Transcript: Lower Extremity Edema Causes - Case Study for New Nurse Practitioners

​Liz Rohr:

So lower extremity edema, I don't know about you, but I feel this happens all the time in primary care, and it feels like it's either nothing or it's something super serious. Patients typically always want some sort of diuretic to make it go away, but is that really the right option? 

Well, I'm going to walk you through a case study, a really interesting one from the last week actually, and walk you through the steps of evaluation, differential diagnosis, and treatment plans going forward. So if you're new here, I'm Liz Rohr from Real World NP, and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. So without further ado, I'm going to jump into this case study and share my screen with you. 

This is Steve. He's 64. He is coming in for left leg pain and swelling. So chief complaint of pain in his left leg that was very swollen, painful. This is all volunteered from him, that it's painful, red, it was interrupting his sleep, and he can stick his finger in it, like pitting edema basically. He volunteered that he went to the ER for the same reason three weeks ago. He did an ultrasound, and it was normal. This is all per the patient because, unfortunately, I don't have any records, which is too bad, but that is how it goes in healthcare sometimes. So he says that he has "bad COPD and CHF," and he's wondering if he has an infection in his leg. He also volunteers... Well, his wife volunteered that he sleeps in a chair sitting up pretty frequently. 

So a couple of other background points about him. His past medical history, significant for obesity, type two diabetes that's uncontrolled, hypertension, COPD, sleep apnea, hyperlipidemia, tobacco dependence, and then randomly... not randomly, but not necessarily relevant to the case, but FYI has colonic polyps as well as depression. 

Past surgical, family history, nothing significant to report. His vital signs were 151/79 blood pressure on one arm and then 161/91 on the other arm; heart rate of 83; temperature normal at 98; and oxygen about 96%, which has been consistent for him; and then a BMI of 36. 

Note I did not say CHF in his past medical history, but just hold that thought. He is a current smoker. He did not disclose how much he is smoking. He kind of sort of quit and is not really smoking anymore, unclear. But he doesn't drink any alcohol.

So medications, there's quite a long list here, but finasteride... I'm not going to read off the doses, but they're all appropriate doses... finasteride... I'm probably not saying that right... Flomax, gabapentin, lisinopril, metformin, simvastatin, trazodone. And then on his med list but he's not taking... Again, I always recommend doing a medication reconciliation. I know it takes a lot of time, and hopefully our medical assistants can help you, but it's very eye opening and important to your history taking. So he's not taking fluticasone. These are all inhalers... ipratropium, [inaudible 00:03:03]... I'm not going to say that right... salbutamol, also known as Combivent for some people; tiotropium, which is also known as Spiriva... Again, I'm not endorsing those brands, just FYI, because that's not what you might know it as. 

So that's quite a laundry list of medications, a lot of comorbidities. We don't necessarily have a full picture of what's going on. At least at that point, I didn't necessarily feel I had all the information. 

So two points that I wanted to bring up going into this case in particular is, number one, try not to be misled by the obvious options. Right? Especially because patients lead with their concerns and they sometimes try to, not purposefully, but they lead us down the path of what they're concerned about, and then we can easily go on there.

So then my other point about that is make sure that you do your own digging in terms of the history questions that you want to ask and your own physical exam, making sure that they're as complete as possible because you can uncover some stuff. So just sit tight. 

One of the things I wanted to offer, if you would like to pause here, you're welcome to think about the other questions that you would ask as well as some of your possible differentials. I know that I talk really fast, so I'm trying to slow down in case you want to pause right here. But anyway, spoiler alert, I'm going to continue on. 

So, yeah, if you paused, welcome back. I don't want you to over-complicate this because this can sound... Especially if you're picturing this patient in front of you and what you want to ask and what you want to do about it, it can be a little bit stressful. Right? So let's not over-complicate things. So number one, what are the other questions you want to ask? Go back to your old cart. Right? I talked about this in last week's video. If you  haven't seen it, I'll link to it down below and at the top right here, but you really just want to bring it back to basics. Try not to get overwhelmed by the fancy stuff that's in front of you or the seemingly complicated patient, so just onset, location, duration, et cetera, et cetera. 

Then review of systems. Again going back to that video from last week if you haven't watched it already, if you're not sure, ask the entire system of any body part that we're talking about and then anything that could be associated, and that will typically cover all the questions that you need. The question I love is, is it worse, better, or the same, which I feel like it gives you a great trajectory of what's going on. Have you ever had this happen before? Again, in that video, I referenced that very beautiful question. That's very helpful. 

And then history questions based on the differential. I referenced this last week as well, but the more experience you get and the more patients that you see, the more comfortable you'll feel coming up with those differential diagnoses, and then keeping those in your mind, what are the questions that you would ask to bring you to plus or minus those differentials? Right? Again, don't super worry about it if you're not there because that took me a very long time to feel like that. But some other things just off the top of my head when I was in the visit, do you have any fever, chills, shortness of breath, chest pain, palpitations, cough, is it productive, orthopnea, paroxysmal nocturnal dyspnea. Other things like thinking about his leg, how is the other leg? How is the skin on his feet? Does he have any injuries before it started? What are his toenails looking like? Does he have any calf pain, a whole bunch of stuff. Right? And this is why it can get a little bit stressful and confusing as a symptom because there's a lot of questions to ask. There's a lot of history.

Then other things to think about are history questions based on the presenting symptoms. So just hold that thought for just a second. I'm going to come back to that, what I mean by that. So for his ROS, he had shortness of breath, a nonproductive cough, but I have stars there because that's chronic for him because he has COPD. He has orthopnea as well, possibly related to his body habitus, his higher BMI, related to the other comorbidities that he has. Negatives overall globally was negative aside from that and the leg pain, of course, but no chest pain, wheezing, palpitations, abdominal pain, nausea, vomiting, diarrhea. I always throw that in and ask there.

For his physical exam though, his lungs were clear. They were diminished at the bases. He had a barrel chest. He did not have any rales. He had some normal heart sounds, regular rate and rhythm. For his legs, he had bilateral pitting edema, three plus up to the knee, high risk. He had a scab on the middle of his left toe where he had had a laceration there or a very mild abrasion rather. His pulses were two plus on the dorsalis pedis and the posterior tibialis if you want to be all fancy. Basically, just in his feet, his pulses were fine. The color was fine. I mean, it was warm actually. I didn't write that down. It was red. It was warm. It wasn't necessarily hot, and it definitely had that pitting edema. 

Jugular venous distention. The JVD was difficult to assess because he has a thick neck. And I'm not going to pull the wool over your eyes that I am super savvy with this because I'm really not. Actually, full disclosure, I should have told you at the beginning that this is a case that I actually consulted with my colleague on because I just felt a little bit uneasy about it and I wanted to get their thoughts as well, and they feel more comfortable with JVD assessment than I do. But we both agreed that we had a hard time seeing because of his thickened neck. 

His abdomen was nontender. His exam was limited by body habitus, having a larger BMI. So we're not really fully able to feel his liver, spleen, and things like that. 

So lower extremity edema. So what I'm coming back to is the specific history questions that are specific to the symptom. So there's a breakdown of your algorithm of diagnosis depending on the history branching. When it comes to lower extremity edema, it's super important to decide is this acute or is this chronic? Did this happen yesterday? Did it happen today or has it been weeks and months? Is it bilateral or is it unilateral? That's hyper important. Right? Is it both sides or is it one side? And again, not getting trapped into what you're worried about, so leading in your thinking, is this a cellulitis? But he didn't necessarily disclose that the swelling is actually on both sides. Is it pitting or is it not pitting? And then do they have other systemic symptoms, which is a little bit vague, but things that you'd think about like fevers, chills, other symptoms. Right? 

So for him, this is technically chronic. I mean, it's not three months, but it's definitely not considered to be in that acute window. Bilateral. Well, fortunately or unfortunately, he came in saying that it was just one side, so that's where you have to use your detective brain and make sure that you're doing a full assessment and a full history, things like that. And it's pitting. It's definitely pitting. He doesn't have any other systemic symptoms based on his exam and his history. 

So a couple of differential diagnoses that I want to pull up here. Again, specifically talking about lower extremity edema, what's super important is that, again, you're classifying is it chronic or acute? Is it bilateral or unilateral? Do you have pitting edema or is it non-pitting? For chronic, bilateral, and pitting edema, the differential is actually pretty wide. This is not necessarily the entire differential list, but these are the most common and some of the lesser common, but more common than the rare ones. Chronic venous disease has a star because it's basically the number one cause of the lower extremity edema bilaterally, chronically. Heart failure is also one that's common and important. They're all important, but in terms of ruling out, it's really important. 

I think a note that I want to make is that there are some misdiagnoses of chronic venous disease, and it's easy to jump right to that without making sure you exclude the other red flags. So that's my only note about that. But, yeah, heart failure and pulmonary hypertension typically related to sleep apnea, similar symptoms to heart failure, but we'll talking about that in just a second. And then typically what I see is medication related. Patients who are on amlodipine or other calcium channel blockers can have bilateral lower extremity edema as well. 

So lesser common ones, but definitely ones to be concerned about and to be thinking about, renal disease, liver disease, pelvic masses and cancer, constrictive pericarditis... again, a little bit more on the rare side... idiopathic... you'd never want to label somebody as idiopathic until you figured out the other things... and then malnutrition/protein loss, so protein-losing enteropathies through the kidneys, things like that. Getting a little fancy there. But anyway, you want to think about the first things first, the most common. 

So like I had in the symptom-based case study of the persistent cough and whether or not to use antibiotics, this is a differential diagnosis table that you could use if you're in school or even after school and if you're thinking about how do you figure out this diagnostic process. Right? So here are the top three. Heart failure/pulmonary hypertension because they're pretty similar in terms of their presentation. And I have a star there again because the patient came in telling you that he had heart failure, and there was literally nothing in years and years of notes. I'd never met this patient before, but in his years and years of notes, it had never been mentioned that he has heart failure. So he doesn't have... Well, who knows? He may have heart failure. This may be the first time that he has heart failure. So you want to think about that. 

Renal disease is definitely on my top for him because of his comorbidities. Chronic venous stasis is definitely there too. And then I have outside of this little differential box is cellulitis. 

So a note here. Other possible but less likely differential diagnoses. HE has redness and warmth in his lower extremity, definitely a concern for cellulitis. Right? Also because he has type two diabetes and severe onychomycosis... It's pretty bad. It's pretty gnarly. And fun fact, tinea, fungal infections are one of the risk factors for developing lower extremity cellulitis in the first place. Right? So he definitely has risk factors. There's also concern for a DVT. Right? But these are both less likely because they're not bilateral. They're unilateral. And then it's also more on the chronic side. Again, it's only been three weeks-ish, but I had to push him to get that number, and I have a feeling it's actually probably longer than that, and he also went to the ER, although we have no notes. But we would hope that a reputable hospital that he went to would give him the appropriate adequate care. Right?

So I'm just going to jump into the top three differentials and some symptoms to look at. So heart failure/pulmonary hypertension, largely similar symptoms. Because when you're talking about pulmonary hypertension, you start to have right ventricular failure and you can have the signs of heart failure that I'm going to be talking about. But anyway, just not the same, but similar. 

So heart failure can have pulmonary congestion, peripheral edema, and then an increased JVD, which again, I'm not perfect at, I'm not very good at, but I try and I continue to practice. It doesn't come up that often. They may also have an S3, a diastolic S3 sound, as well as I guess I said pulmonary congestion, but they might have rales on their exam, pulmonary rales. They may complain of, or likely will complain of, dyspnea, orthopnea, paroxysmal nocturnal dyspnea... so waking up gasping in the middle of the night... fatigue, weakness, especially when it's exertional. And I love these little house MD things. Maybe it's not, but I find it fun, like abdominal pain. That's because of the hepatic congestion that they can get from fluid overload. They can have that abdominal pain, and that commonly can be mistaken for cholecystitis. So fun fact... I love these fun facts. 

So chronic venous stasis signs and symptoms, limb swelling, limb pain. That's like a tired, heavy sensation. It's worse when their feet are dependent. They can have other things like telangiectasias, varicose veins, which can progress as it's more severe to skin pigmentation, ulceration, and dermatitis. 

I'm probably not going to say this right, but lipodermatosclerosis. I'm not good at pronouncing things. You probably know that by now. So it's almost a scarring change that happens when it becomes more advanced, and if you just Google that, you can take a look at pictures, and I'm sure you've seen that before. Also fun fact, those people are prone to cellulitis. So something to think about.

And then renal disease signs and symptoms. There's a variety of diagnoses because renal is such a big topic, but typically... There's something called nephrotic syndrome, if you're not familiar with that, but basically you lose a lot of protein through the kidneys, and you can have a lot of edema in the lower extremities and just globally. But typically if somebody has a severe renal disease for a variety of causes, typically they all present pretty similarly. They tend to have hypertension, edema, sometime pulmonary edema as well. And then they can also have signs of proteinuria and then an abnormal BUN and creatinine, so protein in the urine. 

So again, going back to this differential diagnosis table, this is a really lot of information on this big slide, but I'm going to walk you through it. I threw in cellulitis, even though it's not really there. Pertinent positives for heart failure, we have the edema, hypertension, dyspnea, cough, shortness of breath. However, he doesn't have an S3 heart sound. He doesn't have any rales on auscultation, and he doesn't have any JVD. For renal disease, he also has edema, hypertension as well as that history of diabetes, but he doesn't necessarily have any negatives per se. 

So chronic venous stasis. His pertinent positives are that he sleeps upright. He has bilateral distribution and discoloration in his lower extremities. However, he didn't have any telangiectasias or varicose veins on exam. 

And then the last one is cellulitis. I was actually most concerned about cellulitis when he first came in. However, the redness in his leg... He did have redness in his leg, warmth, tenderness as well as that risk factor of having uncontrolled diabetes with the onychomycosis that's pretty severe. However, it was a bilateral distribution, and it's not worsening. And really, honestly, you would expect that that redness and swelling would have progressed at this point over the course of three weeks.

So plan. Overall, and maybe I should have mentioned this earlier, my main focus here is talking about the evaluation, the causes, and some of the treatment, but I don't necessarily have all of these results, which sorry to disappoint you if that's what you're looking for. But to start the plan for this patient who's looking at you, you're trying to come up with a plan, is to do some labs, so a CBC with differential, a CMP. So a CBC with differential... Oh, it's says CDC. I must have coronavirus on my mind. CBC with differential... so you're looking for signs of infection related to the cellulitis. Another fun fact is that if you have an infection, you can also trigger a CHF flare, a heart failure flare if you have that underlying. A CMP is looking at the renal function as well as the liver function, and liver function tests could be thrown off if you have a fluid-overloaded hepatomegaly situation versus liver disease. But anyway, that's getting a little into the weed there, but that's what you're looking at. 

And then a BNP or an NT proBNP, depending on what your lab does, and that's the brain natriuretic peptide, looking for signs of heart failure, and that's a pretty good lab test. And then a urinalysis. So again, looking for proteinuria and other things.

And just a note in here, if you actually haven't joined us for the lab interpretation crash course and you want to know more about all these labs, BNP is not in there, but the rest of them are. You can go over to realworldnp.com/labs to join that wait list, and then it'll be linked under this video as well.

But anyway... So management for Steve. Diuretic therapy, this is the main thing that everyone wants to treat patients with. Right? Or maybe they come in asking for that. They want furosemide. And really, quite honestly, this depends on the underlying diagnosis. This doesn't really work for chronic venous stasis, and there's a whole bunch of pathophysiology reasons behind it, which are a little bit confusing, but basically, it just doesn't work. So if you find that your actual diagnosis is chronic venous stasis, it's not typically recommended to do that. In fact, patients can get I believe it's called a refractory diuretic-induced edema as well. So that's another reason why you don't necessarily automatically start somebody on those. 

You always want to elevate their legs... remember, he was sleeping in this chair at night... considering compression stockings as well. Most patients do not like that, but it's what works. So that's what's recommended. And then always reviewing alarm signs because we have a working differential diagnosis right now. We're looking into heart-related causes, renal-related causes, possible cellulitis as well as chronic venous stasis at this point. So we always want to think about what are the reasons he would want to seek care in the ER versus call the on-call provider versus when to come back.

And then minimizing salt in the diet is not like super effective necessarily, but it's definitely one of the recommendations that can be effective. So if they have a very high-salt diet, it's definitely worth doing.

So just as a recap... so Steve... so the labs, we did those the same day of the visit. The plan was to follow up in a week with a few days by phone with the nurse. I actually don't have the results of those labs yet, so I actually don't know what's going on. My leading differential, though, is chronic venous stasis, to be quite honest, based on his whole clinical picture, but we're going to wait for the labs and see. So depending on what the labs show, you want to consider an alternative differential diagnosis depending on how the symptoms change. 

So I definitely want to manage his hypertension. He was a little bit overwhelmed at this visit, and so that's why we're going to do a follow-up in a week, work on all the edematous treatment and see if that helps, if we can clear some of that edema, help with the blood pressure, things like that... possibly. Who knows? I definitely want to set him up with health benefits and community outreach because the reason he wasn't taking his inhalers was actually because they were too expensive. We're lucky to have in my clinic a community outreach program that can help with financial stuff to talk about that. 

Not at this visit because he said multiple times he's not wearing his CPAP and he's not interested, but we definitely want to think about that and talk about that because pulmonary hypertension is definitely in that differential because he has untreated sleep apnea right now. 

Did you like this video? If so, hit like and subscribe and share with your NP friends so together we can reach as many new nurse practitioners as possible to help make their first years a little bit easier. And don't forget to head over to realworldnp.com to sign up for the Ultimate Resource Guide for the New NP. You'll get these videos sent straight to your inbox every week with notes from me, patient stories, and bonus content that I really just don't share anywhere else. Thank you of much for watching. Hang in there and I'll see you soon.