Makindo Medical Notes

History Taking

A thorough history is crucial in determining the underlying cause of peripheral oedema or ankle swelling.

• Duration of Oedema: Acute (<72 hours) or chronic (lasting weeks or months).
• Location: Unilateral (more likely a local cause, e.g., DVT) or bilateral (more systemic causes like heart failure).
• Associated Symptoms:
  • Dyspnoea, orthopnoea (heart failure)
  • Pain, redness, tenderness (DVT)
  • Weight gain, foamy urine (nephrotic syndrome)
  • History of prolonged standing (venous insufficiency)
• Medical History:
  • History of heart disease, hypertension, or chronic kidney disease
  • History of liver disease (cirrhosis)
  • Previous deep vein thrombosis (DVT)
  • History of hypothyroidism
• Medications: Some medications (e.g., calcium channel blockers, NSAIDs, steroids) may cause oedema.

Physical Examination

• Inspection: Assess the distribution and symmetry of oedema (unilateral vs bilateral).
• Pitting vs Non-Pitting Oedema: Pitting oedema is associated with conditions like heart failure and nephrotic syndrome, while non-pitting oedema is often seen in lymphoedema or hypothyroidism.
• Cardiovascular Examination: Evaluate for signs of congestive heart failure (e.g., raised jugular venous pressure, displaced apex beat).
• Abdominal Examination: Look for signs of liver cirrhosis (e.g., ascites, hepatomegaly, jaundice).
• Skin Changes: Check for venous stasis changes (e.g., hyperpigmentation, varicosities) and evidence of infection.
• Calf Tenderness and Redness: Assess for possible DVT.

Initial Investigations

• Basic Blood Tests:
  • Full Blood Count (FBC): To evaluate for anaemia or infection
  • Renal Function Tests: To assess for nephrotic syndrome or kidney disease
  • Liver Function Tests: To assess for liver disease
  • Thyroid Function Tests: To rule out hypothyroidism
• Urinalysis: Check for proteinuria (suggestive of nephrotic syndrome).
• BNP or NT-proBNP: Useful to rule out heart failure if elevated.
• Chest X-ray: May show pulmonary congestion in cases of heart failure.
• Venous Doppler Ultrasound: To confirm or rule out DVT in cases of unilateral leg swelling.

Specific Investigations Based on Clinical Suspicion

• Echocardiogram: If heart failure or other cardiac causes are suspected.
• Abdominal Ultrasound: If liver cirrhosis or ascites is suspected.
• Kidney Biopsy: If nephrotic syndrome is suspected and other causes have been excluded.
• Lymphoscintigraphy: For the diagnosis of lymphoedema.

Management

General Measures

• Elevation of Legs: Helps reduce oedema, especially in venous insufficiency or heart failure.
• Compression Stockings: Beneficial for chronic venous insufficiency or post-thrombotic syndrome.
• Fluid and Salt Restriction: Especially in cases of heart failure or nephrotic syndrome to reduce oedema.

Disease-Specific Management

• Heart Failure: Diuretics (e.g., furosemide), ACE inhibitors, beta-blockers, fluid and salt restriction.
• Chronic Venous Insufficiency: Compression stockings, leg elevation, venous surgery if necessary.
• Deep Vein Thrombosis (DVT): Anticoagulation (e.g., heparin, warfarin), compression therapy, thrombolysis in severe cases.
• Liver Cirrhosis: Diuretics (spironolactone, furosemide), low-sodium diet, paracentesis for ascites.
• Nephrotic Syndrome: Diuretics, corticosteroids (if indicated), ACE inhibitors to reduce proteinuria, and salt restriction.
• Hypothyroidism: Thyroid hormone replacement (levothyroxine).
• Lymphoedema: Compression therapy, manual lymphatic drainage, exercise, and, in severe cases, surgery.