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Dr. Andrew Rynne
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Dr. Andrew Rynne

Family Physician

Exp 50 years

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What causes swelling in legs?

Answered by
Dr.
Dr. Ilir Sharka

Cardiologist

Practicing since :2001

Answered : 7011 Questions

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Posted on Mon, 6 Jun 2016 in Hypertension and Heart Disease
Question: Hi Doctor,

I'm a medical student, my grandmother in law is 74 years old, she has history of cholesterol and High blood pressure, she previously did two hip surgeries due to osteoporosis, she is also has arthritis (knees). she was also recently diagnosed with a mild heart ischemia (Angina), she had angina symptoms one time about 2 months ago and it never came back to her since then.

She visited us from her country about a week ago with my mother in law, these days i have been taking them around as tourist and we walked a lot together, and yesterday night till today she developed swelling on her legs, swelling starts under her knees down to the ankle and it's a little bit swollen on her feet. I tried pressing on the area of the swelling to see if there is a sign of pitting edema, but it was normal ( i mean there was no sign of pitting edema) , i was also able to see few varicose veins..

She told me that she usually has this back home but when she came to us she was normal. she also said one doctor told her that her muscles are falling down (i don't know what kind of disease is that as i can't find a medical term for it neither was i taught in school about muscles of legs falling down).

from my point of view it looks to me that it's more related to her walking for long periods of time, or some of her blood pressure medications causing her this edema.

My questions
1-what's your diagnosis of this swelling of her legs?
2-what's best treatment option to consider?
3-she has a diuretic medicine, but she doesn't take it , she said the doctor told her that she can take this medicine when the blood doesn't go down after taking polpril. could this medicine help?
4-what's your suggestion ?
NB: She doesn't have any symptoms such as chest pain, breathing difficulties , vertigo etc.

She also has severe coughing lately she coughs all night,
could one of the blood pressure medications causing this coughing ? as i remember ACE inhibitors cause this coughing in some patient, what do u suggest on that as well?


Thanks

doctor
Answered by Dr. Ilir Sharka 1 hour later
Brief Answer:
I would explain as follows:

Detailed Answer:
Hello!

Welcome and thank you for asking on HCM!

Regarding her swollen legs, I would explain that it could be related to venous insufficiency in her lower limbs (also called varicous edema). This is the most probable cause of this leg swelling as it occurs in the end of the day, after a day full of activity, in which she has not lied down.

From the other hand you should know that leg swelling could be a sign of fluid retention (caused in heart failure, kidney or liver dysfunction, etc.). But the fact that she is an active person and has been all the day walking without shortness of breath, indicates that heart failure or kidney and liver dysfunction are less probable.

So some tests are needed to examine for the possible cause:

- a cardiac ultrasound to examine her cardiac structure
- some blood lab tests (complete blood count, PCR, sedimentation rate for inflammation, kidney and liver function tests, blood electrolytes, fasting glucose)
- A Doppler ultrasound of the leg vessels to examine for possible venous insufficiency.

The best thing to do in case of venous insufficiency is raising her legs up for some hours, in order for the extravased fluid to go away (she should put a pillow under her legs when lying down).

If cardiac tests or other tests are abnormal, and fluid retention is the cause of her symptoms, a diuretic would be helpful.

Regarding the fact that her doctor has told her that her muscles of the leg are breaking down, I would not consider it exactly like this. The fact that she has been walking a lot indicates that her legs are strong enough for this. Elderly people tend to understand partially medical diagnosis. The doctor may have meant arthritis (as inflammation on her joints).

She is also taking rivastigmin, which is a drug helpful in dementia. So you should not take for sure everything she says. Maybe she has misunderstood the doctor or maybe she does not remember exactly what he has told her.

Regarding the cough during the night, it could be relate to different causes:

- allergic reaction
- heart failure
- chronic bronchitis
- gastro-esophageal reflux

Polpril, also called ramipril is an ACE ihibitor, which can cause cough too.

Hope you will find this answer helpful!

Kind regards,

Dr. Iliri


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 4 hours later
Yes it's most probably varicose edema. Since she shows now symptoms of heart,kidney,liver failure, I also haven't seen any sign of pitting edema... She recently told me that she was told to wear tights which is suggestive that she was diagnosed with varicose edema back in her country (Poland)....

Her insurance doesn't work here in Emirates, so I'm not sure if we will be able to take her to hospital here and as long as it doesn't seem that serious we can leave it like this and follow your suggestion by using pillow under he legs when lying or sleeping and see if there is any betterment of the swelling..

Few reassuring questions if you don't mind

1. can she take the diuretic medicine(indampidum 1.5mg) that she has now together with polpril and other medications to see if that will help with reducing the edema or might that cause the blood to go further down leading to hypotension
2. Or can she take the diuretic alone without polpril?
3. If the symptom of coughing that she has is related to ace inhibitors drug she is taking is there an aalternative drug which is not ace inhibitor that we can change for her?


Thanks again
doctor
Answered by Dr. Ilir Sharka 1 hour later
Brief Answer:
My answer as follows:

Detailed Answer:
Hello again!

I would explain as follows:

1. In venous insufficiency diuretics are not really helpful. This is not a fluid retention, but just extravasation of plasma in the soft tissues of the leg, due to accumulation of blood in the leg veins, which are not able to pump the blood into the heart. Diuretics may cause the blood pressure to go down or even cause dehydration or electrolytes imbalances in this case.

I would recommend holding legs in elevated position (she can use a pillow under her legs when lying down or sitting, in order to hold the legs in a higher level and help blood go passively into the central veins).

Compression socks would also be helpful. She should hold them during the day.

2. Regarding polpril, I would recommend to gradually stop it and switch into an ARB drug (valsartan, telmisartan,etc.) which have similar pharmacological mechanisms, but do not cause cough as an adverse effect.

Hope to have been helpful!

Best wishes!

Dr. Iliri


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 41 minutes later
This was so helpful , thanks for the well detailed answers. truly appreciate it . as i'm also enjoying reading your answers being medical student.
we will start as you suggested and if things doesn't work we will go to hospital to do the tests you recommend .

last questions before i close this discussion and review.

She told me that she had the cough for almost 2 months now and she done X-ray and other tests to know the possibility of lung infections or other respiratory problems but all turned out negative. so this way i think we can rule out chronic bronchitis..

1.before i start changing medication for her can i rule out possibility of allergies by giving her over the counter anti-histamines ? or would that not really help with coughing ?
one last point i forgot to mention, she used to take pantoparazole before but she stopped taking it because she forgot to get it... again a suggestive she might be having gastroesophogeal reflux as you stated before.

2.you said to gradually change to ARB drugs do you mean to slowly reduce the dosage of polpril before we completely change it ?

3.if i change for her to ARB drugs such as valsartan, telmisartan etc, should i change it to the same dosage she is taking in polpril i,e 10mg.

4.In Emirates we have drug called Exforge... Exforge contains a combination of amlodipine and valsartan.
5 mg/80 mg
5 mg/160 mg
10 mg/160 mg

my fathers mother takes the 10mg/160mg one and i think it's most popularly used in emirates. could this drug be a good alternative?


Thanks a lot again
doctor
Answered by Dr. Ilir Sharka 2 hours later
Brief Answer:
My opinion:

Detailed Answer:
Hello again!

Here are my answers to your questions:

1. Yes you can try a histamine before sleep. If she is quiet during the night this would indicate probable allergies as the cause of the cough.

2. I would also recommend taking PPI as she has taken it before. Pantoprazole could be helpful to relieve cough during the night related to gastro-esophageal reflux.

3. If the above tips are not helpful, and she keeps coughing during the night, i would recommend stopping polpril and taking valsartan 80mg instead in the morning. You can not do a gradual reduce of polpril and gradual increase of valsartan, as these drugs can not be taken together because have similar pharmacological mechanisms. So it is safe to switch directly from one dose of polpril to the other dose of valsartan.

If her blood pressure is above 135/80 mm Hg you can increase the dose of valsartan.

Regarding exforge I would not recommend it in this case. You should know that amlodipine, present in exforge is a calcium channel blocker, which can cause leg swelling as a adverse effect and would aggravate her problems.

Hope you will find this answer helpful!

Wish you have learned something which will be useful in your future profession!

You can ask me directly at any time for any other uncertainties or if you need any other information on my personal link:

http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=69765

Best wishes,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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