What are the appropriate labs, imaging, and treatment for a 67-year-old with bilateral foot swelling and numbness, history of hypertension (HTN) and chronic obstructive pulmonary disease (COPD), without diabetes mellitus (DM)?

Evaluation and Management of Bilateral Foot Swelling and Numbness in a 67-Year-Old with HTN and COPD

For a 67-year-old patient with bilateral foot swelling and numbness who has hypertension and COPD but no diabetes, a comprehensive foot evaluation with vascular assessment, neurological testing, and appropriate imaging is essential, followed by targeted treatment of the underlying cause. 1

Initial Assessment

History

• Duration and progression of swelling and numbness
• Associated symptoms: pain, burning, claudication, leg fatigue
• History of trauma, prior ulceration, or amputation
• Smoking history (critical with COPD history)
• Medication review (some antihypertensives can cause edema)

Physical Examination

• Visual inspection of feet for skin integrity, color changes, and deformities
• Assessment of edema (pitting vs. non-pitting)
• Neurological assessment:
  • 10-g monofilament testing
  • At least one additional test: pinprick, temperature, or vibration sensation using 128-Hz tuning fork 1
• Vascular assessment:
  • Palpation of pedal pulses (dorsalis pedis and posterior tibial)
  • Inspection for signs of chronic venous insufficiency

Laboratory Testing

• Complete blood count (CBC) to evaluate for anemia or infection
• Comprehensive metabolic panel (CMP) to assess:
  • Renal function (BUN, creatinine)
  • Liver function (albumin levels may affect edema)
  • Electrolytes
• B-type natriuretic peptide (BNP) to evaluate for heart failure
• Urinalysis to assess for proteinuria (kidney involvement)
• HbA1c to rule out undiagnosed diabetes

Imaging and Special Tests

Initial Tests

• Ankle-brachial index (ABI) to evaluate for peripheral arterial disease
  • If ABI >1.40 (noncompressible vessels), perform toe-brachial index (TBI) 1
  • If symptoms of claudication or decreased/absent pedal pulses, refer for ABI and further vascular assessment 1

Additional Tests Based on Initial Findings

• Duplex ultrasound of lower extremities if venous insufficiency is suspected
• Chest X-ray to evaluate for cardiopulmonary causes of edema
• Echocardiogram if heart failure is suspected
• If pulmonary hypertension is suspected (especially with COPD history):
  • Echocardiography to estimate pulmonary artery pressure 1
  • Right heart catheterization may be indicated if echocardiography suggests pulmonary hypertension

Treatment Approach

Management Based on Etiology

1. If peripheral arterial disease is identified:

   • Optimize cardiovascular risk factors
   • Smoking cessation (critical with COPD history)
   • Antiplatelet therapy
   • Consider referral to vascular specialist if severe 1

2. If venous insufficiency is the primary cause:

   • Compression therapy (graduated compression stockings)
   • Leg elevation
   • Exercise program to improve calf muscle pump function
   • Consider referral to vascular specialist for severe cases

3. If neuropathy is the primary issue:

   • Proper footwear to prevent ulceration
   • Regular foot care and inspection
   • Pain management if neuropathic pain is present
   • Referral to foot care specialist for high-risk features 1

4. If heart failure is contributing:

   • Optimize blood pressure control (target <130/80 mmHg) 1
   • Consider diuretic therapy
   • RAS blockers (ACE inhibitors or ARBs) are first-line agents 1

5. If COPD-related pulmonary hypertension is contributing:

   • Optimize COPD management
   • Long-term oxygen therapy if hypoxemic 2, 3
   • Avoid conventional vasodilators which may worsen ventilation-perfusion mismatch 2

Special Considerations

Hypertension Management

• Target blood pressure <130/80 mmHg 1
• Consider medication review as some antihypertensives (particularly CCBs) can cause peripheral edema

COPD Management

• Optimize bronchodilator therapy
• Assess for hypoxemia which may contribute to pulmonary hypertension
• Consider pulmonary rehabilitation

Follow-up and Prevention

• Regular foot examinations at each healthcare visit
• Patient education on foot care and early recognition of problems
• Proper footwear recommendations
• Smoking cessation counseling
• Regular monitoring of blood pressure and COPD symptoms

Red Flags Requiring Urgent Attention

• Acute onset of severe swelling, especially if unilateral (DVT concern)
• Signs of infection (redness, warmth, fever)
• Skin breakdown or ulceration
• Severe pain unresponsive to usual measures
• Signs of critical limb ischemia (severe pain, pallor, pulselessness)

By following this systematic approach to evaluation and management, the underlying cause of bilateral foot swelling and numbness can be identified and appropriately treated, improving outcomes and quality of life for this patient.