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Probability diagnosis

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Physiological:

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  • dependency/gravitational

  • prolonged sitting, standing, walking

  • hot weather

  • pregnancy

  • mechanical (e.g. constricting clothing)

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Chronic venous insufficiency (varicose veins)

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Congestive cardiac failure

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Drugs (e.g. calcium antagonists, NSAIDs)

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Local trauma

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Obesity

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Serious disorders not to be missed

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Vascular:

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  • deep venous thrombosis (DVT)

  • inferior vena cava thrombosis

  • thrombophlebitis

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Infection:

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  • cellulitis

  • tropical infections (e.g. filariasis, hookworm)

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Cancer:

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  • obstruction from pelvic cancer

  • localised malignancy

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Other:

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  • kidney disease (e.g. nephrotic syndrome)

  • liver disease (e.g. cirrhosis)

  • skin allergy (e.g. angioneurotic oedema)

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Pitfalls (often missed)

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Idiopathic (periodic or cyclic) oedema

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Protein-losing enteropathy (e.g. Crohn)

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Lipoedema (fat and fluids) of legs

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Lipidema (fat) of legs

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Rarities:

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  • malnutrition

  • lymphoedema: primary or secondary

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Masquerades checklist

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Diabetes

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Drugs (multiple; see list)

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Thyroid/endocrine (hypothyroidism, Cushing syndrome)

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Key history

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Past history (esp. liver, heart, kidney disease), travel, drugs, occupation, recent trauma. Circumstances of swelling (e.g. prolonged walking, long journey).

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Key examination

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  • Cardiovascular, abdomen (signs of liver disease), legs including circulation, varicose veins and evidence DVT

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Key investigations

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Consider:

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  • urinalysis (?albumin)

  • FBE

  • ESR/CRP

  • U&E

  • KFTs

  • serum albumin/LFTs

  • TSH

  • ultrasound (DVT screen)

  • CXR

  • pelvic ultrasound

  • other radiographs (e.g. CT scan, venogram).

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Diagnostic tips

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  • Not all swollen legs require investigation.

  • If the onset of oedema is acute (often <72 hours) suspect DVT.

  • Pitting oedema is a feature of venous thrombosis or insufficiency, not lymphatic obstruction.

  • The significance of leg swelling varies according to the age group, whether it is bilateral or unilateral and whether the onset is sudden or gradual.

  • Drugs that can cause leg and ankle swelling include calcium antagonists, NSAIDs, corticosteroids, glitazones, beta blockers.

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