Swelling of the legs is abnormal and should be evaluated by a physician if it occurs more than occasionally after a long day of sitting or standing.
Swelling may occur due to high pressure in the veins of the legs, local injury, inflammatory changes, obstruction of lymphatic fluid outflow, infection, low blood protein levels, obesity, pregnancy, fluid retention states, or drug effects. Failure of the calf muscles to pump venous blood out of the legs due to stroke, venous injury, arthritis limiting ankle motion, or inactivity. Localized swelling may be due to trauma, hematoma (collection of non-flowing blood in the soft tissue), infections, fracture, superficial thrombophlebitis (clots in veins of the fatty tissues), rupture of a tendon or muscle, cyst at a joint (such as a synovial cyst at the knee), and, sometimes, spontaneous bleeding into the tissue due to a ruptured blood vessel. Some of the most common medications which cause leg swelling are non-steroidal anti-inflammatory drugs taken for pain relief or for arthritic discomfort and calcium channel blockers taken for heart disease or hypertension.
Cellulitis, infection of the skin and fatty tissues of the leg may cause swelling with pain and tenderness. Swelling of the foot, especially if the skin does not pit with brief application of pressure, may be due to lymphedema, a failure of the microscopic network of channels which move tissue fluid from the extremity back to the blood stream at the level of the upper chest. After venous insufficiency, obesity is the next most common cause of lower extremity swelling in the United States. Routine daily use of graduated compression support hose, often rated at a compression level of 20-30 or 30-40 mm Hg. Lymphedema may require special treatments called manual lymphatic drainage to massage the legs over a period of time with wrapping of the legs in special “short-stretch” elastic wraps and, sometimes, compression pump therapy to mobilize lymphatic fluid from the legs back to the bloodstream in the chest by intermittent squeezing of the legs.
Management of swelling of the legs often becomes a lifelong issue, but it is important because swelling will increase the risk of infection or leg ulcer and the underlying conditions may be associated with serious complications such as deep vein thrombosis or difficulty healing injuries or surgical incisions. The most common causes of leg swelling or soft tissue pain or tenderness in North America are venous insufficiency and obesity.
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Health History Past Cardiac History –CHF, angina, MI, murmurs, rheumatic fever, congenital heart disease Assess for risk factors of coronary artery disease –Hypertension, hyperlipidemia, diabetes, physical inactivity, obesity, smoking, stress, increasing age.


What the History Can Tell You Angina (pain resulting from ischemia) –Onset: Abrupt, often precipitated by event such as emotion, exertion, cold or eating. What the History Can Tell You Myocardial Infarction –Onset: Abrupt, often unrelated to precipitating event. Jugular Venous Pressure Assessment of jugular veins gives estimation of heart function –Ie. Apical Impulse AKA: Point of maximal impulse (PMI) Apical impulse specifically for apex beat.
Murmurs –Swishing or blowing noises that occurs with turbulent blood flow in heart or great vessels.
Murmur Characteristics –Intensity (loudness) 1 - Very faint, heard only after listener has “tuned in;” may not be heard in all positions 2 - Quiet, but heard immediately after placing the stethoscope on the chest 3 - Moderately loud 4 – Loud, with palpable thrill 5 - Very loud, with thrill. 14 Drug therapy: Diuretics ACE Inhibitors Beta Blockers Calcium Channel Blockers Nitroglycerine Positive Inotropic agents Digitalis Beta Adrenergic Stimulator Dopamine,Dobutamine. HEART FAILURE by Nancy Jenkins ? The most common reason for hospitalization in adults >65 years old. Cardiovascular: Valvular, Cardiomyopathy, Aneurysm and Cardiac Surgery Heart valves at work! CV Review Test #2 Hypertension Diuretics Valvular Disease Inflammatory Diseases of the Heart Heart Failure. Pain or tenderness in the legs associated with swelling is an especially important reason to seek evaluation. Further testing is based upon the clinical assessment and may include ultrasound, X-ray,CT, or MRI imaging in the legs or evaluation of the heart or blood vessels in the abdomen or pelvis. The causes of swelling in one leg may be similar to the other leg, but it is not unusual for different factors to cause the swelling in each leg.
High pressure in the veins of the legs results in fluid, proteins, and blood cells leaking through the wall of small veins into the soft tissues, especially near the ankles. Pain from cellulitis may be very severe or may manifest as tenderness and mild pain with faintly pink to bright red skin.


Frequently, conservative measures are helpful and these often are started before the cause of the swelling is fully evaluated. Resolving lower extremity swelling, if possible, prior to extremity surgery is an important means of reducing the chances of wound healing complications including bleeding, hematoma, wound breakdown, or infection. Incidence and Prevalence of Heart Failure Leading cause of death in the US More than 5 million Americans are living.
While some of the causes of leg swelling may be minor self-limiting conditions, others require very urgent medical care to reduce the likelihood of major complications or death. The most common failure of diagnosis occurs due to a venous ultrasound study which is performed in a manner to rule out clots (deep vein thrombosis) in the deep veins of the legs and does not evaluate for failure of one-way valves in the leg veins (venous insufficiency). Frequently, leg swelling is caused by more than one factor such as venous insufficiency, obesity, and previous saphenous vein harvest for heart bypass surgery. This causes pitting edema, swelling which will leave a temporary indentation in the skin with pressure from a shoe, sock, or intentional pressure such as a squeeze with a finger. Obesity also accelerates the stretching of the leg veins due to the effects of gravity, thus contributing to the progression of venous insufficiency. Chronic swelling of the legs with discomfort or a heavy feeling to the legs often contributes to inactivity which worsens the problem since the calf muscle pumping of blood out of the legs with walking is an important means of getting venous blood back to the heat.
Untreated leg swelling may lead to other complications such as infection, poorly-healing wounds, or clots in leg veins. It is common for patients with chronic leg swelling to be told that the ultrasound is “normal” or “was negative for clot” while failing to test for treatable venous insufficiency.



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