Diagnosis: Chronic Venous Insufficiency (Occupational)
This 19-year-old female garment worker presents with bilateral lower extremity edema and pain after prolonged standing (13 hours daily), consistent with occupational chronic venous insufficiency, and should be managed with compression therapy, activity modification, and leg elevation.
Clinical Assessment
The patient's presentation is characteristic of venous insufficiency related to prolonged occupational standing:
- Bilateral foot swelling with pain on palpation indicates venous stasis from prolonged standing, which causes lower leg edema and muscle fatigue 1
- Difficulty bearing weight reflects the heaviness and discomfort typical of venous insufficiency 2
- 13-hour standing work shifts (7am-8pm) significantly exceed the 8-hour threshold associated with chronic venous disorders 3
- Young age does not exclude this diagnosis, as occupational standing increases CVD risk regardless of age, with 83.4% of standing workers showing evidence of venous disorders 4
Immediate Management Plan
Conservative Treatment (First-Line)
Compression therapy:
- Prescribe graduated compression stockings 20-30 mmHg pressure 5, 6
- Apply stockings before getting out of bed in the morning
- Wear throughout work shift, remove at bedtime
- Critical safety note: Compression is safe in this young patient without arterial disease risk factors 7
Activity modifications:
- Implement walking breaks every 1-2 hours during work shift, as walking prevents lower leg swelling while standing causes it 1
- Avoid prolonged static standing; shift weight between legs frequently 6
- Request work accommodation for brief sitting breaks if possible 4
Leg elevation:
- Elevate legs above heart level for 30 minutes, 2-3 times daily after work 5, 6
- Sleep with legs elevated on pillows 6
Medication (Within 300 Peso Budget)
No medication is indicated at this stage, as conservative management is first-line treatment 5, 8. NSAIDs may be used for symptomatic pain relief if needed:
- Ibuprofen 400mg - Take 1 tablet every 8 hours as needed for pain (maximum 3 tablets/day)
- Dispense: 15 tablets
- Duration: 5 days
- Cost: Approximately 50-75 pesos
Medical Certificate
Diagnosis: Chronic venous insufficiency secondary to prolonged occupational standing (bilateral lower extremities)
Recommendation: Patient is fit to return to work with the following restrictions:
- Implement walking breaks every 1-2 hours during work shift
- Wear prescribed compression stockings during all standing work
- Elevate legs during breaks when possible
- Follow-up in 2 weeks to assess response to conservative management
This medical certificate is issued upon the request of the patient for return to work with activity modifications.
Follow-Up Plan
- Return in 2 weeks to assess symptom improvement with conservative measures 5, 8
- If symptoms persist despite 3 months of compression therapy and activity modification, consider venous duplex ultrasonography to evaluate for valvular incompetence 5, 8
- Refer to vascular specialist only if conservative management fails after 3 months 8
Critical Pitfalls to Avoid
- Do not delay conservative treatment - compression therapy and activity modification should begin immediately 5, 6
- Do not order imaging initially - duplex ultrasonography is indicated only when considering interventional therapy or if conservative management fails 5
- Do not prescribe bed rest - continued ambulation and walking are protective against venous stasis 1, 3
- Prolonged standing workers have 83.4% prevalence of CVD compared to 59.4% in sitting workers, making this an occupational health priority 4