Leg Swelling (Leg Edema): Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps:

• General physical examination – including blood pressure, pulse, body temperature, body weight, body height; furthermore:
  • Inspection (viewing).
    • Skin (lower leg, ankle region and feet).
      • Localization of swelling: unilateral or bilateral? → unilateral swelling: often there are disorders in the venous and lymphatic systems. → bilateral swelling (same side or not? Measurement of the circumference of the lower leg on both sides): The cause cannot lie in the leg itself. As a rule, diseases of internal organs (heart, liver, kidneys, thyroid) or systemic diseases (disease affecting an entire organ system) are present. The most common cause of bilateral leg swelling is right heart failure (restriction of the pumping function of the right heart).
        • Is the whole leg swollen or which area (localized swelling)?
        • Proximal (toward the center of the body) or distal (away from the center of the body) emphasized swelling?
      • Nature of the swelling: solid or liquid?
        • Is it a tissue proliferation or edema? → Edema is an accumulation of fluid in the epifascial (above a fascia (component of connective tissue)) Space (large capacity). Fluid accumulation in the subfascial space leads to pain even at small volumes.
      • Resistance when pressing on the swelling and duration of the dent:
        • Soft?
        • Leaving dents?
        • Doughy? rough?
        • Bulging calf

        → Allows conclusions to be drawn about the protein content. If the dent recedes quickly, the edema contains little protein. Thus, in the case of lymphedema, the swelling does not go down completely overnight and the depressed dents remain for a long time.

      • Is there pain?
        • If yes: → Where? → Does the pain radiate?
      • Skin color
        • Redness (rubor)?
        • Overheating (calor)? → If yes: indication of arthritis (joint inflammation) or activated osteoarthritis (inflammatory episode of degenerative joint disease).
        • Cyanotic skin? (purple to bluish discoloration of the skin).
      • Skin changes
        • Corona phlebectatica – appearance of dark blue skin veins at the edge of the foot.
        • Atrophie blanche – usually painful depigmentation of the skin in the area of the lower leg.
        • Reddish brown hyperpigmentation due to local hemosiderosis – increased iron deposition in the ankle / lower leg area.
        • Eczematization – often itchy stasis eczema.
        • Skin redness (erythema, exanthema/rash, stasis dermatosis/chronic venous stasis, erysipelas/chafing).
        • Hyperkeratosis – excessive horn formation of the skin.
        • Interdigital/between the toes (mycosis (fungal disease), skin maceration/swell or softening of the skin).
        • Lipodermatosclerosis – proliferation of connective tissue and reduction of subcutaneous fat layer, especially around the ankle.
        • Lymphangitis (blood poisoning; inflammation of the lymphatic channels of the skin and subcutaneous fat (subcutis)).
        • Ulcus cruris venosum (ulcus cruris (“open leg“), which occurred as a result of advanced venous disease) or scar as a secondary condition.
        • Possible changes in the skin surface: fine-knotted skin surface (colloquially: orange peel skin; synonyms: cellulite; dermopanniculosis deformans); coarse-knotted skin surface with larger dents (medically also “mattress phenomenon”); large, deforming skin flaps and bulges.
        • Varicosis (varicose veins)
  • Foot pulses palpable? (A. tibialis and the A. dorsalis pedis, on both sides).
  • Examination of the heart, possibly detecting: [signs of heart failure?]
    • Displaced (and widened) cardiac apex bump (palpable bump of the cardiac apex against the anterior chest wall during systole/contraction of the heart; placing the palm of the hand on the left parasternal facilitates finding the cardiac apex bump; this is assessed with two fingers: Location, extent, and strength).
    • Auscultation findings: 3rd heart sound present (timing: early diastole (relaxation and filling phase of the heart); approximately 0.15 sec.After the 2nd heart sound; due to the impingement of the blood jet on the stiff wall of the (insufficient) ventricle/heart chamber).
  • Palpation of arterial pulses [Local expansive (expanding) pulsation? Local buzzing? Caveat: aneurysm (blood vessel outpouching)]
  • Auscultation of the lungs [rales (RGs)? Cause: heart failure, pulmonary edema]
  • Abdominal (stomach) examination [hepatomegaly (liver enlargement)? (congested liver in heart failure/heart failure); splenomegaly (splenomegaly)? (secondary to portal hypertension/portal hypertension).
    • Auscultation (listening) of abdomen [vascular or stenotic sounds?]
    • Percussion (tapping) of the abdomen.
      • Meteorism (flatulence): hypersonoric tapping sound.
      • Attenuation of tapping sound due to enlarged liver or spleen, tumor, urinary retention?
      • Hepatomegaly (liver enlargement) and/or splenomegaly (spleen enlargement): estimate liver and spleen size.
    • Palpation (palpation) of the abdomen (abdomen) (tenderness?, knocking pain?, coughing pain?, defensive tension?, hernial orifices?, kidney bearing knocking pain?) [enlarged lymph nodes palpable in the groin?)
  • Enlarged lymph nodes palpable in the groin?
• Health check

Square brackets [ ] indicate possible pathologic (abnormal) physical findings. Wells score for determining the clinical likelihood of deep vein thrombosis (DVT).

Clinical procedure:

• Low-risk group → D-dimer test required; if negative, further diagnosis and anticoagulation may be omitted Cave! This procedure is not safe in the presence of active or treated cancer in the last six months.
• High-risk group → compression sonography required.

Stages of skin lesions