What questions should be asked when evaluating a patient with swelling?

Essential Questions for Evaluating a Patient with Swelling

When evaluating swelling, systematically assess location, timing, associated symptoms, and underlying medical conditions to distinguish between cardiac, renal, infectious, allergic, and other etiologies that require different management approaches.

Location and Distribution

• Ask about the specific anatomical location: extremities (unilateral vs. bilateral), abdomen, face (lips, eyes, tongue), or other areas 1
• Determine if swelling is localized or generalized: unilateral leg swelling suggests venous thrombosis or infection, while bilateral lower extremity swelling points toward systemic causes like heart failure or renal disease 2
• For joint swelling, identify which joints are affected: distinguish between monoarticular (single joint) versus polyarticular (multiple joints) involvement 3
• In joint swelling, ask about peripheral pain/swelling in joints other than neck, back, or hips on a 0-10 scale 1

Temporal Characteristics

• Establish date of onset and duration: acute onset (<72 hours) versus chronic swelling have different differential diagnoses 1
• Document the time course: whether swelling is increasing, stable, or improving since onset 1
• For allergic reactions, determine if swelling began within 3 days of a trigger (insect sting, medication, food exposure) 1
• Ask about frequency: "In the last 4 weeks, how often have you had swelling?" 1

Associated Symptoms and Quality

• Assess for pain or discomfort: ask about severity, character, and whether pain is disproportionate to visible injury (suggests deeper involvement) 4
• Inquire about redness, warmth, or tenderness: these suggest infection or inflammation 1
• Ask about pruritus (itching): rate severity and whether it interferes with daily activities or sleep 1
• For facial/lip swelling, ask about breathing difficulty, tongue swelling, or throat tightness: these indicate potential airway compromise requiring immediate intervention 1, 5
• Document any purulent discharge or skin changes: suggests infection requiring antibiotics 6

Functional Impact and Severity

• Determine weight change: "How much weight have you gained or lost, and over what time frame?" 1
• Assess impact on daily activities: "How much has the swelling affected your quality of life?" and "Does it prevent normal everyday activities?" 1
• For extremity swelling, ask about ability to walk, climb stairs, or perform usual activities 1
• Inquire about ankle swelling specifically: this is a key screening question for cardiac or renal causes 1

Cardiovascular and Volume Status Screening

• Ask about shortness of breath: at rest, on exertion, or when lying flat (orthopnea) 1
• Inquire about paroxysmal nocturnal dyspnea: "Do you wake up suddenly from sleep with difficulty breathing?" 1
• Ask about chest pain, palpitations, or irregular heartbeat 1
• Document any history of heart failure, hypertension, or cardiac disease 1
• Ask: "Do you get short of breath when walking a certain distance?" 1

Renal and Endocrine Screening

• Ask about urinary symptoms: changes in urine output, color, or frequency 1
• Inquire about excessive thirst: suggests diabetes or other endocrine disorders 1
• For women of reproductive age, ask about menstrual changes 1
• Document any history of kidney disease or diabetes 1

Medication and Exposure History

• Review all current medications: diuretics, calcium channel blockers (cause peripheral edema), NSAIDs, lithium, and drugs causing xerostomia that increase fluid intake 1
• Ask about recent vaccinations: limb swelling can occur 1-3 days post-vaccination, typically resolving in 1-10 days 1
• Inquire about insect stings or bites: timing, number of stings, and previous reactions 1, 5
• Document steroid use or immunosuppression: increases risk of fungal and atypical infections 6

Sleep and Neurological Screening

• Ask: "Do you have problems sleeping aside from needing to get up to urinate?" 1
• Inquire: "Have you been told that you gasp or stop breathing at night?" (screens for obstructive sleep apnea) 1
• Ask about leg restlessness or abnormal movements during sleep 1
• Document any neurological symptoms: weakness, tremor, gait abnormalities, or lightheadedness on standing 1

Critical Red Flags to Identify

• Rapidly progressive swelling with severe pain: may indicate compartment syndrome requiring immediate surgical evaluation 2
• Swelling with systemic symptoms (fever, hypotension, respiratory distress): suggests sepsis, anaphylaxis, or pulmonary embolism 2
• Unilateral leg swelling with calf tenderness: high suspicion for deep venous thrombosis requiring immediate anticoagulation 2
• Facial swelling with airway symptoms: requires immediate epinephrine administration 5

Common Pitfalls to Avoid

• Do not assume bilateral leg swelling is always cardiac: consider medication side effects (especially calcium channel blockers), venous insufficiency, and lymphedema 1, 2
• Do not dismiss "just swelling" without fever: infections can present with swelling before systemic signs develop 2, 6
• Do not overlook malignancy: extensive venous thrombosis may unmask underlying cancer 2
• In immunocompromised patients, maintain high suspicion for atypical infections including fungal causes of subcutaneous swelling 6