Peripheral Oedema

1. Overview

Peripheral oedema is swelling of the limbs due to excess fluid accumulation in the interstitial tissues. It most commonly affects the ankles, feet and legs. In an OSCE, the key task is to determine whether the oedema is unilateral or bilateral, acute or chronic, pitting or non-pitting, and whether it is due to systemic disease, venous disease, lymphatic disease, medication effect or local pathology.

Bilateral pitting oedema commonly suggests systemic causes such as heart failure, renal disease, liver disease, hypoalbuminaemia or medication-related fluid retention. Unilateral painful swelling is important because deep vein thrombosis, cellulitis, trauma and venous obstruction must be considered.

Key OSCE priorities

• Clarify whether swelling is unilateral or bilateral.
• Clarify whether onset is acute, subacute or chronic.
• Ask about symptoms of heart failure, renal disease, liver disease and venous disease.
• Ask about pain, redness, warmth and calf tenderness.
• Ask about DVT and PE risk factors.
• Review medications that commonly cause oedema.
• Assess severity, distribution, pitting and skin changes.
• Look for signs of systemic fluid overload.
• Identify red flags requiring urgent assessment.

Important causes

• Heart failure.
• Chronic venous insufficiency.
• Deep vein thrombosis.
• Chronic kidney disease.
• Nephrotic syndrome.
• Liver cirrhosis and hypoalbuminaemia.
• Medication-induced oedema.
• Lymphoedema.
• Cellulitis.
• Hypothyroidism.
• Pregnancy-related oedema.
• Immobility or dependent oedema.

Red flag presentations

• Unilateral painful leg swelling suggesting DVT.
• Leg swelling with acute breathlessness, pleuritic chest pain or haemoptysis suggesting PE.
• Oedema with severe breathlessness, orthopnoea or pulmonary oedema.
• Oedema with chest pain or syncope.
• Oedema with fever, spreading erythema or severe pain suggesting cellulitis or necrotising infection.
• Generalised oedema with reduced urine output suggesting renal disease.
• Pregnancy with headache, visual symptoms or epigastric pain suggesting pre-eclampsia.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about the swelling.
• Gain consent.
• Check whether the patient currently has chest pain, severe breathlessness, fever, leg pain or collapse.
• If acutely unwell, state that you would assess using ABCDE and call for senior help.

Presenting complaint

• Ask when the swelling started.
• Ask whether onset was sudden or gradual.
• Ask whether swelling is unilateral or bilateral.
• Ask whether it affects feet, ankles, calves, thighs, hands, face or abdomen.
• Ask whether the swelling is getting worse, better or fluctuating.
• Ask whether swelling is worse at the end of the day.
• Ask whether swelling improves overnight or with leg elevation.
• Ask whether shoes, socks or rings feel tight.
• Ask whether there has been rapid weight gain.

Character of swelling

• Ask whether the swelling is painful.
• Ask about redness, warmth or skin tenderness.
• Ask about heaviness, aching or discomfort.
• Ask about skin tightness.
• Ask about weeping fluid or ulcers.
• Ask whether pressing the swelling leaves an indentation.
• Ask whether there are varicose veins or skin colour changes.
• Ask whether there has been previous similar swelling.

Heart failure symptoms

• Shortness of breath.
• Reduced exercise tolerance.
• Orthopnoea.
• Paroxysmal nocturnal dyspnoea.
• Nocturnal cough.
• Wheeze or frothy sputum.
• Fatigue.
• Palpitations.
• Chest pain.
• Abdominal swelling.
• Nocturia.

DVT and PE screen

• Unilateral calf or thigh swelling.
• Calf pain or tenderness.
• Redness or warmth of one leg.
• Recent surgery.
• Recent hospital admission.
• Recent long-haul travel or immobility.
• Active cancer.
• Previous DVT or PE.
• Pregnancy or postpartum period.
• Oestrogen therapy or combined oral contraceptive pill.
• Known thrombophilia.
• Acute breathlessness, pleuritic chest pain, haemoptysis or collapse suggesting PE.

Renal symptoms

• Reduced urine output.
• Frothy urine suggesting proteinuria.
• Haematuria.
• Facial puffiness, especially around the eyes.
• Nocturia.
• Flank pain.
• Known kidney disease.
• Diabetes or hypertension history.

Liver disease symptoms

• Abdominal swelling or ascites.
• Jaundice.
• Pruritus.
• Easy bruising or bleeding.
• Dark urine or pale stools.
• Alcohol excess.
• Previous hepatitis.
• Weight loss.
• Confusion or sleep reversal suggesting hepatic encephalopathy.

Venous insufficiency symptoms

• Chronic ankle swelling.
• Swelling worse after standing.
• Swelling improved by leg elevation.
• Aching or heaviness in the legs.
• Varicose veins.
• Brown skin pigmentation around the ankles.
• Venous eczema.
• Previous leg ulcers.
• History of DVT.

Lymphoedema symptoms

• Chronic non-pitting swelling.
• Swelling involving the dorsum of the foot or toes.
• Skin thickening.
• Recurrent cellulitis.
• Previous lymph node surgery.
• Previous radiotherapy.
• Cancer history.
• Travel or residence in areas where filariasis is possible.

Medication history

• Calcium channel blockers, especially amlodipine.
• NSAIDs.
• Steroids.
• Thiazolidinediones such as pioglitazone.
• Gabapentin or pregabalin.
• Hormonal therapy.
• Minoxidil.
• Recent medication changes.
• Diuretics and adherence if already prescribed.
• Drug allergies and reaction.

Past medical history

• Heart failure.
• Ischaemic heart disease.
• Valvular heart disease.
• Atrial fibrillation.
• Hypertension.
• Diabetes mellitus.
• Chronic kidney disease.
• Nephrotic syndrome.
• Liver disease.
• Previous DVT or PE.
• Varicose veins or venous ulcers.
• Cancer.
• Hypothyroidism.
• Previous pelvic or lymph node surgery.

Family history

• Family history of heart failure or cardiomyopathy.
• Family history of kidney disease.
• Family history of liver disease.
• Family history of DVT, PE or thrombophilia.
• Family history of lymphoedema.

Social history

• Smoking history.
• Alcohol intake.
• Occupation, especially prolonged standing or sitting.
• Mobility level.
• Recent immobility or bedbound state.
• Dietary salt intake.
• Fluid intake if heart failure or renal disease is suspected.
• Exercise tolerance.
• Living situation and support.
• Impact on walking, work, footwear and daily activities.

Pregnancy-related history if relevant

• Current pregnancy or postpartum status.
• Gestational age.
• Blood pressure problems in pregnancy.
• Headache.
• Visual disturbance.
• Epigastric or right upper quadrant pain.
• Reduced fetal movements if pregnant.
• Unilateral leg swelling or pain suggesting DVT.

Ideas, concerns and expectations

• Ask what the patient thinks is causing the swelling.
• Ask what they are most worried about.
• Ask whether they are worried about a blood clot, heart disease, kidney disease or cancer.
• Ask what they were hoping would happen today.

Red flags

• Unilateral painful swelling.
• Acute breathlessness or pleuritic chest pain.
• Haemoptysis or collapse.
• Severe breathlessness, orthopnoea or pulmonary oedema.
• Chest pain.
• Fever with spreading redness.
• Severe leg pain out of proportion to examination.
• Reduced urine output.
• New generalized oedema.
• Pregnancy with headache, visual symptoms or epigastric pain.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would examine the legs and perform cardiovascular, respiratory, abdominal and relevant systemic examination.

3. Physical Examination

The examination should assess the oedema itself and search for systemic causes, including heart failure, renal disease, liver disease, venous disease, lymphoedema, DVT and cellulitis.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask if the patient has leg pain, chest pain or breathlessness.
• Position the patient comfortably.
• Expose both legs from feet to knees, and higher if clinically appropriate, while maintaining dignity.
• Ask for a chaperone if appropriate.

Initial assessment

• Look from the end of the bed.
• Assess whether the patient is comfortable, breathless, pale, cyanosed or distressed.
• Look for oxygen therapy, cardiac monitor, IV lines, walking aids or compression stockings.
• If acutely unwell, perform an ABCDE assessment and call for senior help.

Vital signs

• Heart rate.
• Blood pressure.
• Respiratory rate.
• Oxygen saturation.
• Temperature.
• Weight if monitoring fluid status.
• Urine output if inpatient or acutely unwell.

Inspection of the legs

• Compare both legs for symmetry.
• Assess whether swelling is unilateral or bilateral.
• Assess distribution: foot, ankle, calf, thigh or generalized.
• Look for redness, warmth, skin breaks or cellulitis.
• Look for varicose veins.
• Look for venous eczema.
• Look for hyperpigmentation around the gaiter area.
• Look for lipodermatosclerosis.
• Look for venous ulcers, especially around the medial malleolus.
• Look for lymphoedema changes such as thickened skin and swelling of the dorsum of the foot.
• Look for scars from surgery or lymph node dissection.

Palpation of oedema

• Assess temperature of both legs.
• Press over the shin or ankle for at least several seconds to assess pitting.
• Describe oedema as pitting or non-pitting.
• Assess severity and level of oedema.
• Check for tenderness.
• Assess calf tenderness if DVT is suspected.
• Measure calf circumference if unilateral swelling is present.
• Check for sacral oedema if the patient is bedbound.
• Assess skin thickening and Stemmer sign if lymphoedema is suspected.

Peripheral vascular examination

• Palpate dorsalis pedis pulses.
• Palpate posterior tibial pulses.
• Assess capillary refill.
• Check limb temperature.
• Look for peripheral arterial disease signs such as hair loss, shiny skin, ulcers or reduced pulses.
• Avoid compression therapy until significant arterial disease is excluded.

Signs of DVT or cellulitis

• Unilateral swelling.
• Calf tenderness.
• Pitting oedema confined to one leg.
• Dilated superficial veins.
• Redness and warmth.
• Fever or systemic upset.
• Skin break or portal of entry for cellulitis.
• Do not rely on clinical examination alone to exclude DVT.

Cardiovascular examination

• Assess pulse rate and rhythm.
• Look for atrial fibrillation.
• Measure blood pressure.
• Assess jugular venous pressure.
• Palpate the apex beat.
• Listen for heart sounds and murmurs.
• Listen for a third heart sound.
• Look for signs of heart failure.

Respiratory examination

• Assess respiratory rate and work of breathing.
• Auscultate lung bases for crackles suggesting pulmonary oedema.
• Assess for pleural effusions.
• Look for signs of PE if acute breathlessness, pleuritic pain or hypoxia is present.

Abdominal examination

• Inspect for abdominal distension.
• Assess for ascites.
• Palpate for hepatomegaly.
• Look for stigmata of chronic liver disease.
• Assess for renal masses if clinically indicated.
• Check for abdominal or pelvic masses if venous or lymphatic obstruction is suspected.

Signs of renal disease

• Periorbital puffiness.
• Generalised oedema.
• Hypertension.
• Pallor.
• Scratch marks if uraemia is suspected.
• Fluid overload signs such as raised JVP and lung crackles.

Signs of liver disease

• Jaundice.
• Spider naevi.
• Palmar erythema.
• Gynaecomastia.
• Ascites.
• Hepatomegaly or small shrunken liver.
• Bruising.
• Peripheral oedema due to hypoalbuminaemia or portal hypertension.

Specific findings to mention in OSCE

• Bilateral pitting oedema suggests systemic fluid overload or venous insufficiency.
• Unilateral painful oedema requires DVT and cellulitis assessment.
• Non-pitting oedema with skin thickening suggests lymphoedema.
• Raised JVP, bibasal crackles and S3 suggest heart failure.
• Ascites and liver stigmata suggest liver disease.
• Periorbital oedema and proteinuria suggest renal or nephrotic disease.
• Venous pigmentation, eczema and ulcers suggest chronic venous insufficiency.

To complete the examination

To complete my examination, I would check observations, urine dip, weight, fluid balance if inpatient, blood tests including renal function, liver function and albumin, ECG, chest X-ray and natriuretic peptide if heart failure is suspected. If unilateral painful swelling is present, I would assess DVT probability and arrange D-dimer or venous ultrasound according to local VTE protocol.

4. Differential Diagnosis

Bilateral peripheral oedema

• Heart failure.
• Chronic venous insufficiency.
• Chronic kidney disease.
• Nephrotic syndrome.
• Liver cirrhosis.
• Hypoalbuminaemia or malnutrition.
• Medication-induced oedema.
• Hypothyroidism.
• Pregnancy.
• Dependent oedema from immobility.

Unilateral peripheral oedema

• Deep vein thrombosis.
• Cellulitis.
• Venous insufficiency affecting one leg.
• Lymphoedema.
• Trauma or fracture.
• Baker cyst rupture.
• Pelvic or abdominal mass causing venous obstruction.
• Post-thrombotic syndrome.

Cardiac causes

• Right-sided heart failure.
• Biventricular heart failure.
• Constrictive pericarditis.
• Pulmonary hypertension.
• Tricuspid regurgitation.
• Cor pulmonale.

Renal and hepatic causes

• Chronic kidney disease.
• Acute kidney injury with fluid overload.
• Nephrotic syndrome.
• Glomerulonephritis.
• Liver cirrhosis.
• Severe hypoalbuminaemia.

Medication causes

• Calcium channel blockers.
• NSAIDs.
• Steroids.
• Pioglitazone.
• Gabapentin or pregabalin.
• Hormonal therapy.
• Minoxidil.

5. Investigations

Bedside tests

• Full observations.
• Weight.
• Urine dipstick for protein, blood and glucose.
• Fluid balance chart if inpatient or acutely unwell.
• ECG if heart failure, arrhythmia or cardiac disease is suspected.
• Pregnancy test in women of reproductive age when appropriate.
• Measure calf circumference if unilateral swelling is present.

Blood tests

• Full blood count.
• Urea and electrolytes.
• Creatinine and estimated GFR.
• Liver function tests.
• Albumin.
• CRP if infection or inflammation is suspected.
• Thyroid function tests.
• HbA1c and lipid profile if cardiovascular or metabolic risk is being assessed.
• Coagulation profile if liver disease or anticoagulation is relevant.
• BNP or NT-proBNP if heart failure is suspected.

Urine tests

• Urine albumin-to-creatinine ratio.
• Urine protein-to-creatinine ratio if nephrotic syndrome is suspected.
• Urine microscopy if haematuria or renal disease is suspected.

Cardiac investigations

• ECG for arrhythmia, ischaemia or left ventricular hypertrophy.
• Chest X-ray for cardiomegaly, pulmonary oedema or pleural effusion.
• NT-proBNP or BNP if heart failure is suspected.
• Echocardiography to assess ventricular function, valves and pulmonary pressures.

DVT investigations

• Assess clinical probability using a DVT risk score such as Wells score.
• D-dimer may be used when DVT is less likely according to local protocol.
• Compression venous ultrasound is used to diagnose proximal DVT.
• If PE symptoms are present, assess for PE and follow local imaging and anticoagulation pathway.

Other investigations

• Venous duplex ultrasound for chronic venous insufficiency.
• Abdominal ultrasound if liver disease, ascites or abdominal mass is suspected.
• Renal ultrasound if kidney disease or obstruction is suspected.
• Lymphoscintigraphy is rarely needed but may be considered in specialist lymphoedema assessment.
• CT abdomen or pelvis if malignancy or venous obstruction is suspected.

Important investigation points

• Unilateral acute swelling should not be dismissed as simple fluid retention.
• Urine dip is a quick high-yield test for renal protein loss.
• Albumin helps assess hypoalbuminaemia as a cause of oedema.
• NT-proBNP supports assessment of suspected heart failure but must be interpreted clinically.
• Echocardiography is important when heart failure or pulmonary hypertension is suspected.
• DVT investigation depends on clinical probability and local protocol.

6. Management

Management depends on the underlying cause. In OSCEs, separate urgent causes such as DVT, PE, cellulitis, pulmonary oedema and renal failure from chronic causes such as venous insufficiency, lymphoedema and medication-related oedema.

Immediate approach if acutely unwell

1. Assess ABCDE.
2. Call for senior help if severe breathlessness, hypoxia, chest pain, collapse, fever or severe unilateral leg pain is present.
3. Check observations.
4. Give oxygen if hypoxaemic according to local protocol.
5. Obtain IV access and send blood tests if clinically indicated.
6. Perform ECG and chest X-ray if cardiac or respiratory cause is suspected.
7. Treat the likely emergency cause according to local protocol.

If heart failure is suspected

• Assess severity and oxygenation.
• Sit the patient upright if breathless.
• Give oxygen if hypoxaemic.
• Use loop diuretics for fluid overload according to local protocol.
• Monitor weight, fluid balance, renal function and electrolytes.
• Arrange NT-proBNP, ECG, chest X-ray and echocardiography.
• Treat precipitants such as ACS, arrhythmia, infection or medication non-adherence.
• Refer to heart failure team or cardiology where appropriate.

If DVT is suspected

• Assess DVT probability using local protocol.
• Arrange D-dimer or compression ultrasound as indicated.
• Start anticoagulation according to local protocol if DVT is likely or imaging is delayed.
• Assess for PE symptoms.
• Check bleeding risk and contraindications before anticoagulation.
• Provide safety-net advice for breathlessness, chest pain, haemoptysis or collapse.

If cellulitis is suspected

• Assess severity and sepsis features.
• Mark the edge of erythema if appropriate.
• Give antibiotics according to local guideline.
• Elevate the limb.
• Treat pain.
• Look for skin breaks, ulcers or tinea pedis as portals of entry.
• Escalate if rapidly spreading, systemically unwell or necrotising infection is suspected.

If chronic venous insufficiency is likely

• Encourage leg elevation.
• Encourage regular walking and calf muscle activation.
• Consider compression therapy after arterial disease has been excluded.
• Manage weight if overweight.
• Treat venous eczema and ulcers appropriately.
• Refer to vascular or tissue viability services if ulcers, severe varicose veins or complications are present.

If lymphoedema is likely

• Refer to lymphoedema service where available.
• Use compression therapy under specialist guidance.
• Encourage skin care to reduce cellulitis risk.
• Encourage exercise and limb elevation.
• Treat cellulitis promptly if it occurs.
• Assess for malignancy or obstruction if new unexplained unilateral lymphoedema develops.

If medication-induced oedema is suspected

• Review timing of symptoms relative to medication start or dose increase.
• Consider calcium channel blockers, NSAIDs, steroids, pioglitazone, gabapentin and pregabalin.
• Do not stop essential medication without clinician review.
• Discuss dose reduction, switching medication or treating the underlying condition.
• Check for other causes if oedema is severe, asymmetric or associated with systemic symptoms.

General advice

• Avoid prolonged standing or sitting if dependent oedema is present.
• Elevate legs when resting.
• Maintain mobility where possible.
• Reduce excess dietary salt if fluid overload is present.
• Maintain skin hygiene and moisturise dry skin.
• Avoid compression stockings until arterial disease is excluded if pulses are reduced or PAD is suspected.
• Seek urgent help for breathlessness, chest pain, unilateral painful swelling, fever, spreading redness or reduced urine output.

7. Examiner Questions

1. What are the common causes of bilateral peripheral oedema?
2. What are the common causes of unilateral leg swelling?
3. How do you distinguish pitting and non-pitting oedema?
4. What features suggest heart failure?
5. What features suggest DVT?
6. What features suggest chronic venous insufficiency?
7. What features suggest lymphoedema?
8. What medications commonly cause peripheral oedema?
9. What investigations would you request?
10. Why is urine dip useful?
11. Why would you check albumin?
12. When would you request NT-proBNP?
13. When would you arrange venous ultrasound?
14. What red flags require urgent assessment?

Suggested short answers

8. OSCE Pearls

• First decide whether oedema is unilateral or bilateral.
• Unilateral painful swelling is DVT until assessed properly.
• Bilateral pitting oedema often suggests systemic disease or venous insufficiency.
• Always ask about heart failure symptoms: dyspnoea, orthopnoea and PND.
• Always ask about renal symptoms and check urine dip.
• Always review medications, especially amlodipine, NSAIDs, steroids and pioglitazone.
• Non-pitting oedema suggests lymphoedema or hypothyroidism.
• Venous insufficiency is usually worse after standing and improves with elevation.
• Compression therapy requires arterial assessment if PAD is suspected.
• Look for skin changes: pigmentation, eczema, ulcers and cellulitis.
• Do not forget liver disease and hypoalbuminaemia.
• Pregnancy with oedema and headache or visual symptoms is concerning.
• Safety-net for breathlessness, chest pain, unilateral leg pain, fever and reduced urine output.

9. Example Presentation to Examiner

10. References

• NICE NG106: Chronic heart failure in adults: diagnosis and management.
• NICE NG158: Venous thromboembolic diseases: diagnosis, management and thrombophilia testing.
• NICE Clinical Knowledge Summary: Heart failure.
• Standard acute medicine approach to unilateral and bilateral leg swelling.
• Local cardiology, renal, vascular and VTE protocols.