Pedal Edema vs. Chubby Ankles

[tcripp]

Had a patient who presented with shortness of breath. He was leaning back in a chair showing signs of anxiousness and said he couldn't catch his breath. BP was something like 130/90, and slightly tachycardic and tachypneic. Lung sounds included wheezing in the upper lobes and diminished in the lower, but the patient was a large man with significant adipose tissue.

Pt treatment included oxygen, neb treatments and Solumedrol. Upon arrival at the hospital, his respirations, pulse, and ETCO2 were within normal limits although he continued to tell me that he couldn't catch his breath.

Now, because of the elevated BP, description of the pedal edema and lung sounds, some suggest CHF might have also been indicated which would have suggested a different course of treatment.

Not looking for validation of my treatment plan, but rather…how do you differentiate in your patient description the difference between what might be considered a fluid shift (pedal edema) vs obesity/simply fat ankles? I'm wanting to find a better way to present my patient in writing to get a more clear picture of what I saw.

Toni

(edited for formatting only)

Edited May 5, 2011 by tcripp

[paramedicmike]

Based on what you've presented I'm not sure what you're looking for. Was this guy fat? Or was there edema present? Or is that what you're looking to know? You made no mention of pedal edema until you mention "the description of pedal edema" with no previous mention of it. Your description doesn't really make this very clear.

There's a lot to wonder with your scenario. He was leaning back in the chair. Were his legs elevated, too? Or were his legs hanging off the chair towards the floor? When you pushed in on his foot to check for edema what happened?

Are you familiar with how to assess for pedal edema? Please don't be offended by that question because most medics don't know. And since you're asking I'm thinking the answer is no.

Generally, if the patient is just fat you shouldn't get pitting like you would with edema. If there's a fluid shift like you see in edema you should see some form of indentation that takes a few seconds to resolve. Combine that with the rest of your physical exam findings and it should give you a better idea if it's just fat or something else.

Hope this helps.

[DwayneEMTP]

I'm with Mike..

Other than a generalized 'feeling' when comparing the legs/ankles to the other extremities and even distal to proximal, pitting is the most important finding for me...not in the assessment, but in the finite edema/non edema context.

Dwayne

[tcripp]

I was afraid my brief scenario wasn't complete enough. But, simply, I was looking to see how you would indicate the guy was fat. Please see my responses to your questions below - in red.

Based on what you've presented I'm not sure what you're looking for. Was this guy fat? Or was there edema present? Or is that what you're looking to know? You made no mention of pedal edema until you mention "the description of pedal edema" with no previous mention of it. Your description doesn't really make this very clear.

There's a lot to wonder with your scenario. He was leaning back in the chair. Were his legs elevated, too? Or were his legs hanging off the chair towards the floor?

Leaning back in the chair; no, his legs were not elevated. The point of notiing "leaning back" was to indicate that he was not in any type of tripod position. I can also add that he was not using any accessory muscles to breathe.

When you pushed in on his foot to check for edema what happened?

Nothing...it plumped back up very nicely.

Are you familiar with how to assess for pedal edema? Please don't be offended by that question because most medics don't know. And since you're asking I'm thinking the answer is no.

I assume you are asking about pitting, and the answer is yes. And, in my PCR, I wrote "non-pitting edema". If you are not suggesting pitting, please be more descriptive. I'd be interested to hear other options. (and, not offended...)

Generally, if the patient is just fat you shouldn't get pitting like you would with edema. If there's a fluid shift like you see in edema you should see some form of indentation that takes a few seconds to resolve. Combine that with the rest of your physical exam findings and it should give you a better idea if it's just fat or something else.

Hope this helps.

Essentially, I'm looking to see how I could have written the description better to convey - fat dude / not a CHFer.

[paramedicmike]

How about simply, "dude was fat"?

More seriously, play up the obesity aspect of your assessment findings. Mention height and weight. Throw in a BMI. Document all your other findings (positioning, lack of accessory muscle usage etc...) including your edema assessment of his lower extremities. If you include all of this information it will better portray fat versus CHF.

But I still really like "dude was fat".

[tcripp]

But I still really like "dude was fat".

And to think I was trying to be all PC and everything.

[JakeEMTP]

Once again I agree with Mike on this one. Based on your second post TC, I would not suspect CHF, rather the other option, "Dude was fat" Sometimes you just can't be politically correct! If you must, morbidly obese seems to work.

[Bieber]

Another thing to consider is that the patient could very well have had RIGHT sided heart failure as a result of COPD, which could also cause pedal edema. It doesn't sound, based on what you've said, that this patient's problem was an exacerbation of CHF.

Anecdotally, it seems like bronchodilators in CHF's flood them like crazy. I think I've heard conflicting stories as to whether or not they've been shown to worsen the pulmonary edema, but in my limited experience, it's seemed to be the case. That this guy didn't get any worse, while it doesn't necessarily prove he wasn't having a CHF exacerbation, still means that he didn't get any worse.

And that's goal number one.

[DartmouthDave]

Hello,

Thanks for posting Tripp.

I think PM summed it up quite well:

"Generally, if the patient is just fat you shouldn't get pitting like you would with edema. If there's a fluid shift like you see in edema you should see some form of indentation that takes a few seconds to resolve. Combine that with the rest of your physical exam findings and it should give you a better idea if it's just fat or something else."

Medical history and medications can help fine tune things. Onset of symptoms: fast or slow? History of hospitalization? You get my drift. Sure, it could be COPDE or CHF or something totally different. PE? ARF?

Way back in the day I did a call for a 125kg (or so) 28 year-old male with a c/o SOB and SOBOE. No past medical history or medications other than NSAID and Tly for MSK pain. Smoker. Worked as a bouncer in a dive of a bar and lived in a hotel room. Wheezing lungs. Pedal edema. I figure he was developing failure.

It turned out he had Nephrotic or Nephritic Syndrome (can't recall which one) and he was medevac to a larger hospital later that day.

So, I think management with Salbutamol, positioning, o2 and transport is a good idea. IMHO.

Just one quick general questions here. I assume most areas treatment of CHF is NTG SL? As opposed to Lasix and Morphine?

Thank you

DD

Edited May 6, 2011 by DartmouthDave

[zippyRN]

I'm with Mike..

Other than a generalized 'feeling' when comparing the legs/ankles to the other extremities and even distal to proximal, pitting is the most important finding for me...not in the assessment, but in the finite edema/non edema context.

Dwayne

i'd agree with that

flab is 'springy' Oedema even if not barn door pitting oedema will take a little while to settle ...