🦵 Symptom-Based Approach: Edema

“Why is this patient swollen?” — Think beyond the legs. Think systemic. Think strategy.

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🚪 Doorway Information

• Age: 62
• Gender: Male
• Chief Complaint: “My legs and face have been getting more swollen recently.”
• Vital Signs: BP 138/82, HR 76, RR 14, Temp 36.6°C, SpO₂ 98%

What do you consider based on this presentation?
What further questions would you ask?

🧩 Here’s more…

• The swelling started about a month ago and has gradually worsened.
• He has gained 5 kg during this period.
• Facial puffiness is more noticeable in the morning.
• His urine has appeared foamy recently.
• He denies chest pain, dyspnea, or orthopnea.
• No history of liver disease, recent infection, or NSAID use.
• Past medical history includes well-controlled hypertension.

Now, what is your leading diagnosis?
What would you like to confirm with physical exam or labs?

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🔍 Step 1: Think Anatomically

Edema is the accumulation of fluid in the interstitial space.

• Generalized (Anasarca) → Think systemic causes: heart, liver, kidney.
• Localized (Peripheral edema) → Think regional causes: DVT, CVI, cellulitis, lymphedema.

🧠 Step 2: History Taking – OPQRST + PAM HITS FOSS

Category	Sample Questions
O – Onset	“When did the swelling begin?”
P – Provocation	“Does elevation help?” “Any foods worsen it?”
Q – Progression	“Has the swelling been increasing?”
R – Region	“Is it in both legs or just one side?”
S – Symptoms	“Any dyspnea, chest pain, or weight changes?”
T – Timing	“Is it constant or does it come and go?”
P – Past episodes	“Have you ever had this before?”
A – Allergy/Anaphylaxis	“Any new exposure or allergies?”
M – Medications	“Are you taking NSAIDs, calcium blockers, or steroids?”
H/T/S – Hospitalization/Trauma/Surgery	“Any recent hospitalization or procedures?”
I – Illness (PMH)	“Heart, liver, kidney, thyroid disease history?”
F – Family history	“Any family history of edema or kidney disease?”
O/S/S	“Are you pregnant?” “When was your last period?”

🩺 Step 3: Physical Examination

• General appearance: Unilateral vs bilateral vs generalized (anasarca)
• Skin: pitting vs non-pitting, warmth, color, ulcers, cords
• Cardiovascular: JVD, heart sounds
• Lungs: Crackles, rales (CHF)

🧬 Step 4: Mechanism of Edema – Pathophysiology

Mechanism	Typical Causes
↑ Hydrostatic pressure	CHF, CKD, pregnancy, DVT, CVI
↓ Oncotic pressure	Nephrotic syndrome, cirrhosis, malnutrition
↑ Capillary permeability	Sepsis, cellulitis, angioedema
Lymphatic obstruction	Malignancy, lymphadenectomy, filariasis

💡 Step 5: Pitting vs Non-Pitting

Type	Examples
Pitting	CHF, nephrotic syndrome, DVT, cirrhosis
Non-pitting	Myxedema, pretibial myxedema, lymphedema

🧪 Common Differential Diagnoses

Location	Likely Causes
Face (AM puffiness)	Nephrotic syndrome, hypothyroidism
Legs (PM swelling)	CHF, venous insufficiency
Unilateral leg	DVT, cellulitis, lymphedema
Generalized	CHF, cirrhosis, renal failure, pregnancy

🗣️ Useful Expressions

• “Have you noticed any swelling anywhere in your body?”
• “Do your legs or face look puffier than usual?”
• “When did the swelling first appear?”
• “Is it worse in the morning or at night?”
• “Has the swelling made it difficult to walk or sleep?”
• “Any shortness of breath, weight gain, or foamy urine?”
• “Are you currently on any medications that could cause swelling?”

🧠 Clinical Pearls

• Puffy eyes in the morning? → Think nephrotic syndrome.
• Unilateral, painful, warm leg? → Rule out DVT.
• Non-pitting edema with thickened skin? → Consider lymphedema or myxedema.
• Diuretics help volume overload but not lymphatic or endocrine causes.

📌 Take-Home Messages

• Always assess: pitting vs non-pitting, localized vs generalized
• Use OPQRST + PAM HITS FOSS for thorough history
• Don’t forget medication history and thyroid disease
• Periorbital swelling + foamy urine → Think nephrotic syndrome

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Challenge to cases:
🌳Standard
🔥Challenging

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