lower leg swelling atherton sorrenti, kent clark, lee hardin
TRANSCRIPT
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Lower Leg Swelling
Atherton Sorrenti, Kent Clark, Lee Hardin
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Lower Leg Swelling
Leg swelling generally occurs because of an abnormal accumulation of fluid in the tissues of the lower extremity. The medical term for leg swelling from excessive fluid in the tissues is edema. Persisting indentation of a swollen leg after pressure from a finger is known as pitting edema.
Less common causes of leg swelling include diseases that cause thickness of the layers of skin, such as scleroderma and eosinophilic fasciitis. In these diseases, the leg swelling is characterized by non-pitting edema.
REFERENCE:Fauci, Anthony S., et al. Harrison's Principles of Internal Medicine. 17th ed. United States: McGraw-Hill Professional, 2008.
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Bilateral Systemtic Condition CHF Liver/Kidney Na+ Imbalance Lymphedema Diabetes Drugs Tumor/Space Occupying
Lesion (proximate)
Unilateral DVT Muscular Sprain/Strain Compartment
Syndrome Tumor/Space
Occupying Lesion
Bilateral vs. Unilateral
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CHF
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Liver/Kidney
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Na+ Imbalance
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Lymphadema
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Tumor/Space Occupying Lesion
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Diabetes
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Drugs
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Deep Vein Thrombosis
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Compartment Syndrome
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Possible Causes of LLS
Baker CystCellulitisCirrhosis (liver)Congestive Heart FailureEosinophilic FascitisPhlebitisSclerodermaDVT
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Possible Causes of LLS Continued
Idiopathic EdemaLeg Vein ObstructionMedicationsNephrotic SyndromeSalt RetentionTrauma InjuryCompartment Syndrome
Source: Medicinenet
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How to take a good patient history
Obviously, height, weight and vitals
Determine unilateral or bilateral swelling
This will help narrow your differential list
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Unilateral vs Bilateral
If Unilateral Swelling?Determine the following:
Involved traumaHistory of contraceptive use or
immobilizationDetermine whether there was a
sudden or gradual onset of pain w/ exercise
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Unilateral DDX
DVTMuscle tearAnterior compartment syndromeBaker’s cyst/ popliteal cystTumorsFractures
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Unilateral vs Bilateral
Bilateral swelling? Determine the following:
Age at onsetCardiopulmonary statusDrug and food consumption that
may cause salt retention.Hours a day pt standsVaricosities in leg.
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Bilateral
CHFlymph blockage that may occur
with tumorsVenous insufficiencyLiver pathologyKidney pathologyObesityHyperthyroidism
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History
Onset Acute/ chronic With/without activityTrauma
Timing and position bilateral/unilateral relieved with elevationImmobilized
Meds, drugs, diet (birth control)
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Exam
Pitting vs non pittingSwelling local and degreeSkin TexturePitting vs non pittingPitting – CHFNon-pitting- lymph blockage that
occurs with tumors
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Exam
Pitting vs non pittingPitting – CHFNon-pitting- lymph blockage that
occurs with tumors
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Exam
Swelling (B) swelling which spares the
ankles in obese women fat deposition( lipedma)
localized behind the kneebakers cyst (popliteal cyst) or medial gastroc rupture
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Exam
SwellingSwelling of tibial crest
Myxedema in hyperthyroid ptsLocalized hard and tender
bone or soft tissue tumorUnilateral swelling in calf
DVT
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Exam
Skin TextureDry and scaly skin with
progressive thickening Lymphedema
Diffuse redness and warm skin or red streaks appear on leg Cellulitis
Golden brown skin, hemosideran depositionChronic venous insufficiency
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Exam
Skin TextureIndurated orange peel skin.
Lymphatic obstruction Bluish purple discoloration at the medial malleolus
Gastroc tearSkin cool and hypersensitive-
early stage, taut shiny thin skin- late stageRSD
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Exam
Considered orthosHoman’s- DVT or venous
insufficiencyBancrofts test- thrombophelebitisTrendelenburgs- venous valve
insufficiencyLowenburg’s sign- thrombosis
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Case Study #1 Big Dan
25 year old college studentHeight 5’10” Weight 256lbsChief Complaint: Low back pain and
bilateral leg swellingOnset: insidiously over the past weekNothing makes it better or worse and it
remains constantPain is described as a deep boring
pain rated at a 4 on the QVAS
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Big Dan’s Chief Complaint
Pt also complains of slight abdominal pain located primarily in the RUQ
Pt has not received medical treatment for this condition
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Big Dan’s History
No MVA’sFractured R fibula from HS football 99Drinks 3-4 sodas per dayHas several adult beverages per
weekendDiet involves fast food 4-5 times/weekNo Hx of smoking or elicit drug useTaking weight loss supplement from
GNC for about 1 year
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Big Dan’s Exam Findings
BP 160/88 BilateralHR 110Cardiac: Posterior Tibial and Dorsal
Pedial pulses are weakAscultory findings: No mumors, clicks,
heart rate regular and rhythmic Pulmonic findings: Clear
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Big Dan’s Exam Cont’
Abdominal exam: Bowel sounds heard in all four quadrants, Splenic percussion was dull on inhalation
Marked tenderness on light and deep palpation of RUQ and LUQ and smooth edge of the liver palpated as smooth and firm with a blunt edge
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Big Dan’s Exam Cont’
Cranial Nerves: WNL, slight yellow tint to sclera
Motor: 5/5 both upper and lowerSensory: NAD for both accurate and
non accurate pathwaysChiro Exam: +Y R shoulder, +Z head,
+Y R hip, Bilateral internally rotated shoulders
C1 ASRP, C5L, T4L, L4L, R AS
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Big Dan’s Differentials Hepatitis: considered d/t palpable finding in
RUQ, yellow sclera, and general college lifestyle
CHF: considered d/t bilateral leg swelling and hypertension
Diabetes: considered b/c systemic metabolic disorders may cause bilateral leg swelling
Cirrhosis: considered d/t yellow sclera, liver palpation, and Hx of alcohol consumption
Liver Failure: Considered d/t yellow sclera, liver and spleen palpation and percussion
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Big Dan’s Imaging and Labs
Radiology: Full spine series-unremarkable
CT: reveals liver and spleen enlargement
Labs: Increased Alk Phos, LDH, AST, ALT, and bilirubin
Decreased A:G
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Big Dan’s Diagnosis
Acute Liver Failure
While awaiting lab results, with in one day pt acquired substantial systemic jaundice and went directly to ER via EMS were diagnosis was made
The only perceivable contributor was the high doses of the weight loss supplement
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Mechanism
Once hepatocytes are damaged, the liver becomes non functional resulting in a decrease of albumin production. This decrease production has a dramatic effect on oncotic pressure in the capillary beds. The jaundice is produced as the bile products are not processed by the liver. Portal hypertension results in splenomegaly and lower leg swelling
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Case #2 Mary Jane
37 year old Female5’3” 190lbsWorks in retailChief complaint: Pain in left calf that is
worse when walking or standing for long periods of time. She also says that her left calf feels tight and appears to be slightly larger than the right.
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Mary Jane’s Complaint Cont’
Onset: Pain began after getting home from a family vacation in Sydney about 3 days ago
There has been no recent traumaSeverity: 4/10Provocative: prolonged standingPalliative: restNo previous treatment
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Mary Jane’s History
Cholecycectomy and appendectomy 99
MVA: rear-ended @ 35 mph in 87Social Hx: 3 cups of coffee per day,1-3
glasses of wine per day, 20 pack years smoker
Meds: Ibuprofen for pain, BCP for 12 years
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Mary Jane’s Exam
BP: 140/82 HR:90 PERRLAPulmonary: wheezing on exhalationAbdomen: NADCN: NADMotor: C5=4/5 all else WNLSensory: Paresthesia in L5/S1
dermatomes on leftOrthos: Hip, knee, ankle (-),
Homans (+)
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Mary Jane’s Workup
Blood work: WNL
Radiology: Hip, knee, ankle series-unremarkable
Next step?
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Mary Jane’s Workup Cont’
Next step should include referral for Doppler ultrasound
Doppler US is slowly replacing the gold standard of ascending contrast venography
Also include D-dimer- global indicator coagulation activation and fibrinolysis, <250 ng/mL= low risk for recurrence of venous thrombosis
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Mary Jane’s Differentials DVT: Ruled in with hx of smoking, bcp, and long term
immobilization, confirmed with Doppler US Lipedma: Pt complains of LLS and is over weight,
R/O: typically bilateral Primary varicosities: Pt complains of dull achy pain in lower
extremity with associated swelling, overweightR/O: via inspection, pain is typically on medial aspect
of leg because the Great Saphenous vein is usually compromised
Venous insufficiency: Pt complains of LLS with dull achy pain that is worse with prolonged standing
R/O: trendelenbergs test Thrombophlebitis: Inflammation of a vein + thrombosis,
common with immobilization, bcp, smoking,Still a possible dx: more common than DVT
and some sources show that a (+) Homans is indicative of thrombophlebitis, less likely if superficial veins are competent
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Case #3 Betty Chase
63 year old female 5’4” 158 lbs Chief Complaint: Bilateral leg swelling and
shortness of breath with occasional coughing up of sputum. Pt also has mid back pain located between her scapulas
Onset: insidious over the past year Timing: mostly constant, but symptoms are
made worse upon exertion or when lying down
Previous Dx: Hypertension (10 years ago)
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Betty’s HistoryPast History:
MI in 1998Appendectomy in 19892 MVAs-minor no tx
Social History: 4 cups of coffee per day1-2 packs per day for 25 years
Occasional drinkerMeds: 9 different medications per day
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Betty’s Exam
BP: 172/92 (controlled?) HR:98Temp:99.2
Eyes: AV nicking and soft exudates
Cardiovascular: -jugular venous distention -increased heart rate -ventricular gallop -skin is pale
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Betty’s Exam Cont’
Pulmonary: Crackles and wheezes are present
Abdomen: Tender to palpate the RUQ, and LUQ
-Bowel sounds heard in all 4-No bruits ascultated
Inspection and Palpation of lower extremities reveals bilateral pitting edema
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Betty’s WorkupRadiology: Chest x-ray
-Cardiomegaly-Pleural effusion-Blunting of costophrenic angles
Next step?CT
Blood: Elevated creatinine and BNPUA: WNL, urine is very concentrated
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Betty’s Differentials
CHF: Considered d/t bilateral leg swelling, cardiac exam, long standing hypertension
R/I: with chest x-ray & CT and elevated BNP Liver Failure: Considered d/t bilateral leg swelling
R/O: Liver enzymes not elevated Nephrotic syndrome: Considered d/t bilateral leg swelling,
high blood pressure, and concentrated urineR/O: serum albumin was WNL, no proteinuria
COPD: Considered d/t pt hx of smoking, cough, sputum, and wheezing
R/O: as main concern d/t bilateral leg swelling, still a possibility if pt continues her current lifestyle
Pericardial disease: Considered d/t edema, cough, SOB, and low grade fever
R/O: CT did not show evidence of pericardial fibrosis or thickening
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Lower Leg Swelling
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