What is the workup for a patient with swelling in an outpatient setting?

Workup for Swelling in an Outpatient Setting

The workup for a patient with swelling in an outpatient setting should begin with identifying the location, duration, and characteristics of the swelling, followed by appropriate diagnostic testing based on the suspected etiology. 1

Initial Assessment

History

• Duration and onset of swelling (acute vs. chronic)
• Location and extent of swelling
• Associated symptoms (pain, redness, warmth, fever)
• Recent trauma or injury
• Previous episodes of similar swelling
• Underlying medical conditions (heart, kidney, liver disease)
• Current medications (especially those known to cause edema)

Physical Examination

• Vital signs (temperature, blood pressure, heart rate)
• Inspection of swollen area for:
  • Color changes
  • Skin texture
  • Symmetry compared to contralateral side
  • Extent of swelling
• Palpation to assess:
  • Temperature of the area
  • Tenderness
  • Consistency (pitting vs. non-pitting)
  • Pulses in affected limb if applicable

Diagnostic Approach Based on Location

Joint Swelling

1. Aspiration of joint fluid if infection or crystal arthropathy is suspected 2, 3, 4

   • Send for:
     • Cell count and differential
     • Gram stain and culture
     • Crystal analysis
     • Glucose and protein levels

2. Imaging studies:

   • Plain radiographs to evaluate for fracture, dislocation, or degenerative changes
   • Ultrasound to assess for effusion, synovitis, or soft tissue abnormalities
   • MRI if internal derangement is suspected (meniscal or ligamentous injury)

Limb Swelling

1. Laboratory tests:

   • Complete blood count (CBC)
   • Comprehensive metabolic panel (CMP)
   • D-dimer if DVT is suspected

2. Imaging studies:

   • Duplex ultrasound if DVT is suspected 1
   • CT scan if compartment syndrome or mass is suspected

Facial/Neck Swelling

1. Laboratory tests:

   • CBC with differential
   • CMP
   • Thyroid function tests if indicated

2. Imaging studies:

   • CT scan if deep space infection or mass is suspected
   • Ultrasound for thyroid or salivary gland pathology

Generalized Swelling

1. Laboratory tests:

   • CBC
   • CMP (including albumin, liver and kidney function)
   • Urinalysis (protein, blood)
   • Brain natriuretic peptide (BNP) if heart failure suspected
   • Thyroid function tests

2. Imaging studies:

   • Chest X-ray if cardiopulmonary cause suspected
   • Echocardiogram if heart failure suspected

Specific Considerations for Common Causes

Bone Tumors with Swelling

• Persistent non-mechanical pain in any bone lasting more than a few weeks requires immediate investigation
• Initial imaging should include conventional radiographs in two planes
• MRI of the whole compartment with adjacent joints for local staging
• Biopsy should be performed at a reference center by the surgeon who will perform definitive tumor resection 1

Vascular Access-Related Swelling

• Evaluate for venous outflow obstruction
• Consider ultrasound examination to confirm extravasations, hematomas, or purulent infiltrations
• Treat persistent swelling with balloon angioplasty if venous stenosis is found 1

Diverticulitis with Swelling

• CT scan is the preferred initial imaging test
• Ultrasound can be considered when CT cannot be obtained
• MRI can be considered when ultrasound provides inconclusive results 1

Corneal Edema and Swelling

• Detailed slit lamp examination
• Intraocular pressure measurement
• Referral to corneal specialist if complex management is needed 1

Cerebral Infarction with Swelling

• Urgent neuroimaging (CT or MRI)
• Close monitoring of neurological status
• Consider decompressive craniectomy in selected patients 1

Red Flags Requiring Urgent Attention

• Rapidly progressive swelling
• Severe pain disproportionate to examination findings
• Systemic symptoms (fever, chills)
• Neurological deficits
• Respiratory distress
• Signs of compartment syndrome (pain with passive movement, paresthesias)

Follow-up Recommendations

• Follow-up intervals should be based on clinical judgment and suspected diagnosis
• Patients should be instructed to return immediately for worsening symptoms
• Consider referral to specialists based on suspected etiology:
  • Orthopedics for joint or bone pathology
  • Vascular surgery for venous or arterial issues
  • Dermatology for skin-related swelling
  • Nephrology for kidney-related edema
  • Cardiology for heart failure

Conclusion

The outpatient workup for swelling requires a systematic approach based on location and suspected etiology. While many cases can be managed in the outpatient setting, recognition of red flags requiring urgent intervention is essential for appropriate patient care.