Leg / Ankle Swelling
Leg or ankle swelling is the abnormal accumulation of fluid (edema) in the lower extremities, resulting from venous insufficiency, lymphatic obstruction, heart failure, hypoalbuminemia, or local inflammatory and musculoskeletal conditions.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Chronic venous insufficiency (CVI) / Varicose veins | Bilateral, worse PM, varicose veins visible, relieved by elevation, skin changes (pigmentation, eczema) [6] | 「隻腳有冇青筋凸出嚟？放高隻腳會唔會好啲？」(Visible varicose veins? Better with elevation?) |
| Dependent oedema / Drug-induced (amlodipine, NSAIDs) | Bilateral, temporal association with medication | 「你幾時開始食呢隻藥？腳腫係咪之後先開始？」(When did you start this drug? Did swelling follow?) | |
| Serious Not To Miss | Deep vein thrombosis (DVT) | Acute unilateral calf swelling + pain + warmth; risk factors per Virchow's triad [1][4] | 「隻腳係突然腫起嚟？有冇痛？有冇摸落去熱？」(Sudden swelling? Pain? Warm?) |
| Heart failure | Bilateral oedema + SOB + orthopnoea/PND + ↑JVP + S3 [3] | 「瞓低有冇氣喘？要枕高幾多個枕頭？」(SOB lying flat? How many pillows?) | |
| Nephrotic syndrome | Bilateral pitting oedema + periorbital oedema (AM) + frothy urine + hypoalbuminaemia [2] | 「朝早起身眼皮有冇腫？小便有冇好多泡？」(Puffy eyes in AM? Frothy urine?) | |
| Cellulitis | Unilateral, erythema, warmth, fever, skin break/portal of entry | 「隻腳有冇紅腫、發熱？有冇傷口？有冇發燒？」 | |
| Pre-eclampsia (pregnant) | Bilateral oedema + hypertension + proteinuria after 20 weeks | 「你而家懷孕幾多週？血壓高唔高？」 | |
| Pitfalls | Ruptured Baker's cyst | Acute onset behind knee → tracks to calf; Hx of knee arthritis | 「膝頭後面有冇腫過？有冇關節炎？」 |
| Lymphoedema | Non-pitting, progressive, no relief with elevation, may follow surgery/radiation | 「你之前有冇做過淋巴手術或者電療？㩒落去凹唔凹？」 | |
| Liver cirrhosis with hypoalbuminaemia | Bilateral oedema + ascites + jaundice + spider naevi | 「眼白有冇黃？個肚有冇脹大？」 | |
| Masquerades | Hypothyroidism (myxoedema) | Non-pitting oedema + fatigue + cold intolerance + weight gain + constipation | 「你怕唔怕凍？有冇成日攰、便秘、肥咗？」 |
| Drug-induced oedema | Temporal link to CCB (amlodipine), NSAIDs, OCP, pioglitazone, steroids | 「最近有冇轉過藥？」 | |
| CKD | Bilateral oedema + ↑Cr + proteinuria + Hx of DM/HT [5] | 「你有冇糖尿、高血壓？之前驗過腎功能未？」 | |
| Trying to Tell Me Something? | Anxiety about DVT/cancer, occupational stress, cosmetic concern (varicose veins), family worry | Hidden agenda: fear of serious disease; functional limitation | 「你最擔心係咩？有冇嘢令你特別唔安樂？」 |
Leg / Ankle Swelling — Family Medicine Clinical Test Page
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce self, set agenda | 「你好，我係X醫生。今日想同你傾下你嚟睇醫生嘅原因，了解吓你嘅情況，可以嗎？」(Hello, I'm Dr X. I'd like to talk about why you came today, OK?) | Rapport, permission — interpersonal marks |
| 0:30–2:00 | Open-ended HPI → symptom analysis (SOCRATES), onset, uni/bilateral, pitting, timing, aggravating/relieving | 「可唔可以話我知你隻腳腫咗幾耐？一隻定兩隻？朝早腫定夜晚腫啲？有冇痛？」 | Chief complaint + HPI completeness |
| 2:00–3:00 | Red flags: SOB/chest pain, haemoptysis, fever, weight loss, decreased urine, recent immobility/surgery/travel, calf pain | 「有冇氣喘、胸口痛、咳血？有冇試過發燒？小便有冇少咗？最近有冇做手術或者搭長途飛機？」 | Detects DVT/PE, HF, nephrotic, cellulitis |
| 3:00–3:45 | PMH (cardiac, renal, liver, thyroid, DM), Drug Hx (CCB, NSAIDs, OCP, steroids), Allergy, FHx | 「你有冇心臟病、腎病、糖尿病？食緊咩藥？有冇藥物敏感？屋企人有冇類似問題？」 | Drug-induced oedema is a masquerade; CKD/HF screen |
| 3:45–4:30 | ICE: Ideas, Concerns, Expectations | 「你自己覺得腳腫係咩原因？你最擔心啲咩？你今日嚟想我點樣幫到你？」 | Direct case-report marks for ICE |
| 4:30–5:15 | Social/functional Hx: occupation (prolonged standing), smoking, alcohol, diet (salt), impact on daily life | 「你做咩工作？企得多唔多？食嘢鹹唔鹹？腳腫有冇影響你返工或者行路？」 | Biopsychosocial problems |
| 5:15–5:45 | Summarise and check understanding | 「咁即係話你隻腳腫咗大約X個禮拜，兩隻腳，無痛，晏晝會差啲，我有冇聽錯？」 | Summarising scores interpersonal marks |
| 5:45–6:00 | Close: safety-net advice, signpost next steps | 「如果你突然覺得好喘、胸口痛、或者隻腳突然好腫好痛，一定要即刻去急症室。我哋而家做個檢查同安排啲驗血好嗎？」 | Safety-net + professional close |
Hidden agenda tip: The patient may fear cancer, DVT, or heart disease. Always ask 「你最擔心啲咩？」 — the real reason for consultation (RFC) is often fear/worry, not just the symptom.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset/Duration | When did it start? Sudden or gradual? | 「腳腫幾時開始？突然定係慢慢嚟？」 | Acute → DVT, cellulitis; Chronic → CVI, HF, CKD | DVT if acute; CVI/HF if chronic |
| Unilateral vs Bilateral | One leg or both? | 「一隻腳定兩隻腳？」 | Unilateral → DVT, cellulitis, Baker's cyst; Bilateral → systemic (HF, CKD, nephrotic, liver, venous insufficiency, drugs) [1] | DVT if unilateral; HF/renal if bilateral |
| Pitting | Does pressing leave a dent? | 「你㩒落去會唔會凹咗？」 | Pitting → fluid overload, DVT; Non-pitting → lymphoedema, myxoedema | Lymphoedema if non-pitting chronic |
| Diurnal variation | Worse at end of day or morning? | 「朝早定夜晚腫啲？」 | Evening worse → CVI/dependent; Morning periorbital → nephrotic [2] | Nephrotic if periorbital AM oedema |
| Pain | Is it painful? Where exactly? | 「痛唔痛？邊度痛？」 | Painful → DVT, cellulitis, gout; Painless → CVI, HF, nephrotic | DVT if unilateral calf pain |
| SOB/Orthopnoea/PND | Any breathlessness? Worse lying flat? Wake up at night gasping? | 「有冇氣喘？瞓低會唔會喘啲？半夜會唔會喘醒？」 | HF screen — orthopnoea/PND very specific [3] | Heart failure |
| Chest pain/Haemoptysis | Any chest pain or coughing blood? | 「有冇胸口痛或者咳血？」 | PE red flag | Pulmonary embolism |
| Immobility/Surgery/Travel | Recent surgery, bed rest, or long flight? | 「最近有冇做手術、住院、或者搭長途飛機？」 | Virchow's triad — stasis [1][4] | DVT → PE |
| Urine output/Frothy urine | Less urine? Foamy urine? | 「小便有冇少咗？有冇好多泡？」 | Proteinuria → nephrotic syndrome; Oliguria → AKI/CKD [2] | Nephrotic syndrome, CKD |
| Fever/Skin redness | Any fever? Is the skin red/hot? | 「有冇發燒？隻腳有冇紅、熱？」 | Cellulitis, septic arthritis | Cellulitis if unilateral erythema + fever |
| Weight gain/Abdominal swelling | Any weight gain or tummy swelling? | 「有冇肥咗？個肚有冇脹？」 | Fluid retention — HF, cirrhosis, nephrotic | Ascites if liver disease |
| Drug history | CCBs, NSAIDs, OCP, steroids, thiazolidinediones? | 「食緊咩藥？有冇食止痛藥、血壓藥、避孕藥？」 | Drug-induced oedema is a masquerade [5] | Drug-induced oedema (amlodipine very common) |
| PMH | Heart disease, kidney disease, liver disease, thyroid, cancer? | 「你有冇心臟病、腎病、肝病、甲狀腺問題？」 | Directs towards cause | HF, CKD, cirrhosis, hypothyroidism |
| Alcohol/Smoking | Alcohol and smoking habits? | 「你飲唔飲酒？食唔食煙？」 | Liver disease; smoking → PVD/VTE risk | Cirrhosis, VTE |
| Family history | Any family DVT or clotting problems? | 「屋企人有冇試過腳腫或者血管塞？」 | Inherited thrombophilia [4] | Thrombophilia |
| Occupation | Prolonged standing/sitting? | 「你返工企得多定坐得多？」 | CVI risk; immobility → DVT | Varicose veins, CVI |
| Functional impact | Does it affect walking, work, sleep? | 「腳腫有冇影響你行路、返工或者瞓覺？」 | Biopsychosocial problem for CRF | Social/functional impact |
| OCP/Pregnancy (if female) | On OCP? Could you be pregnant? | 「有冇食避孕藥？有冇機會懷孕？」 | OCP → VTE risk; Pregnancy → physiological oedema / pre-eclampsia | DVT, pre-eclampsia |
Case Report Form Answer Builder
- CC: "Leg/ankle swelling for [duration]"
- HPI must include: Onset (acute vs gradual), duration, unilateral vs bilateral, pitting vs non-pitting, diurnal variation, aggravating/relieving factors, associated symptoms (pain, redness, warmth, SOB, orthopnoea, PND, chest pain, haemoptysis, decreased urine, frothy urine, fever, weight gain), recent immobility/surgery/travel, drug changes.
Examples:
- "Patient noticed progressive bilateral ankle swelling affecting daily activities and is worried about heart or kidney problems."
- "Patient noticed acute painful unilateral calf swelling after long-haul flight and is concerned about blood clot."
- Tip: Phrase it as: symptom + trigger for attendance today + underlying worry
| Likely Examples | Exact Wording | |
|---|---|---|
| Ideas | "I think it might be my heart/kidney"; "My friend said it could be a blood clot" | "Patient thinks swelling may be due to heart problem / kidney problem / blood clot." |
| Concerns | Fear of DVT, cancer, heart failure, kidney failure; cosmetic | "Patient is worried this could be something serious like cancer or heart failure." |
| Expectations | Blood tests, ultrasound, referral, medication change | "Patient expects investigation to identify the cause and appropriate treatment/referral." |
Choose based on the stem clues:
- Bilateral, chronic, elderly + HTN/IHD + SOB → Congestive heart failure
- Bilateral, frothy urine, periorbital oedema, young → Nephrotic syndrome
- Unilateral, acute, post-surgery/immobility, calf pain → Deep vein thrombosis
- Bilateral, end of day, varicose veins visible, occupation → Chronic venous insufficiency
- Bilateral, started after amlodipine → Drug-induced oedema
Minimum evidence: state the key history features + one supporting physical sign.
| DDx | One Key Discriminator |
|---|---|
| DVT | Acute unilateral calf swelling + pain + VTE risk factors [1] |
| Heart failure | Bilateral oedema + SOB/orthopnoea/PND + ↑JVP [3] |
| Nephrotic syndrome | Bilateral oedema + frothy urine + periorbital AM oedema + hypoalbuminaemia [2] |
| CVI / Varicose veins | Chronic bilateral, worse PM, visible varicosities, skin changes [6] |
| Drug-induced | Temporal link to amlodipine/NSAID/OCP |
| Cellulitis | Unilateral erythema + warmth + fever + portal of entry |
| Hypothyroidism | Non-pitting + fatigue + cold intolerance |
| Liver cirrhosis | Bilateral oedema + ascites + stigmata of chronic liver disease |
(Pick three that contrast with your most likely diagnosis.)
| Domain | Example |
|---|---|
| Biological | Underlying CHF / CKD / DVT requiring investigation and treatment |
| Psychological | Anxiety about serious diagnosis (cancer, heart failure); sleep disturbance from discomfort |
| Social/Functional | Difficulty with prolonged standing at work; reduced mobility; need for sick leave; cosmetic impact on self-esteem (varicose veins) |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Heart failure | Elevated JVP | Patient at 45°, observe right internal jugular vein; measure height above sternal angle | Elevated JVP ( > 4 cm above sternal angle) indicates raised right atrial pressure — highly specific for HF [3] |
| DVT | Asymmetric calf swelling ( > 3 cm difference) | Measure circumference of both calves at 10 cm below tibial tuberosity | Unilateral swelling > 3 cm is a Wells score criterion [1][4] |
| Nephrotic syndrome | Periorbital oedema | Inspect face in morning; check for bilateral periorbital puffiness | Present because patient can lie flat (no orthopnoea) → fluid redistributes to face overnight; distinguishes from cardiac oedema [2] |
| CVI / Varicose veins | Visible varicose veins with skin changes (pigmentation, lipodermatosclerosis) | Inspect lower limbs with patient standing; look along GSV/SSV distribution [6] | Varicosities + haemosiderin staining = chronic venous hypertension |
| Cellulitis | Unilateral erythema, warmth, and tenderness with clear demarcation | Inspect and palpate affected limb; check temperature; look for portal of entry | Spreading erythema + warmth + fever = infection, not DVT |
| Hypothyroidism | Non-pitting oedema (myxoedema) + delayed ankle reflex relaxation | Press shin for 10s — no pitting; test ankle jerk — slow relaxation phase | Mucopolysaccharide deposition causes non-pitting oedema unlike fluid overload |
| Liver cirrhosis | Shifting dullness (ascites) + spider naevi | Percuss abdomen in supine and lateral positions | Ascites + hypoalbuminaemia = hepatic synthetic failure |
Must-Not-Miss Red Flags — Refer Urgently
- Acute unilateral calf swelling + pain + VTE risk factors → Suspect DVT → Urgent ultrasound Doppler; if concurrent chest pain/SOB → suspect PE → A&E [1][4]
- Bilateral oedema + severe SOB at rest / unable to lie flat → Acute decompensated heart failure → A&E
- Oedema + hypertension + proteinuria in pregnancy > 20 weeks → Pre-eclampsia → Obstetric emergency
- Rapidly spreading erythema + fever + systemic toxicity → Necrotising fasciitis → Surgical emergency
Top Traps That Lose Marks
- Forgetting to ask unilateral vs bilateral — this single question changes your entire differential.
- Not asking about drugs — amlodipine-induced ankle oedema is extremely common in HK primary care and a classic exam masquerade.
- Missing ICE — if you don't explicitly ask 「你覺得係咩原因？你最擔心咩？你想我點幫你？」, you lose guaranteed marks.
- Writing "oedema" as the diagnosis — oedema is a sign, not a diagnosis. Always write the underlying cause.
- Confusing nephrotic vs nephritic — Nephrotic = oedema + heavy proteinuria + hypoalbuminaemia + hyperlipidaemia; Nephritic = haematuria + HTN + oliguria [2].
- Not differentiating cardiac from renal oedema on PE — Periorbital oedema present = renal (can lie flat); absent = cardiac (orthopnoea prevents supine fluid redistribution) [2].
- Forgetting to safety-net — always close with when to seek urgent care.
Shortest Safe Management/Safety-Net Line
「如果你突然隻腳好痛好腫、氣都唞唔到、或者胸口痛，要即刻去急症室。我哋而家會安排驗血同檢查，跟住再覆診睇結果。」
(If sudden severe leg pain/swelling, SOB, or chest pain → A&E immediately. We'll arrange blood tests and follow up.)
GC Lecture High-Yield Points:
- From GC 234 (Common Foot and Ankle Conditions) and GC 230 (Knee Sport Injuries): Swelling assessment must differentiate extra-articular from intra-articular, fluid vs solid, and use fluid shift test / patellar tap [7]. While these are orthopaedic signs, the principle of systematic swelling assessment applies to ankle oedema stations.
- From Vascular clinical demonstration: Varicose vein examination must be done with patient standing; note distribution (GSV vs SSV), pitting vs brawny oedema, pigmentation, ulceration [6].
High Yield Summary
What to ASK: Unilateral vs bilateral; onset; pitting; SOB/orthopnoea/PND; frothy urine/periorbital oedema; drugs (amlodipine, NSAIDs); VTE risk factors; ICE (every single time).
What to WRITE: CC with duration → HPI with red flags covered → RFC (symptom + why today + worry) → ICE explicitly → Diagnosis with supporting evidence → 3 DDx with discriminators → 3 BPS problems → 1 physical sign with how to elicit it.
What NOT TO MISS: DVT (unilateral + acute + risk factors → urgent referral); Heart failure (bilateral + SOB + ↑JVP); Drug-induced oedema (masquerade); Pre-eclampsia in pregnant patients; Always safety-net for PE symptoms.
Active Recall - Family Medicine Clinical Test
[1] Senior notes: Block A - Leg swelling and chest pain: deep vein thrombosis; pulmonary embolism; Thrombophilia.pdf (Clinical features, Virchow's triad, DDx of DVT) [2] Senior notes: Block A - Glomerular and Tubulo-interstitial Diseases and Acute Kidney Injury.pdf (Nephrotic syndrome features, periorbital vs cardiac oedema distinction) [3] Senior notes: Block A - Shortness of breath on exertion: heart failure.pdf (HF signs sensitivity/specificity, Framingham criteria) [4] Senior notes: Maksim Medicine Notes.pdf (p288 — VTE risk factors, Wells score, clinical features of DVT and PE) [5] Senior notes: Block A - Chronic Kidney Disease and its Complications.pdf (CKD systemic features, drug-related nephropathy) [6] Lecture slides: Clinical Demonstration_Vascular.pdf (Varicose vein history and PE); Senior notes: Maksim Surgery Notes.pdf (p172 — CVI, CEAP, varicose veins); Ryan Ho Cardiology.pdf (p237 — varicose vein signs) [7] GC lecture slides: GC 230. Knee Sport Injuries_Part 1.pdf (Swelling assessment — fluid shift test, patellar tap)
Knee Pain
Knee pain is a common musculoskeletal complaint arising from injury, overuse, or degenerative, inflammatory, or infectious processes affecting the bones, cartilage, ligaments, tendons, or bursae of the knee joint.
Leg Pain
Leg pain is a symptom arising from musculoskeletal, vascular, neurological, or other causes, ranging from benign muscle cramps to limb-threatening conditions such as peripheral arterial disease or deep vein thrombosis.