INR ● APPT ● Venometer ● Fibrinogen testing ● ECG: increased S waves in lead I, increased Q waves in lead III and inverted T waves in lead III. ● Vital capacity decreased by a third of maximum value (congestive HF) ● ECG may indicate underlying cause, e.g. MI, BBB, ventricular hypertrophy, pericardial disease, arrhythmia ● Skin biopsy shows acute/ subacute dermatitis; acute lesions: superficial, perivascular lymphocytic infiltrate, epidermal spongiosis, serous exudate, scale and crust; chronic lesions: epidermal acanthosis, hyperkeratosis ● Urine dipstick: proteinuria >3g/24h ● Renal biopsy 
Full Article CellulitisDVTHeart FailureNot Available(Sorry!) - You could always write oneNephritic and Nephrotic Syndrome