High clinical suspicion requiring immediate imaging
PERC rule
When to use
Low pretest probability after clinician gestalt
Adult patients
When not to use
Moderate or high pretest probability
Pregnancy or postpartum local protocol dependent
MRI
MRI
MRI venography
Iliocaval thrombosis when ultrasound nondiagnostic
Contrast considerations local protocol dependent
Cardiac MRI
Myocarditis concern in selected cases
Not routine for isolated edema
CT
CT
CT pulmonary angiography
PE concern with positive D dimer or high risk features
Contrast nephropathy risk
CT abdomen pelvis with contrast
IVC compression concern
Malignancy concern
Radiation considerations
Pregnancy
Young patients
Ultrasound
Ultrasound
Venous duplex ultrasound legs
Suspected DVT
Pitfall
Iliac vein thrombosis missed on standard study
Repeat imaging if symptoms persist
POCUS cardiac
LV function gross estimate
RV strain patterns in PE concern
POCUS lung
B lines pattern
Pleural effusion
POCUS IVC
Size and collapsibility
Pitfall
Poor correlation in ventilated patients
Athletic baseline variation
Special Tests
Bedside maneuvers and measurements
Bedside maneuvers and measurements
Weight
Baseline comparison
Daily trend if admitted
Orthostatic vitals
Volume depletion coexistence
Diuretic overuse clue
Hepatojugular reflux
Right sided heart failure support
Technique dependent limitation
Procedural diagnostics
Procedural diagnostics
Diagnostic paracentesis
New ascites
Fever or abdominal pain
Ascitic fluid interpretation
PMN count
SAAG local protocol dependent
ECG
Indications and key patterns
ECG indications and key patterns
Indications
Dyspnea
Chest pain
Syncope
Ischemia patterns
ST elevation
ST depression
Arrhythmia patterns
Atrial fibrillation
SVT
Hyperkalemia patterns
Peaked T waves
QRS widening
Assessment
Problem representation
Problem representation
Bilateral lower extremity edema
With dyspnea
Without dyspnea
Time course
Acute
Subacute
Chronic
Working diagnoses and stratification
Working diagnoses and stratification
Volume overload physiology
Heart failure likely
Renal sodium retention likely
Low oncotic pressure physiology
Nephrotic syndrome likely
Cirrhosis likely
Dependent edema physiology
Venous insufficiency likely
Medication effect likely
Plan
First 5 minutes workflow
First 5 minutes workflow
Triage and monitoring
Cardiac monitor if dyspnea
SpO2 continuous if respiratory symptoms
IV access criteria
Two large bore IV if respiratory distress
One IV if stable and outpatient workup likely
Oxygen criteria
Supplemental oxygen if SpO2 < 92% local protocol dependent
Escalate to noninvasive ventilation if pulmonary edema with distress
Time targets
ECG within 10 minutes if chest pain or dyspnea with ischemia concern
CXR early if dyspnea or hypoxia
Immediate consult activation triggers
ICU team if hypotension or escalating oxygen needs
Obstetrics if pregnancy with hypertension and edema
Diagnostic sequencing
Diagnostic sequencing
If dyspnea or hypoxia
CXR
BNP or NT proBNP
Troponin if ischemia concern
If nephrotic or renal concern
Urinalysis
Urine protein quantification
Albumin
If cirrhosis or ascites concern
Liver panel
INR
Diagnostic paracentesis if indicated
If DVT or PE concern
Wells criteria pathway
Venous duplex ultrasound
D dimer in low to intermediate risk local protocol dependent
Therapeutics
Therapeutics
Suspected acute decompensated heart failure
Furosemide IV 20 mg to 40 mg
If on chronic loop diuretic, IV dose at least home daily dose equivalent
Nitroglycerin SL 0.4 mg every 5 minutes up to 3 doses if hypertensive pulmonary edema
Contraindication
Suspected right ventricular infarct
Recent PDE5 inhibitor use
Suspected medication induced edema
Offending agent review
Hold or reduce dose if clinically appropriate
Suspected venous insufficiency
Leg elevation
Compression therapy if no critical limb ischemia and no severe PAD concern
Cellulitis present
Antibiotics per local protocol dependent
MRSA coverage criteria local protocol dependent
Hyperkalemia present
Calcium gluconate IV 1 g if ECG changes
Insulin regular IV 10 units with dextrose
Nebulized albuterol 10 mg to 20 mg
Monitoring and reassessment loop
Monitoring and reassessment loop
Reassessment timing
Every 30 to 60 minutes if IV diuresis
Every 15 minutes if pulmonary edema on noninvasive ventilation
What to repeat
Vitals
Lung exam
Urine output
Response markers
Improved dyspnea
Improved oxygenation
Net diuresis
Consultation
Consultation
Cardiology
New heart failure diagnosis
Refractory congestion
Nephrology
Severe AKI
Nephrotic syndrome suspicion
Hepatology or GI
New ascites
Decompensated cirrhosis complications
Obstetrics
Pregnancy with hypertension
Preeclampsia concern
Disposition
Level of care criteria
Level of care criteria
ICU
Requiring noninvasive ventilation
Persistent hypotension
Rising lactate with sepsis concern
Inpatient admission
New oxygen requirement
IV diuresis required with monitoring
AKI with electrolyte derangements
Nephrotic syndrome with anasarca and complications
Observation pathway
Mild to moderate heart failure exacerbation responsive to initial diuresis
Stable vitals with short interval reassessment
Discharge
No dyspnea at rest
Stable vitals
Clear outpatient follow up plan within 3 to 7 days
Transfer criteria
Transfer criteria
Dialysis not available and emergent indication
Refractory hyperkalemia
Pulmonary edema refractory to diuretics
High risk pregnancy complication
Severe preeclampsia concern
Limited obstetric resources
Discharge Instructions
Copy discharge instructions
Copy discharge instructions
Summary
You were seen for swelling in both legs.
Your evaluation suggests fluid retention from .
Medications
Take your prescribed diuretic exactly as directed.
Avoid NSAIDs unless your clinician says they are safe for you.
Self monitoring
Daily morning weight.
Record weights and bring to follow up.
Activity
Elevate legs when resting.
Walking as tolerated unless instructed otherwise.
Follow up
Primary care within 3 to 7 days.
Cardiology or nephrology follow up if arranged.
Return to ED immediately if
New or worsening shortness of breath.
Chest pain.
Fainting.
One leg becomes much more swollen or painful than the other.
Fever or rapidly spreading redness.
References
Guidelines and key sources
Guidelines and key sources
ACC AHA heart failure guideline focused update 2022
Diuretic therapy framework
Disposition and risk features
ESC heart failure guideline 2023
Congestion assessment
Acute heart failure pathways
KDIGO clinical practice guideline for CKD evaluation and management 2012
Kidney disease staging
Proteinuria evaluation
KDIGO glomerular disease guideline 2021
Nephrotic syndrome evaluation
Proteinuria quantification
ACOG practice bulletin on hypertensive disorders of pregnancy 2020
Preeclampsia recognition
Severe features
Project instructions source
Formatting rules
Required section structure
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.