60YO male who presents with progressive bilateral lower extremity oedema…
60YO male who presents with progressive bilateral lower extremity oedema for the past month
SOB => consider mainly cardiac or pulmonary issues
Exertional dyspnea or orthopnea at night => heart failure. Other sx: bilateral leg edema with relatively rapid onset (days to weeks); rapid weight gain; tachycardia is common; swollen and tender liver; hx of heart disease; cardiomegaly may be present; 3rd or 4th heart sounds may be present; elevated JVP
Accompanied with chest pain => pulmonary edema due to AMI. Other sx: tachypnea; diaphoresis; wet rales; possibly diastolic gallop (S3) and heart murmurs
Accompanied with abdominal distension => tense ascites due to pressure on diaphragm. Other sx: shifting dullness; fluid wave on abdominal percussion
Unintentional weight loss => Cancer, possibly prostate CA; lymphoma; kidney CA OR protein-losing enteropathy (e.g. inflammatory bowel disease; celiac disease).
Elevated JVP => ESRF/nephritic syndrome. Also refer to "SOB". May be due to insufficient dialysis requiring dry weight titration; hematuria; proteinuria; hypertension; blurred vision; oligouria. Could also be renal sodium retention, other sx: may present with pulmonary/peripheral edema
Severe proteinuria (may have foamy urine) => ESRF/nephritic syndrome; nephrotic syndrome. Other sx of nephrotic syndrome: hypoalbuminemia; may have prominent periorbital edema due to low tissue pressure in this areal occasionally presents with ascites
Is there pain?
Pain present => DVT; reflex sympathetic dystrophy
Pain absent => Lymphoedema. Also refer to "pitting edema". Secondary lymphoedema commonly caused by: tumour (lymphoma, prostate CA, renal CA); surgery; radiotherapy; infection (bacterial infection/filariasis); positive Stemmer's sign (cannot pinch and lift a skinfold at the base of the second toe or middle finger)
Some aching => chronic venous insufficiency (with venous hypertension). Other sx: pain particularly in the evenings; leg swelling usually develops more slowly than heart failure; stasis dermatitis possible (earliest cutaneous sequolae): browning of the skin on the inner side of the ankle and loss of skin hair; varicose veins
Medication hx. Common culprits: Ca channel blockers, e.g. dihydropyridines (direct vasodilators the reduce the BP), nifedipine; anti-inflammatories/NSAIDs; pioglitazone/rosiglitazone (stimulate sodium reabsorption by sodium channels in luminal membrane of cortical collecting tubule cells); corticosteroids; sex hormones
Occupational/lifestyle => Prolonged standing. Obesity and work involving standing may predispose to pitting edema in the evenings.
Alcohol intake => edema due to liver disease, e.g. hepatic cirrhosis. Other sx: jaundice; marked ascites; portal hypertension (splenomegaly and caput medusae)
Is there pitting edema? (indent in skin following finger pressure, most marked over tibia)
Pitting edema => Refer to "history"; DVT; venous insufficiency (Also refer to "pain"); early stages of lymphoedema;
Elderly individuals and paralysed patients who sit for prolonged periods with bent knees, may cause venous emptying to diminish to an extent that pitting edema develops => venous insufficiency of lower limbs
Mild => Obstructive sleep apnea. Other sx: daytime fatigue; snoring; obesity
Non-pitting edema that's unchanged overnight is rare => disturbance in lymph flow
Lymphoedema. Also refer to "pain". Primary form is rare, due to poorly developed or missing vessels. Sx usu. evident in childhood/adolescence but in some cases >35YO (lymphedema tarda)
Thyroid disease, e.g. myxoedema (hypothyroidism, typical of non-pitting edema) and Graves disease (pretibial myxoedema)
Lipedema. Other sx: spares feet, ankles, upper torso; weight loss doesn't improve edema; increased distribution of soft adipose tissue