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  1. How can the history and physical examination findings direct the evaluation of lower extremity edema?

  2. What diagnostic or laboratory studies will help better delineate the differential diagnosis?

  3. What therapeutic options may be beneficial in the management of edema?

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Case 84-1

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 included traditional vascular risk factors (hypertension, diabetes, hyperlipidemia), coronary artery disease (four myocardial infarctions, s/p stent placement, ischemic cardiomyopathy with ejection fraction of 25% of left apical thrombus), venous thromboembolism (deep venous thromboembolism, pulmonary embolism, s/p inferior vena caval filter placement), warfarin associated gastrointestinal bleeding, and status post partial amputation of her right foot due to osteomyelitis. She had not been taking her medications for two weeks. She complained of acute blisters of unknown etiology on her feet. The left was more involved than the right. She had previously been evaluated at an outside hospital for similar findings and a biopsy was done without defining an underlying etiology.

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

Initial laboratory examination revealed a hemoglobin of 7.7 g/dl; hematocrit 26.1%. Albumin was 1.8 g/dl, prealbumin 5.0 mg/dl, and total protein was 6.5 g/dl. BUN and creatinine were 21 and 1.14 respectively. Glucose was elevated at 401 mg/dl. Urinalysis demonstrated 3+ protein, 2+ blood, and 1000 mg/dl glucose. Further workup during the admission was directed at identifying the etiology of the volume overload, managing the edema, and local wound care.

Edema or lower extremity swelling is a common clinical complaint of both hospitalized and ambulatory patients. The differential diagnosis for lower extremity swelling is quite extensive. Despite the clinical frequency of the complaint, few clinical series address the etiology, evaluation, or diagnostic approach to lower extremity swelling. Clinically, edema and lymphedema are often mistakenly used interchangeably to refer to soft tissue fluid accumulation. However, these conditions are very different with respect to their pathophysiology and clinical implications.

All swelling results from an increase in interstitial or tissue fluid, which is mostly water. The transcapillary tissue fluid may ...

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