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For further information, see CMDT Part 2-07: Lower Extremity Edema
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History of venous thromboembolism
Symmetry of swelling
Pain
Change with dependence
Hyperpigmentation, stasis dermatitis, lipodermatosclerosis, 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
Most common cause of chronic lower extremity edema
Affects up to 2% of the population
Strong predictor of all-cause death
Deep venous thrombosis (DVT)
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Unilateral or bilateral lower extremity edema
Pitting with or without tenderness
Measure calves 10 cm below the tibial tuberosity
Swelling of the entire leg or one leg is 3 cm larger than the other suggests DVT
The left calf is normally slightly larger than the right as left common iliac vein courses under the aorta
Chronic venous insufficiency
Sensation of "heavy legs," followed by itching
Skin findings range from hyperpigmentation and stasis dermatitis to lipodermatosclerosis and atrophie blanche to skin ulceration
Stasis dermatitis: brawny, fibrotic skin changes
Skin ulceration
Shallow, large, modestly painful ulcer
Location over the medial malleolus is a hallmark of chronic venous insufficiency
Assess heart, lungs, and abdomen for pulmonary hypertension, heart failure (HF), or cirrhosis
Lymphedema
Can be difficult to distinguish lymphedema from venous insufficiency by physical examination
Kaposi-Stemmer sign (inability to pinch or pick up a fold of skin at the base of the second toe because of its thickness) is a significant predictor of lymphedema