examinations:legs
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'
Oedema of Heart failure
- usually 'pits'
- responds to elevation, may not if related to low albumin
- responds to diuretics
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