b'SECTION 1: PRIMARY9. Does the patient have a cardiac or renal history or any medication changes that could affect AND SECONDARYdiagnosis and treatment?10. Does the patient have a significant surgical LYMPHEDEMA ANDhistory, such as tumor resection, axillary lymph LIPEDEMA node dissection, or vascular procedures?The Patients Physical Exam A. CLINICAL FEATURES & DIAGNOSIS The most pertinent components of the physical examination should include evaluation of the skin, soft HISTORY AND PHYSICAL EXAMINATION tissue, vasculature, and lymph nodes, documentation Author: Sarena Banas, PT, DPT of any surgical scars or evidence for trauma, as well as a comprehensive assessment to identify any other A thorough medical history and physical examinationareas on the body that may be swollen.are important in the evaluation of the patient with a possible diagnosis of lymphedema (LE), lipedema, Differential Diagnosis:or other lymphatic disease (LD). Indeed, it is key to Lymphedema or Lipedemathe next steps in the management of your patientto determine immediately whether the patient isKey points to consider when examiningpresenting with signs and symptoms of lymphedemayour patient:vs. lipedema. The patient may present with similarLipedema is a bilateral condition and issymptoms of pain, swelling, and heaviness in thegenerally symmetrical.affected limb that could represent either primary orLymphedema can be unilateral, but commonly secondary lymphedema, lipedema, other lymphatic diseases, or possibly even other diseases associatedcan be bilateral and is asymmetrical in with the LS.presentation. Lymphedema, in its early stages, involves pitting The Patients Historyedema, whereas lipedema presents as non-Upon initially evaluating a patient that you suspectpitting edema.may have a lymphatic disease, the following questionsStemmers Signa diagnostic test carried outshould be addressed as a part of the comprehensiveduring a physical exam in which the provider history of the presenting illness: pinches the skin over the dorsum of the base1. When did the symptoms first begin? of the second toe. A positive Stemmers Sign2. What has been the duration of these symptoms?occurs when the thickened skin is difficult to lift3. What are the symptoms reported?off the underlying tissue and is positive for lymphedema in the early stages.4. How does the patient describe their pain/Lipedema does not involve the feet whereas discomfort?lymphedema can present with very edematous Lipedema is often called the painful fat and swollen ankles and feet. syndrome because individuals living withWhile skin infections are common in lymphedema, lipedema describe painful hard nodules (fat)under the skin.it is not common to see infection in lipedema. However, individuals living with lymphedemareport that their pain is diffuse, causing aSpecial attention should be paid to the conditiontightness and/or heaviness of the entire extremity. of the skin, the presence of skin pitting, and a 5. What makes the symptoms better? What makescomparison of limb circumferences. At the initialonset, the affected extremity may exhibit pitting, the symptoms worse? which is an indication of excess interstitial fluid moving 6. How have the symptoms progressed?when pressure is applied to the skin, such as is seen in Lipedema in the advanced stages may progress lymphedema, or non-pitting, such as seen in lipedema.to developing symptoms of lymphedema.With chronic lymphedema, the skin may have less 7. Any prior history of treatment for the symptoms?pitting and instead become thickened and fibrotic.And, what was the outcome of the treatment?Additional findings suggestive of venous involvement 8. Does the patient have a significant past medicalmay include the presence of visibly distended veins,history, such as recurrent infections, deep veindelayed emptying of the superficial veins during thrombosis (DVT), trauma, cancer, or cancerelevation of the extremity, and venous telangiectasias.treatment, including chemotherapy or radiotherapy?| Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|9'