What is the diagnosis for a 78-year-old patient with worsening purpura (blanchable discoloration) to the bilateral lower extremities (BLE), accompanied by 2+ pitting edema, increasing pain with ambulation, poor capillary refill, and diminished pedal pulses, which worsens with compression stockings?

Differential Diagnosis for 78-year-old with Lower Extremity Symptoms

Single most likely diagnosis

• Chronic Venous Insufficiency (CVI): The patient's symptoms of worsening purpling blanchable discoloration, 2+ pitting edema, and pain increasing with ambulation are consistent with CVI. The exacerbation of discomfort with compression stockings may indicate a more severe form of the disease.

Other Likely diagnoses

• Peripheral Artery Disease (PAD): The patient's poor capillary refill, 0-+1 pedal pulses, and pain increasing with ambulation suggest possible PAD. However, the presence of pitting edema and worsening discoloration with compression stockings makes CVI a more likely diagnosis.
• Deep Vein Thrombosis (DVT): The patient's symptoms of edema, pain, and discoloration could be consistent with DVT. However, the chronic nature of the symptoms and the exacerbation with compression stockings make this diagnosis less likely.
• Lymphedema: The patient's 2+ pitting edema could be consistent with lymphedema. However, the presence of purpling discoloration and poor capillary refill suggests a more vascular etiology.

Do Not Miss diagnoses

• Acute Limb Ischemia: Although less likely given the chronic nature of the symptoms, acute limb ischemia is a medical emergency that requires prompt diagnosis and treatment. The patient's poor capillary refill and 0-+1 pedal pulses increase the concern for this diagnosis.
• Cellulitis or Infectious Process: The patient's symptoms of edema, pain, and discoloration could be consistent with a infectious process. Although less likely, this diagnosis should not be missed as it requires prompt antibiotic treatment.
• Compartment Syndrome: Although less likely given the chronic nature of the symptoms, compartment syndrome is a medical emergency that requires prompt diagnosis and treatment. The patient's pain increasing with ambulation and poor capillary refill increase the concern for this diagnosis.

Rare diagnoses

• Ehlers-Danlos Syndrome: A rare genetic disorder that affects the blood vessels and can cause chronic venous insufficiency and other vascular symptoms.
• Sickle Cell Disease: A rare genetic disorder that can cause chronic venous insufficiency and other vascular symptoms due to sickling of red blood cells.
• Buerger's Disease: A rare disease that affects the blood vessels and can cause chronic venous insufficiency and other vascular symptoms.