The evaluation of a patient who presents with a chief complaint of a swollen leg or legs begins with a history and physical examination. History should include determining the chronicity of the swelling (acute versus chronic), any associated symptoms, and assessment of risk factors that could contribute to the various etiologies of a swollen extremity, including hypercoagulability (i.e. pregnancy, use of hormonal contraceptives, malignancy history, recent surgery or travel, and history of inherited conditions such as antithrombin III deficiency) [1], lymphedema risk factors (including surgical history, malignancy and radiation history, and infectious exposures) [2], and medical comorbidities that could predispose to either systemic edema or chronic venous disease.

venous or lymphatic disease, or, if bilateral, symmetric, and accompanied by edema elsewhere in the body, of an underlying medical disorder such as congestive heart failure or nephrotic syndrome. Examination should include assessment of pulses, sensation, and motor function and should also note the presence of pain, warmth, erythema or discoloration, skin changes including lipodermatosclerosis, dilated veins, and/or ulceration. Laboratory testing should include a D-dimer if there is clinical concern for DVT. The imaging modality of choice for diagnosing DVT is compression ultrasonography. To evaluate for systemic sources of edema, laboratory evaluation should include a pro-NBP to assess for heart failure, urinalysis or urine dipstick for protein, serum creatinine and blood urea nitrogen (BUN) to assess for renal pathology/nephrotic syndrome, serum albumin to assess for hypoalbunimenia driving edema, liver function tests to assess for cirrhosis, and thyroid-stimulating hormone to assess for thyroid disease and resultant myxedema. Chronic venous disease is diagnosed with the demonstration of venous reflux on venous duplex ultrasound, defined as reversed flow greater than 500 ms in superficial and deep calf veins and greater than 1000 ms in femoropopliteal veins Lymphedema is primarily diagnosed by history and physical exam, but can be confirmed with lymphoscintigraphy in cases of diagnostic uncertainty.

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John Mathews
Journal Manager
Journal of Phlebology and Lymphology
Email: phlebology@eclinicalsci.com