cardiovascular disorders
Edema
Evaluation of Edema
History of present illnessshould include location and duration of edema and presence and degree of pain or discomfort. Female patients should be asked whether they are pregnant and whether edema seems related to menstrual periods. Having patients with chronic edema keep a log of weight gain or loss is valuable. Review of systemsshould include symptoms of causative disorders, including dyspnea during exertion, orthopnea, and paroxysmal nocturnal dyspnea (heart failure); alcohol or hepatotoxin exposure, jaundice, and easy bruising (a liver disorder); malaise and anorexia (cancer or a liver or kidney disorder); and immobilization, extremity injury, or recent surgery (DVT). should include any disorders known to cause edema, including heart, liver, and kidney disorders and cancer (including any related surgery or radiation therapy). The history should also include predisposing conditions for these causes, including streptococcal infection, recent viral infection (eg, hepatitis), alcohol use disorder, and hypercoagulable disorders. Drug history should include specific questions about drugs known to cause edema (see table Some Causes of Edema ). Patients are asked about the amount of sodium used in cooking and at the table. The area of edema is identified and examined for extent, warmth, erythema, and tenderness; symmetry or lack of it is noted. Presence and degree of pitting (visible and palpable depressions caused by pressure from the examiner’s fingers on the edematous area, which displaces the interstitial fluid) are noted. In the general examination, the skin is inspected for jaundice, bruising, and spider angiomas (suggesting a liver disorder). Lungs are examined for dullness to percussion, reduced or exaggerated breath sounds, crackles, rhonchi, and a pleural friction rub. The internal jugular vein height, waveform, and reflux are noted. The heart is palpated for thrills, thrust, parasternal lift, and asynchronous abnormal systolic bulge. Auscultation for loud pulmonic component of 2nd heart sound (P2), 3rd (S3) or 4th (S4) heart sounds, murmurs, and pericardial rub or knock is done; all suggest cardiac origin. The abdomen is inspected, palpated, and percussed for ascites, hepatomegaly, and splenomegaly to check for a liver disorder or heart failure. The kidneys are palpated, and the bladder is percussed. An abnormal abdominal mass, if present, should be palpated. Certain findings raise suspicion of a more serious etiology of edema: Sudden onset Significant pain Shortness of breath Fever History of a heart disorder or an abnormal cardiac examination Hemoptysis, dyspnea, or pleural friction rub Hepatomegaly, jaundice, ascites, splenomegaly, or hematemesis Unilateral leg swelling with tenderness Potential acute life threats, which typically manifest with sudden onset of focal edema, must be identified. Such a presentation suggests acute Deep Venous Thrombosis (DVT) , soft-tissue infection, or angioedema. Acute DVT may lead to Dyspnea may occur with edema due to heart failure, DVT if PE has occurred, acute respiratory distress syndrome, or angioedema that involves the airways. Generalized, slowly developing edema suggests a chronic heart, kidney, or liver disorder. Although these disorders can also be life threatening, complications tend to take much longer to develop. These factors and other clinical features help suggest the cause (see table Some Causes of Edema ). nitrogen (BUN), creatinine, Laboratory Tests of the Liver and Gallbladder , serum protein, and urinalysis (particularly noting the presence of protein and microscopic hematuria). Other tests should be done based on the suspected cause (see table Patients with isolated lower-extremity swelling should usually have venous obstruction excluded by ultrasonography. 