Mock Patient Script: Leg Edema – Three Classic Clinical Cases

Practice clinical English and sharpen your diagnostic reasoning with three realistic cases of lower extremity swelling. Not every swollen leg shares the same story.

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🚪 Case 1 – Bilateral Leg Swelling in a Patient with Cardiac History

“When a patient’s legs start to swell, we often think of the heart — but even a common case deserves a careful look.”

• Age: 72
• Gender: Male
• Chief Complaint: “My legs are swollen.”
• Vital Signs: BP 138/84, HR 90, RR 18, Temp 36.5°C, SpO2 95%

📋 Structured History

• Opening: “I’ve been feeling more short of breath lately, and my shoes barely fit.”
• Onset & Course: “It got worse over the past week.”
• Associated Symptoms: Orthopnea, leg heaviness at night
• PMH: Hypertension, old MI
• Medications: Aspirin, bisoprolol, furosemide
• Social History: Ex-smoker

🩺 Physical Examination

• Elevated JVP
• Bilateral pitting edema
• S3 gallop
• Bibasilar crackles

🧠 Differential Diagnosis

1. Congestive Heart Failure (Most likely)
   (+) Orthopnea, pitting edema, past MI
   (−) No chest pain
2. Renal dysfunction
   (+) Edema
   (−) No oliguria, no frothy urine
3. Liver cirrhosis
   (+) Edema
   (−) No ascites, no jaundice

📄 SOAP Note

• S: Progressive LE swelling, exertional dyspnea
• O: JVD, S3, pitting edema, crackles
• A: Likely CHF exacerbation
• P: BNP, CXR, echo; optimize diuretics

🧠 Clinical Reflection

Cardiogenic edema is common, but don’t forget to confirm with physical signs such as elevated JVP and S3. These findings help differentiate heart failure from other systemic causes.

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🚪 Case 2 – Generalized Edema with Protein Loss

“Swelling isn’t always what it seems. Sometimes, the answer lies hidden in physical mysteries.”

• Age: 58
• Gender: Female
• Chief Complaint: “I’ve been swelling all over.”
• Vital Signs: BP 108/72, HR 88, RR 16, Temp 36.8°C, SpO2 97%

📋 Structured History

• Opening: “My ankles and even my face feel puffy in the morning.”
• Onset & Course: Chronic, progressive
• Associated Symptoms: Chronic diarrhea
• PMH: Hypothyroidism (treated)
• Medications: Levothyroxine
• Social History: Baker, no alcohol

🩺 Physical Examination

• Periorbital swelling
• Non-pitting edema of LE
• Normal heart/lung sounds
• Mild abdominal distension

🧠 Differential Diagnosis

1. Protein-losing enteropathy (Most likely)
   (+) Chronic diarrhea, hypoalbuminemia, non-pitting edema
   (−) No proteinuria
2. Nephrotic syndrome
   (+) Edema
   (−) Normal urinalysis
3. Uncontrolled hypothyroidism
   (+) Puffy face
   (−) On treatment, normal TSH

📄 SOAP Note

• S: Generalized edema, diarrhea
• O: Puffy face, non-pitting edema, soft distended abdomen
• A: Suspected protein-losing enteropathy
• P: Albumin, stool alpha-1-antitrypsin, GI consult

🧠 Clinical Reflection

When faced with non-pitting edema and GI symptoms, always think beyond cardiac and renal causes. Hypoalbuminemia from enteric loss is rare but critical to catch.

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🚪 Case 3 – Unilateral Leg Swelling with Postoperative Risk

“Sometimes, swelling tells a deeper story — one that starts in the leg and ends in the lungs.”

• Age: 65
• Gender: Female
• Chief Complaint: “My right leg is swollen and hurts.”
• Vital Signs: BP 124/78, HR 104, RR 22, Temp 37.2°C, SpO2 94%

📋 Structured History

• Opening: “My leg suddenly started swelling two days ago.”
• Onset & Course: Sudden onset
• Associated Symptoms: Dyspnea on exertion
• PMH: Knee surgery 3 weeks ago
• Medications: None
• FHx: Sister had DVT

🩺 Physical Examination

• Right leg: warm, swollen, tender
• Mild tachypnea
• Tachycardia, lungs clear

🧠 Differential Diagnosis

1. DVT with PE (Most likely)
   (+) Post-op, unilateral swelling, tachycardia
   (−) No hemoptysis
2. Cellulitis
   (+) Redness, swelling
   (−) No fever, no WBC rise
3. Baker’s cyst rupture
   (+) Sudden posterior pain
   (−) No bruising

📄 SOAP Note

• S: Leg swelling, SOB, recent surgery
• O: Warm swollen leg, tachycardia, clear lungs
• A: Likely DVT with PE
• P: Doppler US, D-dimer, CT-PA, anticoagulation

🧠 Clinical Reflection

Even when the chief complaint is localized swelling, think systematically. Post-op patients with unilateral swelling and SOB must be evaluated for thromboembolism.

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💬 Summary Clinical Reflection

Same symptom, different mechanisms. Edema can stem from cardiac, oncotic, or vascular causes. Tailoring your history, exam, and tests to rule out urgent conditions like PE is key to safe and effective care.

🌟 Clinical Pearls

• PE can present subtly—be alert when swelling is unilateral and post-op.
• Non-pitting edema may indicate protein imbalance or endocrine dysfunction.
• Bilateral pitting + orthopnea = Think heart.

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