Leg Examination
Leg Swelling
A common problem creating clinical doubt about likely causes and therefore investigation, management and referral issues.
History
History is, as always, vital and will help guide next steps.
may be asymptomatic
ask about associated pain, localised or general - aching, sharp, heaviness
duration of swelling
<72/24 more likely DVT, infection, trauma and sometimes exacerbation of chronic conditions such as Heart Failure
chronic - venous insufficiency, lymphatic dysfunction or other chronic medical condition
check for
Hx of varicose veins, DVT, clotting problems
look out for other causes: rheumatological, renal, hepatic and endocrine causes
medication
Hx - CCB's, chemotherapy agents, NSAIDs, hormones (steroids etc) and others
Examination
assess both legs even if unilateral swelling
look for distribution - even vs local
discolouration to suggest bruising, venous insufficiency, redness associated with infection
check for ulcers, varicose veins
Lymphoedema
hyperkeratosis (thick, dry and scaly) is common
often with small blisters - lymphangioma
often leaks - lymphorrhoea
minimally responsive to leg elevation
does not respond to diuretics
often doesn't 'pit'
Celluitis
can also appear swollen and oedematous
usually more erythematous and painful
usually more localised or circumscribed swelling
may also have bullae, blisters, petechaie or bruises
hotter to touch
Investigation
routine bloods:
U&E,
FBC, Glu, bone profile,
CRP looking for broad suspicion of systemic pathology
d-Dimer, doppler USS if suspecting DVT
blood cultures and wound swabs
other depending on suspicion of other systemic pathology
Author: Dr Dylan Jenkins Oct 23