What is the initial workup for hand and feet swelling?

Initial Workup for Hand and Feet Swelling

The initial workup for hand and feet swelling should include a comprehensive clinical examination, complete blood count, urinalysis, liver function tests (transaminases), and antinuclear antibodies to exclude inflammatory, autoimmune, and other systemic causes. 1

Clinical Assessment

History Taking

• Duration and pattern of swelling (acute vs chronic)
• Associated symptoms (pain, stiffness, redness)
• Morning stiffness duration (>30 minutes suggests inflammatory arthritis)
• Trauma history
• Systemic symptoms (fever, weight loss, fatigue)
• Medication history (especially diuretics, calcium channel blockers)

Physical Examination

• Bilateral vs unilateral swelling
• Distribution pattern (symmetric vs asymmetric)
• "Squeeze test" of metacarpophalangeal and metatarsophalangeal joints 1
• Skin changes (erythema, warmth, shiny skin)
• Joint examination for tenderness, range of motion
• Sharp demarcation at wrists/ankles (may indicate inflammatory cause) 1
• Assessment of peripheral pulses
• Examination for lymphadenopathy

Laboratory Tests

First-Line Tests

• Complete blood count (CBC) 1, 2
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) 2
• Urinalysis 1
• Liver function tests (transaminases) 1
• Antinuclear antibodies (ANA) 1

Second-Line Tests (Based on Clinical Suspicion)

• Rheumatoid factor (RF) and anti-citrullinated protein antibodies (anti-CCP) if inflammatory arthritis is suspected 2
• Serum albumin and protein levels if hypoproteinemia is suspected 3
• Renal function tests (BUN, creatinine) if renal disease is suspected 1
• Thyroid function tests if thyroid disease is suspected

Imaging Studies

First-Line Imaging

• Clinical examination is the method of choice for detecting synovitis 1
• In doubtful cases, ultrasound with power Doppler can help detect synovitis 1, 2

Additional Imaging (Based on Clinical Findings)

• MRI for deeper structures or when ultrasound is inconclusive 2
• Conventional radiography to assess for structural changes or erosions 2

Special Considerations

Diabetic Patients

For patients with diabetes, additional assessment should include:

• Evaluation for peripheral arterial disease (PAD) 1
• Assessment for loss of protective sensation (LOPS) 1
• Foot deformity examination 1
• Risk stratification using the International Working Group on Diabetic Foot system 1

Elderly Patients

• More careful assessment for cardiac causes (heart failure)
• Medication review for potential causes of edema
• Assessment of mobility and functional impact

Differential Diagnosis Algorithm

1. Bilateral symmetric swelling

   • With joint pain/stiffness > 30 minutes: Consider inflammatory arthritis (RA, SLE)
   • Without joint pain: Consider systemic causes (renal, cardiac, hepatic)

2. Unilateral or asymmetric swelling

   • With trauma history: Consider mechanical/traumatic cause
   • Without trauma: Consider venous/lymphatic obstruction, infection, or regional inflammatory condition

3. Swelling with systemic symptoms

   • Fever, weight loss: Consider infection, malignancy
   • Rash: Consider autoimmune conditions, infection

4. Swelling in diabetic patients

   • Assess for neuropathy, vascular disease, and infection 1
   • Stratify risk using IWGDF risk classification 1

Common Pitfalls to Avoid

• Assuming all hand/foot swelling in older adults is due to osteoarthritis 2
• Overlooking early inflammatory arthritis when only one or few joints are affected 2
• Relying solely on laboratory tests without thorough clinical examination 1
• Failing to refer patients with inflammatory arthritis to a rheumatologist within 6 weeks of symptom onset 1
• Neglecting to assess for diabetic foot complications in patients with diabetes 1

Early diagnosis and appropriate referral to specialists are crucial for preventing long-term complications and improving outcomes, especially in cases of inflammatory arthritis or diabetic foot conditions.