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Key Clinical Questions

  • image How may the history and physical examination findings direct the evaluation of lower-extremity edema?

  • image What diagnostic or laboratory studies will help better delineate the differential diagnosis?

  • image What therapeutic options may be beneficial in the management of edema?

CASE 86-1

A 42-year-old woman with a medical history of vascular disease presented to the emergency department with difficulty walking from painful leg and foot wounds present for 4 weeks. Her medical history includes traditional vascular risk factors, hypertension, diabetes, and hyperlipidemia, coronary artery disease (four myocardial infarctions, s/p percutaneous coronary intervention and stent placement, ischemic cardiomyopathy with ejection fraction of 25% and left apical thrombus, venous thromboembolism (deep venous thromboembolism, pulmonary embolism, s/p inferior vena caval filter placement), warfarin associated gastrointestinal bleeding, and partial amputation of her right foot due to osteomyelitis. She has not been taking her medications for 2 weeks. She complains of acute blisters of unknown etiology on her feet. The left is more involved than the right. She has been evaluated at an outside hospital for similar findings and a biopsy was done without defining an underlying etiology.

On examination vital signs include temperature 99.4°F; heart rate 116; blood pressure 133/93 mm Hg, respiratory rate 20, with a room air pulse oximetry at 100%. Her neck veins are distended and elevated to 14 cm. She is tachycardic with a regular rate with a 3/6 systolic murmur at the apex. No gallop is noted. Her lungs are clear without wheezes or crackles. Her abdomen is soft. No abdominal bruits are noted. She is tender to palpation in the right upper quadrant. Lower-extremity edema extends from the feet to the proximal hips and lower abdominal wall bilaterally. There are multiple punched-out fibrous-based wounds as well as intact fluid-filled blisters over the thighs and posterior knees. The left foot is completely involved with a partially hemorrhagic bulla. Pulses are not palpable.

Initial laboratory examination reveals hemoglobin of 7.7 g/dL, hematocrit 26.1%, albumin 1.8 g/dL, prealbumin 5.0 mg/dL, total protein 6.5 g/dL. BUN 21 mg/dL, creatinine 1.14 mg/dL, and glucose 401 mg/dL. Urinalysis demonstrates 3+ protein, 2+ blood, and 1000 mg/dL glucose. Further workup during the admission is directed at identifying the etiology of her volume overload, managing her edema, and local wound care.

A limited study due to her edema, Duplex ultrasound demonstrated normal compressibility in the visualized segments and the proximal waveforms were pulsatile bilaterally (see Figure 86-3), consistent with intravascular volume overload and elevated right heart pressures. On echocardiogram her left ventricle ejection fraction was 20% to 25% with global hypokinesis and a restrictive diastolic filling pattern. The right ventricle was moderately dilated with decreased systolic function and a calculated systolic pressure of 85 mm Hg. A 24-hour urine collection demonstrated protein loss of 2071 mg/24 hours. Under the direction of the heart failure service she was managed with aggressive diuresis, sodium and fluid restriction, and control of her diabetes with the addition ...

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