Subjective
Date of visit
Reason for visit (evaluation of new edema, follow-up)
History of present illness:
Onset and duration of swelling
Location and symmetry of edema (both legs, unilateral, etc.)
Worsening factors (prolonged sitting, standing)
Relief with elevation of legs
Associated symptoms (pain, tightness, skin changes)
Past medical history (relevant conditions, previous surgeries)
Medications (current medications)
Allergies
Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam:
General (signs of fluid overload)
Focused examination of the affected area(s):
Location and extent of edema (pitting vs. non-pitting)
Skin changes (color, warmth, dryness)
Joint mobility (limited movement due to swelling)
Cardiovascular examination (presence of jugular venous distention [JVD] may suggest heart failure)
Abdominal examination (ascites – fluid in the abdomen – may be present in some causes)
Assessment
Peripheral edema (confirmed)
Consider underlying cause(s) based on history, physical exam, and risk factors:
Heart failure
Liver disease (cirrhosis)
Kidney disease (nephrotic syndrome)
Lymphedema (obstruction of lymphatic drainage)
Protein deficiency (rare)
Medication side effects (certain medications can cause fluid retention)
Pregnancy (normal in some cases)
Infection (inflammatory process can cause edema)
Deep vein thrombosis (DVT) – rule out with appropriate tests if high suspicion
Plan
Diagnostic testing (may be ordered depending on suspected cause):
Laboratory tests:
Complete blood count (CBC)
Electrolytes
Liver function tests (LFTs)
Kidney function tests (KFTs)
Urinalysis
Imaging studies (may be indicated):
Chest X-ray (to assess for heart failure)
Ultrasound of the legs (to rule out DVT)
Abdominal ultrasound (to evaluate liver and kidneys)
Treatment:
Depends on the underlying cause and severity of edema
Management of the underlying condition (e.g., diuretics for heart failure)
Compression stockings to improve lymphatic drainage and reduce swelling
Elevation of the affected limbs
Dietary modifications (may be needed for some conditions)
Follow-up
Schedule for next appointment:
Monitor response to treatment (improvement of edema)
Repeat diagnostic tests if necessary (e.g., monitor kidney function)
Address the underlying cause
Note: This is a template and may need to be modified based on the individual patient’s presentation, suspected cause of edema, and presence of additional symptoms.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of peripheral edema.