Differential Diagnosis for 60-year-old Female with Bilateral Leg Swelling

Single Most Likely Diagnosis

• Chronic Venous Insufficiency (CVI) with possible Superimposed Cellulitis: The patient's symptoms of bilateral leg swelling, particularly in the evenings, and the appearance of venous dermatitis are highly suggestive of CVI. The presence of glucose, protein, and blood in the urine could indicate an underlying condition such as diabetes or kidney disease, which might be contributing to or exacerbating the CVI.

Other Likely Diagnoses

• Heart Failure: The symptoms of fatigue, palpitations, and bilateral leg swelling could be indicative of heart failure, especially given the patient's history of smoking and alcohol consumption, which are risk factors for cardiovascular disease.
• Nephrotic Syndrome: The presence of protein and blood in the urine, along with edema, suggests nephrotic syndrome as a possible diagnosis. This condition could be primary (due to kidney disease) or secondary (due to another underlying condition like diabetes).
• Diabetic Nephropathy: Given the glucose in the urine, diabetic nephropathy is a consideration, especially if the patient has undiagnosed or poorly managed diabetes. This condition could explain both the renal findings and the edema.

Do Not Miss Diagnoses

• Deep Vein Thrombosis (DVT): Although the patient's presentation is more chronic, DVT must be considered, especially with symptoms of leg swelling. Missing this diagnosis could be fatal due to the risk of pulmonary embolism.
• Lymphoma or Other Malignancies: While less likely, malignancies can cause leg swelling and systemic symptoms like fatigue. Given the patient's age and smoking history, this is a diagnosis that should not be missed.
• Severe Uncontrolled Hypertension: The presence of blood in the urine could indicate severe hypertension, which is a medical emergency. Uncontrolled hypertension can lead to renal failure, heart failure, and stroke.

Rare Diagnoses

• Lipedema: A condition characterized by the abnormal growth of fat cells in the legs, leading to swelling. It's more common in women and can be mistaken for other causes of leg swelling.
• Fabry Disease: A rare genetic disorder that can cause leg swelling among other systemic symptoms. It's less likely but should be considered in patients with unexplained multi-system involvement.
• Sarcoidosis: A condition that can affect multiple organs, including the lungs, skin, and kidneys, and could potentially explain some of the patient's symptoms, although it would be an uncommon presentation.