History of Present Illness Template for Leg Swelling
A comprehensive HPI template for leg swelling should include onset, duration, location, characteristics, associated symptoms, risk factors, and previous treatments to effectively evaluate potential vascular, cardiac, and systemic causes.
Key Components to Include
Temporal Characteristics
- Onset and duration: When did the swelling begin? Was it sudden (hours/days) or gradual (weeks/months)?
- Pattern: Is the swelling constant or intermittent? Does it worsen at certain times of day (e.g., end of day, morning)?
- Progression: Has the swelling worsened, improved, or remained stable since onset?
Location and Distribution
- Unilateral vs. bilateral: Affects one or both legs?
- Anatomic distribution: Localized to foot/ankle, extends to calf, or involves entire leg?
- Symmetry: If bilateral, is it symmetric or asymmetric?
Swelling Characteristics
- Severity: Mild, moderate, or severe swelling
- Pitting vs. non-pitting: Does pressing on the swollen area leave an indentation?
- Associated skin changes: Color changes, warmth, redness, skin thickening, ulceration, or varicosities
Associated Symptoms
- Pain: Presence, character, severity (0-10 scale), timing, and exacerbating/relieving factors
- Claudication: Pain with walking that improves with rest 1
- Dyspnea: At rest or with exertion, orthopnea, paroxysmal nocturnal dyspnea 1
- Neurological symptoms: Numbness, tingling, burning sensation in legs or feet
- Systemic symptoms: Fever, fatigue, weight changes
Aggravating and Relieving Factors
- Position: Does elevation improve swelling? Does standing or sitting worsen it?
- Activity level: Relationship to exercise or prolonged immobility
- Effect of compression: Response to compression stockings if used
Risk Factors and Medical History
- Previous episodes: History of leg swelling, DVT, or venous insufficiency
- Cardiovascular history: Heart failure, hypertension, coronary artery disease
- Vascular history: Previous DVT, varicose veins, venous insufficiency, arterial disease 1
- Surgical history: Recent surgeries, especially pelvic, abdominal, or lower extremity
- Trauma: Recent injury to the affected limb
- Endocrine disorders: Thyroid disease, diabetes mellitus
- Liver or kidney disease: History of hepatic or renal insufficiency
- Cancer history: Active or previous malignancy
- Immobility: Recent long travel, bedrest, or reduced mobility 1
Medication Review
- Current medications: Particularly calcium channel blockers, NSAIDs, thiazolidinediones, hormonal therapies
- Recent medication changes: New medications or dosage changes
- Compliance with diuretics: If prescribed for edema management
Previous Evaluations and Treatments
- Previous diagnostic tests: Ultrasound, echocardiogram, blood tests
- Previous treatments: Diuretics, compression stockings, leg elevation, exercise
- Response to treatments: Effectiveness of previous interventions
Physical Examination Focus Points
- Vital signs: Blood pressure in both arms, heart rate, respiratory rate 1
- Cardiovascular exam: Heart sounds, jugular venous distension
- Pulmonary exam: Presence of crackles or other abnormal lung sounds
- Abdominal exam: Hepatomegaly, ascites, masses
- Lower extremity exam:
Red Flags to Document
- Acute onset of unilateral swelling (concerning for DVT)
- Swelling with shortness of breath (concerning for heart failure or pulmonary embolism)
- Swelling with fever or skin changes (concerning for cellulitis or infection) 2
- Swelling with recent trauma or surgery
- Swelling with active cancer
This structured approach ensures comprehensive documentation of leg swelling and guides appropriate diagnostic workup and management decisions based on the most likely etiology.