Swollen Legs

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Swollen Legs

Establishes presenting complaint of swollen limbs, classifies the extent of the swelling (one or both legs), and whether this extends to the sacrum

Enquires about factors that make the symptoms better or worse- worse after a long day of walking, better when putting feet up at end of the day

How long the symptoms have been developing and their progression

Establishes the nature of the swelling is pitting oedema

Have they suffered previous episodes? How were they treated before?

Specifically asks about orthopnoea and paroxysmal nocturnal dyspnoea

Cardio-resp associations ->

SOB

Palpitations

Orthopnoea

Paroxysmal nocturnal dyspnoea- how many pillows do you sleep with at night

Haemoptysis

Sputum

Calf swelling/ pain

Systemic Associations ->

Nausea

Fever

Vomiting

Weight Loss

Sweating

Pain elsewhere

Risk for Venous Thromboembolic Event -> (formation of blood clots in the vein)

Recent surgery

Long haul flights

Past history of venous thromboembolic event

Fam history of clotting disorders

History of malignancy

Risk factors for heart disease ->

Diabetes

High cholesterol

High BP

Fam history of cardiac disease

Previous heart disease

Past medical and surgical history- particularly cardiac and renal

Diagnosis of Congestive Cardiac Failure ->

Differentials are Pulmonary oedema exacerbation of COPD, silent MI triggering worsening of heart failure

72 year old

Past month feel like you have been getting rather puffy, especially at the end of the day

Specifically think that both you legs and calves are swollen

Pitting oedema

Swelling is worse when you are on your feet during the day

Calf swelling only extends to just below your knees

No redness or pain

No swelling elsewhere

No trauma or fractures to your legs

Last long haul flight 20 years ago

Usually SOB anyway and can only manage walking 20m until need rest

In last 2 weeks this is slightly worse and can only manage walking 15m

Slept for a long time with 3 pillows

Very short of breath if made to lie flat

Have hypertension, heart failure diagnosed 3 years ago (ECHO 3 months ago said left side isn't working as well as it should) , DVTs and PEs diagnosed 5 years ago and now stopped warfarin

Furosemide side effects needing to go to the toilet more regularly

Investigations- (FBC, U+E, LFT, CRP, serial troponins, NT-pro-BNP, glucose) (ABG, ECG, CXR, repeat ECHO)

Managment- monitor urine output and daily fluid intake/ weights, Increasing dose of patient's diuretic

If patient developed acute pulmonary oedema and was severely SOB -> high flow oxygen, intravenous morphine (with antiemetic) ,a nitrate infusion and high dose diuretics

N-terminal prohormone of brain natriuretic peptide. Both BNP and NT-proBNP levels in the blood are used for screening, diagnosis of acute congestive heart failure and may be useful to establish prognosis in heart failure, as both markers are typically higher in patients with worse outcome. The plasma concentrations of both BNP and NT-proBNP are also typically increased in patients with asymptomatic or symptomatic left ventricular dysfunction and is associated with coronary artery disease and myocardial ischaemia.