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For further information, see CMDT Part 2-07: Lower Extremity Edema
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Essentials of Diagnosis
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Inquire about
History of venous thromboembolism
Symmetry of swelling
Pain
Change with dependence
Skin findings: hyperpigmentation, stasis dermatitis, lipodermatosclerosis, atrophie blanche, ulceration
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General Considerations
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Lower extremities can swell in response to
Increased venous or lymphatic pressures
Decreased intravascular oncotic pressure
Increased capillary leak
Local injury or infection
Chronic venous insufficiency is the most common cause of chronic lower extremity edema, affecting up to 2% of the population
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Deep venous thrombosis
Life-threatening
History of cancer, recent limb immobilization, or confinement to bed for at least 3 days following major surgery within the past month are suggestive clues
Adults with varicose veins have a significantly increased risk of DVT
Postphlebitic syndrome with valvular incompetence seen in patients with lower extremity swelling and inflammation in a limb recently affected by DVT
Other causes of a painful, swollen calf
Cellulitis
Musculoskeletal disorders (Baker cyst rupture ["pseudothrombophlebitis"])
Gastrocnemius tear or rupture
Calf strain or trauma
Left common iliac vein compression (May-Thurner syndrome)
Other sites of nonthrombotic venous outflow obstruction, such as the inguinal ligament, iliac bifurcation, and popliteal fossa
Swelling of the ankle can be a manifestation of Charcot neuropathic osteoarthropathy
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Bilateral involvement and significant improvement upon awakening
Favor systemic causes (eg, venous insufficiency)
Can be presenting symptoms of volume overload (HF, cirrhosis, kidney disease [eg, nephrotic syndrome])
Sensation of "heavy legs" is the most frequent symptom, followed by itching
Brawny, fibrotic skin changes; predisposition toward skin ulceration, particularly in the medial malleolar area
Lymphedema and lipedema
Pain is uncommon
Medications that may cause lower extremity swelling
Pelvic congestion syndrome worsens symptoms of chronic venous symptoms of the lower extremities
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Differential Diagnosis
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Cardiovascular
Noncardiovascular
Cirrhosis
Low albumin (nephrotic syndrome, malnutrition, protein-losing enteropathy)
Cellulitis
Premenstrual fluid retention
Drugs (vasodilators, eg, calcium channel blockers; salt-retaining medications, eg, nonsteroidal anti-inflammatory drugs, thiazolidinediones)
Musculoskeletal (Baker cyst, gastrocnemius tear, compartment syndrome)
Lymphatic obstruction
Lymphedema (the Kaposi-Stemmer sign [the inability to pinch or pick up a fold of skin at the base of the second toe because of its thickness] can distinguish between lymphedema and chronic venous insufficiency)
Eclampsia
Hypothyroidism with myxedema
Filariasis
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Serum creatinine, blood urea nitrogen
D-dimers
Urinalysis
Liver chemistries: serum alkaline phosphatase, aspartate aminotransferase, gamma glutamyl-transpeptidase, total bilirubin, albumin
Thyroid-stimulating hormone
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