Bilateral Leg SwellingAPPROACH

CHEST AND CARDIOVASCULAR · 19 SECTIONS

⚲

682 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Pacemaker And Icd Related Presentations Acute Limb Ischemia And Leg Pain Suspected Deep Vein Thrombosis Symptoms Hypertension Chest Pain Palpitations And Tachyarrhythmia Symptoms Bradycardia Symptoms Syncope And Presyncope Syncope With Neurologic Concern Unilateral Leg Swelling Bilateral Leg Swelling Calf Pain And Swelling

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx80

Presenting symptom

›Bilateral leg swelling symptom characterization

›Laterality

›Bilateral

›Symmetric

›Asymmetric

›Distribution

›Feet

›Ankles

›Calves

›Thighs

›Generalized edema

OPQRST

›OPQRST

›Onset

›Sudden

›Gradual

›Time course

›Provocation or palliation

›Worse with standing

›Worse late day

›Worse with salt intake

›Better with elevation

›Better overnight

›Quality

›Tightness

›Heaviness

›Painful

›Nonpainful

›Region or radiation

›Distal predominant

›Proximal predominant

›Scrotal or vulvar edema

›Abdominal distension

›Severity

›Functional limitation

›Shoe size change

›Skin breakdown

›Timing

›Intermittent

›Persistent

›Diurnal variation

Associated symptoms

›Associated symptoms

›Cardiopulmonary

›Dyspnea

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Chest pain

›Palpitations

›Cough

›Renal

›Oliguria

›Foamy urine

›Flank pain

›Hepatic

›Abdominal distension

›Early satiety

›Jaundice

›Pruritus

›Vascular or thrombotic

›New unilateral pain or redness within bilateral swelling

›Recent immobilization

›Hemoptysis

›Endocrine

›Cold intolerance

›Weight gain

›Constipation

›Infectious or inflammatory

›Fever

›New skin erythema

›Warmth

›Purulent drainage

Baseline and trajectory

›Prior episodes and baseline status

›Baseline edema pattern

›Prior heart failure diagnosis

›Prior kidney disease diagnosis

›Prior liver disease diagnosis

›Baseline weight

›Functional impact

›Exercise tolerance change

›Sleep position change

›Ability to ambulate

02Alarm Features/alarm57

Immediate life threats

›Immediate life threats

›Acute decompensated heart failure with pulmonary edema

›Severe dyspnea at rest

›Hypoxia

›Pink frothy sputum

›Massive pulmonary embolism concern

›Syncope

›Persistent hypotension

›Severe hypoxia

›Hyperkalemia from renal failure

›Weakness

›Bradycardia

›Sepsis from cellulitis or necrotizing infection

›Fever

›Toxic appearance

›Rapidly progressive pain

›Preeclampsia concern

›Pregnancy

›Headache

›Visual symptoms

Vital sign danger thresholds

›Vital sign danger thresholds

›Hemodynamic instability

›Systolic BP < 90 mmHg

›MAP < 65 mmHg

›Respiratory compromise

›SpO2 < 90% on room air

›RR > 30

›Sepsis physiology

›Temp ≥ 38.0 C

›HR > 120

High risk exam findings

›High risk exam findings

›Respiratory distress

›Accessory muscle use

›Inability to speak full sentences

›Pulmonary edema

›Diffuse crackles

›New S3

›DVT or phlegmasia concern

›Marked asymmetry within bilateral swelling

›Severe limb pain

›Soft tissue emergency

›Bullae

›Crepitus

›Pain out of proportion

›Decompensated cirrhosis complications

›Altered mental status

›GI bleeding signs

Escalation triggers

›Escalation triggers

›If hypoxia or respiratory distress, immediate resuscitation bay

›Continuous monitoring

›Early noninvasive ventilation if appropriate

›If hypotension or shock, immediate shock workflow

›Two large bore IV

›Point of care ultrasound

›If suspected sepsis, sepsis pathway

›Lactate

›Broad spectrum antibiotics per local protocol dependent

03Medications/meds26

Medication reconciliation

›Current medications and recent changes

›New medication within 1 to 4 weeks

›Calcium channel blockers

›NSAIDs

›Thiazolidinediones

›Corticosteroids

›Gabapentin or pregabalin

›Diuretic regimen

›Loop diuretic type

›Missed doses

›Anticoagulants

›Warfarin

›DOAC

›Hormones

›Estrogen therapy

›Testosterone therapy

High risk medication considerations

›High risk medication considerations

›NSAIDs

›Fluid retention risk

›Kidney injury risk

›CCB edema

›Dihydropyridine predominant

›Dose related

›Steroids

›Sodium retention

›Hyperglycemia risk

04Diet/diet10

Sodium and fluid patterns

›Sodium and fluid patterns

›High salt intake

›Processed foods

›Restaurant meals

›Fluid intake change

›Increased intake

›Decreased intake

›Alcohol exposure

›Recent increase

›Heavy use history

05Review of Systems/ros38

Cardiopulmonary

›Cardiopulmonary ROS

›Dyspnea exertional

›Reduced exercise tolerance

›New limitation

›Orthopnea

›Pillow count increase

›Sleep upright

›Chest pain

›Exertional

›Pleuritic

Renal and urinary

›Renal and urinary ROS

›Decreased urine output

›Oliguria

›Anuria

›Urine changes

›Foamy urine

›Hematuria

Hepatic and GI

›Hepatic and GI ROS

›Ascites symptoms

›Abdominal distension

›Early satiety

›Chronic liver disease symptoms

›Jaundice

›Pruritus

Constitutional and infectious

›Constitutional and infectious ROS

›Fever or chills

›Present

›Absent

›Skin infection symptoms

›Local warmth

›Spreading erythema

Endocrine

›Endocrine ROS

›Hypothyroid symptoms

›Cold intolerance

›Constipation

›Cushingoid symptoms

›Proximal weakness

›Easy bruising

06Collateral History and Family History/chafh18

Collateral and reliability

›Collateral and reliability

›Source

›Family

›Caregiver

›Facility

›Reliability

›High

›Limited

Family history

›Family history

›Cardiovascular disease

›Early coronary disease

›Cardiomyopathy

›Renal disease

›Polycystic kidney disease (Q61.3)

›Nephrotic syndrome history

›Thrombophilia

›Venous thromboembolism

›Known inherited thrombophilia

07Risk Factors/rf34

Cardiac risk factors

›Cardiac risk factors

›Heart failure history

›Reduced ejection fraction

›Preserved ejection fraction

›Coronary artery disease

›Prior MI

›Prior stent or CABG

›Hypertension (I10)

›Longstanding

›Poor control

Renal and hepatic risk factors

›Renal and hepatic risk factors

›Chronic kidney disease (N18.9)

›Recent creatinine rise

›Dialysis history

›Chronic liver disease or cirrhosis (K74.60)

›Viral hepatitis history

›Alcohol related liver disease

Thrombotic risk factors

›Thrombotic risk factors

›Recent immobilization

›Surgery within 4 weeks

›Long travel

›Malignancy

›Active cancer treatment

›Unexplained weight loss

›Estrogen exposure

›OCP

›Hormone therapy

Pregnancy related

›Pregnancy related

›Pregnancy status

›Third trimester physiology

›Postpartum within 6 weeks

›Preeclampsia risk

›Prior preeclampsia

›Chronic hypertension

08Differential Diagnosis/ddx60

Life threatening

›Life threatening differential

›Acute decompensated heart failure (I50.9)

›Orthopnea

›Crackles

›Elevated BNP

›Pulmonary embolism (I26.99)

›Dyspnea out of proportion

›Pleuritic chest pain

›Tachycardia

›Acute kidney injury with volume overload (N17.9)

›Oliguria

›Rising creatinine

›Hyperkalemia

›Nephrotic syndrome with anasarca (N04.9)

›Heavy proteinuria

›Hypoalbuminemia

›Severe cellulitis or necrotizing soft tissue infection (L03.116)

›Fever

›Rapid progression

›Pain out of proportion

›Preeclampsia (O14.9)

›Hypertension in pregnancy

›Headache

›Visual symptoms

Common

›Common differential

›Chronic venous insufficiency (I87.2)

›Dependent edema

›Hyperpigmentation

›Varicosities

›Medication induced edema

›Dihydropyridine calcium channel blocker

›NSAID exposure

›Obesity related dependent edema

›Worse with prolonged standing

›Improvement with elevation

›Heart failure chronic edema

›Weight gain

›Diuretic nonadherence

›Cirrhosis with portal hypertension (K76.6)

›Ascites

›Low albumin

›Chronic kidney disease with sodium retention (N18.9)

›Reduced GFR

›Hypertension

Less common

›Less common differential

›Lymphedema (I89.0)

›Nonpitting later

›Skin thickening

›Hypothyroidism (E03.9)

›Nonpitting myxedema features

›Elevated TSH

›IVC obstruction or compression

›Pelvic malignancy history

›New prominent abdominal wall veins

›Constrictive pericarditis (I31.1)

›Elevated JVP

›Hepatomegaly

›High output heart failure

›Severe anemia

›Hyperthyroidism

09Past Medical History/pmh26

Relevant chronic conditions

›Relevant chronic conditions

›Heart failure (I50.9)

›Last echocardiogram result

›Prior admissions for volume overload

›Chronic kidney disease (N18.9)

›Baseline creatinine

›Nephrology follow up

›Cirrhosis (K74.60)

›Variceal bleed history

›Ascites history

›Diabetes mellitus (E11.9)

›Nephropathy

›Cardiovascular disease

›Venous thromboembolism history

›Prior DVT

›Prior PE

Procedures and devices

›Procedures and devices

›Cardiac devices

›Pacemaker

›ICD

›Dialysis access

›AV fistula

›Central catheter

›Recent surgery

›Orthopedic

›Abdominal or pelvic

10Physical Exam/exam50

Vitals and general

›Vitals and general

›Volume status patterns

›Hypertension with edema

›Hypotension with dyspnea

›General appearance

›Respiratory distress

›Toxic appearance

Cardiopulmonary

›Cardiopulmonary exam

›JVP assessment

›Elevated

›Normal

›Heart exam

›S3 gallop

›Murmur

›Lung exam

›Crackles

›Wheeze

›Diminished bases

Extremities and skin

›Extremities and skin

›Edema characterization

›Pitting grade

›Nonpitting

›Symmetry

›Symmetric

›Asymmetric features

›Skin changes

›Erythema

›Warmth

›Hyperpigmentation

›Ulcers

›Tenderness

›Calf tenderness

›Pain out of proportion

Abdomen

›Abdomen

›Ascites signs

›Distension

›Shifting dullness

›Hepatic stigmata

›Jaundice

›Spider angiomas

›Hepatomegaly

›Present

›Absent

Neurologic

›Neurologic

›Mental status

›Encephalopathy concern

›Normal

›Focal deficits

›Present

›Absent

11Lab Studies/labs41

Core labs

›Core labs

›CBC

›Leukocytosis pattern

›Anemia severity

›Electrolytes and renal function

›Sodium

›Potassium

›Creatinine

›Liver panel

›AST

›ALT

›Bilirubin

›Albumin

›Hypoalbuminemia severity

›Trend if available

Targeted labs by suspected cause

›Targeted labs by suspected cause

›BNP or NT proBNP

›Heart failure support

›Chronic elevation limitations

›Urinalysis

›Protein

›Blood

›Urine protein quantification

›Protein creatinine ratio

›Albumin creatinine ratio

›TSH

›Hypothyroidism support

›Nonthyroidal illness limitations

›Troponin

›Myocardial ischemia concern

›Chronic kidney disease baseline elevation limitation

›Pregnancy test

›Reproductive age

›Postpartum status clarification

Point of care testing

›Point of care testing

›Glucose

›Hypoglycemia exclusion

›Hyperglycemia severity

›Venous blood gas if respiratory distress

›pH

›pCO2 in mmHg

12Imaging/img49

Scoring Systems

›Scoring Systems

›Wells criteria for PE

›When to use

›Dyspnea or chest pain with PE concern

›No clear alternative diagnosis

›When not to use

›Hemodynamic instability

›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 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

13Special Tests/spec17

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

14ECG/ecg14

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

15Assessment/ax18

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

16Plan/plan79

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

17Disposition/dispo24

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

18Discharge Instructions/di22

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.

19References/r19

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Bilateral Leg SwellingAPPROACH

CHEST AND CARDIOVASCULAR · 19 SECTIONS

⚲

682 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx80

Presenting symptom

›Bilateral leg swelling symptom characterization

›Laterality

›Bilateral

›Symmetric

›Asymmetric

›Distribution

›Feet

›Ankles

›Calves

›Thighs

›Generalized edema

OPQRST

›OPQRST

›Onset

›Sudden

›Gradual

›Time course

›Provocation or palliation

›Worse with standing

›Worse late day

›Worse with salt intake

›Better with elevation

›Better overnight

›Quality

›Tightness

›Heaviness

›Painful

›Nonpainful

›Region or radiation

›Distal predominant

›Proximal predominant

›Scrotal or vulvar edema

›Abdominal distension

›Severity

›Functional limitation

›Shoe size change

›Skin breakdown

›Timing

›Intermittent

›Persistent

›Diurnal variation

Associated symptoms

›Associated symptoms

›Cardiopulmonary

›Dyspnea

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Chest pain

›Palpitations

›Cough

›Renal

›Oliguria

›Foamy urine

›Flank pain

›Hepatic

›Abdominal distension

›Early satiety

›Jaundice

›Pruritus

›Vascular or thrombotic

›New unilateral pain or redness within bilateral swelling

›Recent immobilization

›Hemoptysis

›Endocrine

›Cold intolerance

›Weight gain

›Constipation

›Infectious or inflammatory

›Fever

›New skin erythema

›Warmth

›Purulent drainage

Baseline and trajectory

›Prior episodes and baseline status

›Baseline edema pattern

›Prior heart failure diagnosis

›Prior kidney disease diagnosis

›Prior liver disease diagnosis

›Baseline weight

›Functional impact

›Exercise tolerance change

›Sleep position change

›Ability to ambulate

02Alarm Features/alarm57

Immediate life threats

›Immediate life threats

›Acute decompensated heart failure with pulmonary edema

›Severe dyspnea at rest

›Hypoxia

›Pink frothy sputum

›Massive pulmonary embolism concern

›Syncope

›Persistent hypotension

›Severe hypoxia

›Hyperkalemia from renal failure

›Weakness

›Bradycardia

›Sepsis from cellulitis or necrotizing infection

›Fever

›Toxic appearance

›Rapidly progressive pain

›Preeclampsia concern

›Pregnancy

›Headache

›Visual symptoms

Vital sign danger thresholds

›Vital sign danger thresholds

›Hemodynamic instability

›Systolic BP < 90 mmHg

›MAP < 65 mmHg

›Respiratory compromise

›SpO2 < 90% on room air

›RR > 30

›Sepsis physiology

›Temp ≥ 38.0 C

›HR > 120

High risk exam findings

›High risk exam findings

›Respiratory distress

›Accessory muscle use

›Inability to speak full sentences

›Pulmonary edema

›Diffuse crackles

›New S3

›DVT or phlegmasia concern

›Marked asymmetry within bilateral swelling

›Severe limb pain

›Soft tissue emergency

›Bullae

›Crepitus

›Pain out of proportion

›Decompensated cirrhosis complications

›Altered mental status

›GI bleeding signs

Escalation triggers

›Escalation triggers

›If hypoxia or respiratory distress, immediate resuscitation bay

›Continuous monitoring

›Early noninvasive ventilation if appropriate

›If hypotension or shock, immediate shock workflow

›Two large bore IV

›Point of care ultrasound

›If suspected sepsis, sepsis pathway

›Lactate

›Broad spectrum antibiotics per local protocol dependent

03Medications/meds26

Medication reconciliation

›Current medications and recent changes

›New medication within 1 to 4 weeks

›Calcium channel blockers

›NSAIDs

›Thiazolidinediones

›Corticosteroids

›Gabapentin or pregabalin

›Diuretic regimen

›Loop diuretic type

›Missed doses

›Anticoagulants

›Warfarin

›DOAC

›Hormones

›Estrogen therapy

›Testosterone therapy

High risk medication considerations

›High risk medication considerations

›NSAIDs

›Fluid retention risk

›Kidney injury risk

›CCB edema

›Dihydropyridine predominant

›Dose related

›Steroids

›Sodium retention

›Hyperglycemia risk

04Diet/diet10

Sodium and fluid patterns

›Sodium and fluid patterns

›High salt intake

›Processed foods

›Restaurant meals

›Fluid intake change

›Increased intake

›Decreased intake

›Alcohol exposure

›Recent increase

›Heavy use history

05Review of Systems/ros38

Cardiopulmonary

›Cardiopulmonary ROS

›Dyspnea exertional

›Reduced exercise tolerance

›New limitation

›Orthopnea

›Pillow count increase

›Sleep upright

›Chest pain

›Exertional

›Pleuritic

Renal and urinary

›Renal and urinary ROS

›Decreased urine output

›Oliguria

›Anuria

›Urine changes

›Foamy urine

›Hematuria

Hepatic and GI

›Hepatic and GI ROS

›Ascites symptoms

›Abdominal distension

›Early satiety

›Chronic liver disease symptoms

›Jaundice

›Pruritus

Constitutional and infectious

›Constitutional and infectious ROS

›Fever or chills

›Present

›Absent

›Skin infection symptoms

›Local warmth

›Spreading erythema

Endocrine

›Endocrine ROS

›Hypothyroid symptoms

›Cold intolerance

›Constipation

›Cushingoid symptoms

›Proximal weakness

›Easy bruising

06Collateral History and Family History/chafh18

Collateral and reliability

›Collateral and reliability

›Source

›Family

›Caregiver

›Facility

›Reliability

›High

›Limited

Family history

›Family history

›Cardiovascular disease

›Early coronary disease

›Cardiomyopathy

›Renal disease

›Polycystic kidney disease (Q61.3)

›Nephrotic syndrome history

›Thrombophilia

›Venous thromboembolism

›Known inherited thrombophilia

07Risk Factors/rf34

Cardiac risk factors

›Cardiac risk factors

›Heart failure history

›Reduced ejection fraction

›Preserved ejection fraction

›Coronary artery disease

›Prior MI

›Prior stent or CABG

›Hypertension (I10)

›Longstanding

›Poor control

Renal and hepatic risk factors

›Renal and hepatic risk factors

›Chronic kidney disease (N18.9)

›Recent creatinine rise

›Dialysis history

›Chronic liver disease or cirrhosis (K74.60)

›Viral hepatitis history

›Alcohol related liver disease

Thrombotic risk factors

›Thrombotic risk factors

›Recent immobilization

›Surgery within 4 weeks

›Long travel

›Malignancy

›Active cancer treatment

›Unexplained weight loss

›Estrogen exposure

›OCP

›Hormone therapy

Pregnancy related

›Pregnancy related

›Pregnancy status

›Third trimester physiology

›Postpartum within 6 weeks

›Preeclampsia risk

›Prior preeclampsia

›Chronic hypertension

08Differential Diagnosis/ddx60

Life threatening

›Life threatening differential

›Acute decompensated heart failure (I50.9)

›Orthopnea

›Crackles

›Elevated BNP

›Pulmonary embolism (I26.99)

›Dyspnea out of proportion

›Pleuritic chest pain

›Tachycardia

›Acute kidney injury with volume overload (N17.9)

›Oliguria

›Rising creatinine

›Hyperkalemia

›Nephrotic syndrome with anasarca (N04.9)

›Heavy proteinuria

›Hypoalbuminemia

›Severe cellulitis or necrotizing soft tissue infection (L03.116)

›Fever

›Rapid progression

›Pain out of proportion

›Preeclampsia (O14.9)

›Hypertension in pregnancy

›Headache

›Visual symptoms

Common

›Common differential

›Chronic venous insufficiency (I87.2)

›Dependent edema

›Hyperpigmentation

›Varicosities

›Medication induced edema

›Dihydropyridine calcium channel blocker

›NSAID exposure

›Obesity related dependent edema

›Worse with prolonged standing

›Improvement with elevation

›Heart failure chronic edema

›Weight gain

›Diuretic nonadherence

›Cirrhosis with portal hypertension (K76.6)

›Ascites

›Low albumin

›Chronic kidney disease with sodium retention (N18.9)

›Reduced GFR

›Hypertension

Less common

›Less common differential

›Lymphedema (I89.0)

›Nonpitting later

›Skin thickening

›Hypothyroidism (E03.9)

›Nonpitting myxedema features

›Elevated TSH

›IVC obstruction or compression

›Pelvic malignancy history

›New prominent abdominal wall veins

›Constrictive pericarditis (I31.1)

›Elevated JVP

›Hepatomegaly

›High output heart failure

›Severe anemia

›Hyperthyroidism

09Past Medical History/pmh26

Relevant chronic conditions

›Relevant chronic conditions

›Heart failure (I50.9)

›Last echocardiogram result

›Prior admissions for volume overload

›Chronic kidney disease (N18.9)

›Baseline creatinine

›Nephrology follow up

›Cirrhosis (K74.60)

›Variceal bleed history

›Ascites history

›Diabetes mellitus (E11.9)

›Nephropathy

›Cardiovascular disease

›Venous thromboembolism history

›Prior DVT

›Prior PE

Procedures and devices

›Procedures and devices

›Cardiac devices

›Pacemaker

›ICD

›Dialysis access

›AV fistula

›Central catheter

›Recent surgery

›Orthopedic

›Abdominal or pelvic

10Physical Exam/exam50

Vitals and general

›Vitals and general

›Volume status patterns

›Hypertension with edema

›Hypotension with dyspnea

›General appearance

›Respiratory distress

›Toxic appearance

Cardiopulmonary

›Cardiopulmonary exam

›JVP assessment

›Elevated

›Normal

›Heart exam

›S3 gallop

›Murmur

›Lung exam

›Crackles

›Wheeze

›Diminished bases

Extremities and skin

›Extremities and skin

›Edema characterization

›Pitting grade

›Nonpitting

›Symmetry

›Symmetric

›Asymmetric features

›Skin changes

›Erythema

›Warmth

›Hyperpigmentation

›Ulcers

›Tenderness

›Calf tenderness

›Pain out of proportion

Abdomen

›Abdomen

›Ascites signs

›Distension

›Shifting dullness

›Hepatic stigmata

›Jaundice

›Spider angiomas

›Hepatomegaly

›Present

›Absent

Neurologic

›Neurologic

›Mental status

›Encephalopathy concern

›Normal

›Focal deficits

›Present

›Absent

11Lab Studies/labs41

Core labs

›Core labs

›CBC

›Leukocytosis pattern

›Anemia severity

›Electrolytes and renal function

›Sodium

›Potassium

›Creatinine

›Liver panel

›AST

›ALT

›Bilirubin

›Albumin

›Hypoalbuminemia severity

›Trend if available

Targeted labs by suspected cause

›Targeted labs by suspected cause

›BNP or NT proBNP

›Heart failure support

›Chronic elevation limitations

›Urinalysis

›Protein

›Blood

›Urine protein quantification

›Protein creatinine ratio

›Albumin creatinine ratio

›TSH

›Hypothyroidism support

›Nonthyroidal illness limitations

›Troponin

›Myocardial ischemia concern

›Chronic kidney disease baseline elevation limitation

›Pregnancy test

›Reproductive age

›Postpartum status clarification

Point of care testing

›Point of care testing

›Glucose

›Hypoglycemia exclusion

›Hyperglycemia severity

›Venous blood gas if respiratory distress

›pH

›pCO2 in mmHg

12Imaging/img49

Scoring Systems

›Scoring Systems

›Wells criteria for PE

›When to use

›Dyspnea or chest pain with PE concern

›No clear alternative diagnosis

›When not to use

›Hemodynamic instability

›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 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

13Special Tests/spec17

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

14ECG/ecg14

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

15Assessment/ax18

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

16Plan/plan79

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

17Disposition/dispo24

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

18Discharge Instructions/di22

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.

19References/r19

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.