11/13/24, 8\:10 PM Guide | Leg swelling history

Leg swelling history

Table of contents

Introduction

Fluid is
lymphatic system. The movement of the limbs promotes
If there is an imbalance between
swelling. This commonly a
drainage is the predominant problem, whilst the term oedema is used when the primary cause is excess
into the interstitial space.
Lymphoedema may be caused by reduced mobility, damage or obstruction to the lymphatic system, or medications.
Oedema may be caused by\:
Increased hydrostatic pressure in the microvasculature\: due to local causes (deep vein thrombosis, cellulitis, in
trauma, chronic venous insuheart failure or cor pulmonale). It can also be due to a pelvic mass
which increases hydrostatic pressure by obstructing venous return.
Reduced colloid osmotic pressure in the microvasculature\: due to hypoalbuminaemia secondary to nephrotic syndrome,
liver cirrhosis or severe malnutrition.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.
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Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
“ W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?”
“ T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
“ O k , c a n y o u t e l l m e m o r e a b o u t t h e l e g s w e l l i n g ?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

Gather further details about the patient’s leg swelling using the SOCRATES acronym.

SOCRATES

The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most
commonly used to explore pain but can be applied to other symptoms, although some of the elements of SOCRATES may not
be relevant to all symptoms.
Site
Ask if the leg swelling is unilateral (if so, which leg) or bilateral\:
" A r e b o t h l e g s s w o l l e n , o r j u s t o n e l e g ?"
In bilateral swelling, the legs may be swollen to di
Unilateral leg swelling
Causes of unilateral leg swelling include\:
Deep vein thrombosis (DVT)\: occlusion or partial occlusion by thrombus of one of the veins in the leg
Super
commonly the saphenous vein); the swelling is localised to the a
more generalised swelling seen with DVT
Cellulitis\: infection of the soft tissues (most commonly a
commonly S t r e p t o c o c c u s p y o g e n e s or S t a p h y l o c o c c u s a u r e u s ) may be introduced via an open wound on the leg or
foot, or from splits in the skin caused by tinea pedis (athlete’s foot)
Baker’s cyst\: accumulation of synovial
is a non-serious condition but is di
Dysfunction of the lymphatic system (a
lymph nodes, surgical removal of inguinal lymph node(s), or trauma.
In
Trauma (can be minimal)\: soft tissue injury, ruptured Achilles tendon
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Bilateral leg swelling
Causes of bilateral leg swelling include\:
Congestive cardiac failure and cor pulmonale
Chronic venous insu
of pressure in the veins
Dysfunction of the lymphatic system (a
the lymph nodes, surgical removal of inguinal lymph node(s), or trauma.
Increased hydrostatic pressure\: can be caused by a pelvic mass (e.g. ovarian tumour); the size of the uterus from the
second trimester of pregnancy onwards has a similar e
Conditions which cause hypoalbuminaemia, such as nephrotic syndrome, liver cirrhosis and severe malnutrition
Decreased mobility may cause dependent oedema due to reduced
Medications\: calcium channel blockers (e.g. amlodipine) cause decreased lymphatic drainage; non-steroidal anti-
in
Onset
Clarify how and when the swelling developed\:
" W h e n d i d t h e l e g s w e l l i n g s t a r t ?"
" D i d i t s t a r t s u d d e n l y o r d e v e l o p s l o w l y ?
The onset of leg swelling may suggest di
Onset over minutes to hours is seen with in
Onset over hours to a few days is suggestive of DVT/STP, cellulitis or rupture of a Baker’s cyst
Onset over weeks to months indicates more chronic pathology, such as hypoalbuminaemia, heart failure or cor pulmonale,
chronic venous insu
Character
Ask about the speci
Is the swelling pitting (a dimple remains after the skin is pressed with a
Chronic venous insu
associated with pitting oedema.
Radiation
Ask about the progression of the leg swelling\:
" W h e r e i n t h e l e g d i d t h e s w e l l i n g
" D i d t h e l e g s w e l l i n g s t a r t i n a s p e c i
" H a s t h e s w e l l i n g m o v e d a n y w h e r e e l s e ?"
Swelling starting at the knee and moving distally into the calf and foot suggests a ruptured Baker’s cyst. Other knee pathology,
such as arthritis of any type, gout or pseudogout can also cause swelling which moves down into the lower leg due to gravity.
Swelling starting in the foot or lower leg and moving proximally (possibly as high as the thigh) is seen with DVT, lymphatic
dysfunction, pelvic mass, heart failure/cor pulmonale, chronic venous insu
immobility and medication side e
can also cause swelling that moves up into the leg.
Swelling which starts in a localised area and spreads outwards is seen in cellulitis, STP, trauma and in
Associated symptoms
Ask if there are other symptoms which are associated with the leg swelling\:
“ A r e t h e r e a n y o t h e r s y m p t o m s a s s o c i a t e d w i t h t h e l e g s w e l l i n g ?”
Speci
Acute pain suggests cellulitis, DVT/STP, a ruptured Baker’s cyst, or an in
Chronic, aching pain and heaviness occur in chronic venous insu
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Other causes of leg swelling are painless
Other important associated symptoms to ask about include\:
Erythema is seen in cellulitis, DVT/STP, ruptured Baker’s cyst and in
Itching suggests a reaction to a bite or sting
Fever suggests cellulitis (septic arthritis should also be considered if the swelling originated around a joint)
Weight loss, back pain and urinary urgency may suggest a pelvic malignancy; in women, there may be abnormal vaginal
bleeding or discharge
Shortness of breath, particularly when lying heart failure and cor pulmonale
Patients may report frothy urine in nephrotic syndrome due to proteinuria, and more generalised oedema
In liver cirrhosis, other symptoms may include jaundice, ascites and easy bruising
Time course
Clarify how the leg swelling changes over time\:
" I s t h e s w e l l i n g t h e r e a l l t h e t i m e , o r d o e s i t c o m e a n d g o ?"
Exacerbating or relieving factors
Ask if anything makes the leg swelling worse or better\:
“ D o e s a n y t h i n g m a k e t h e l e g s w e l l i n g w o r s e ?”
“ D o e s a n y t h i n g m a k e t h e l e g s w e l l i n g b e t t e r ?”
Swelling which improves with elevation of the legs (e.g. whilst the patient is in bed overnight) suggests the primary problem is
excess interstitial
Ask whether the swelling has coincided with the initiation of new medications.
Severity
N/A
Wells score for DVT
When a DVT is suspected, the two-level DVT Wells score is used to assess the condition's pre-test probability and
guide further investigations. The score should not be used for pregnant women or those in the
as these patients should all be referred for same-day assessment.
Clinical feature Points
Active cancer (currently receiving treatment or treatment within
6 months or palliative)
1
Paralysis, paresis or recent plaster immobilisation 1
Recently bedridden (3 days or more), or major surgery within
the last 3 months
1
Localised tenderness along the distribution of the deep venous
1
system
Entire leg swollen 1
Calf swelling at least 3cm larger than the asymptomatic side 1
Pitting oedema in the symptomatic leg 1
Collateral super
Previously documented DVT 1
An alternative diagnosis is at least as likely as DVT -2
* if both legs are symptomatic, the more symptomatic leg should be used
Remember the rule of 3s\:
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Bedridden for 3 days
Surgery in the last 3 months
Leg 3cm larger
A DVT is considered likely if the score is two points or more and unlikely if the score is one point or fewer.

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns, and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred, and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue\:
“ W h a t d o y o u t h i n k t h e p r o b l e m i s ?”
“ W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g ?”
“ I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u gh t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
Explore the patient’s current concerns\:
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h i s p r o b l e m a t t h e m o m e n t ?”
“ W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i g h t b e ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
”
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l
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Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fever, unintentional weight loss
Cardiovascular\: chest pain, palpitations
Respiratory\: shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea
Gastrointestinal\: features of liver disease (e.g. jaundice, abnormal bruising, abdominal distension) or pelvic malignancy
(abdominal bloating, pain, change in bowel habit)
Genitourinary\: frothy urine (nephrotic syndrome), urinary urgency and/or frequency (pelvic mass); in women, ask about
abnormal vaginal bleeding or discharge

Past medical history

Ask if the patient has any medical conditions\:
“ D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?”
“ A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e gu l a r l y ?”
Ask if the patient has previously undergone any surgery (e.g. lower limb surgery, pelvic surgery, cancer surgery)\:
“ H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?”
“ W h e n w a s t h e o p e r a t i o n / p r o c e d u r e , a n d w h y w a s i t p e r f o r m e d ?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Examples of relevant medical conditions
Relevant medical conditions in the context of leg swelling include\:
History of DVT/PE\: may increase the risk of further thrombotic events; past DVT is also a cause of chronic venous
insu
Cardiovascular disease, such as myocardial infarction (increases the risk of heart failure)
Chronic respiratory conditions, such as COPD (increases risk of cor pulmonale)
Peripheral vascular disease or varicose veins
Malignancy, including surgery for any previous malignancy.
Conditions which increase the risk of infection (e.g. diabetes mellitus)
Musculoskeletal conditions, such as arthritis, gout and pseudogout
Liver disease
Renal disease
Eating disorders (risk of malnutrition)

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
anaphylaxis).
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Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter
medications, document the medication name, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any side e
“ H a v e y o u n o t i c e d a n y s i d e e
“ D o y o u t h i n k y o u r l e g s w e l l i n g s t a r t e d a f t e r y o u b e ga n t a k i n g a n y o f y o u r c u r r e n t m e d i c a t i o n s ?”
Medication examples
Medications which increase the risk of DVT include\:
Combined oral contraceptive pill (e.g. Microgynon)
Hormone replacement therapy (HRT)
Norethisterone
Tranexamic acid
Amlodipine, prescribed for hypertension, commonly causes oedema of the lower limbs.
NSAIDS (e.g. ibuprofen and naproxen) cause salt and
Quinolone antibiotics (e.g. cipro
Medications which increase the risk of infection include corticosteroids (e.g. prednisolone) and disease-modifying anti-
rheumatic drugs (e.g. methotrexate).
Medications which patients may already be taking for leg swelling include\:
Anticoagulants for previous thromboembolic events (e.g. rivaroxaban, apixaban or warfarin)
Loop diuretics for oedema (e.g. furosemide, bumetanide)

Family history

Ask the patient if there is any family history of lymphoedema, malignancy, venous thromboembolism (DVT/PE) or
cardiovascular disease.
“ D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y m e d i c a l c o n d i t i o n s ?”
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic
factors).
If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death\:
“ I’ m r e a l l y s o r r y t o h e a r t h a t , d o y o u m i n d m e a s k i n g h o w o l d y o u r d a d w a s w h e n h e d i e d ?”
“ D o y o u r e m e m b e r w h a t m e d i c a l c o n d i t i o n w a s f e l t t o h a v e c a u s e d h i s d e a t h ?”

General social context
Explore the patient’s general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
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what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
See our smoking cessation guide for more details.
Smoking increases the risk of DVT, cardiovascular disease and chronic venous insu
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information.
Excess alcohol consumption increases the risk of liver cirrhosis.
Recreational drug use
Ask the patient if they use recreational drugs and if so, determine the type of drugs used and their frequency of use.
Intravenous drug use is a risk factor for DVT.
Fluid intake
Patients with poor
Occupation
Ask about the patient’s current occupation and how their symptoms impact their ability to perform their role.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

BMJ NICE Best CKS. Practice. A s s e s s m e n t o f p e r i p h e r a l o e d e m a . S u p e r LINK]
from\: [LINK]
NICE CKS. D e e p v e i n t h r o m b o s i s . Available from\: [LINK]
Source\: geekymedics.com
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