Leg Swelling History Taking – OSCE Guide

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Taking a comprehensive leg swelling history is an important skill often assessed in OSCEs. This guide provides a structured framework for taking a history from a patient with leg swelling in an OSCE setting.


Fluid is filtered from the microvasculature into the interstitial tissues and is returned to the systemic circulation via the lymphatic system. The movement of the limbs promotes fluid entry into the lymphatic system.

If there is an imbalance between filtration and lymphatic drainage, fluid accumulates in the interstitial space, resulting in swelling. This commonly affects the lower limbs due to gravity. The term lymphoedema is used when decreased lymphatic drainage is the predominant problem, whilst the term oedema is used when the primary cause is excess fluid being filtered into the interstitial space.

Lymphoedema may be caused by reduced mobility, damage or obstruction to the lymphatic system, or medications.

Oedema may be caused by:

  • Increased hydrostatic pressure in the microvasculature: due to local causes (deep vein thrombosis, cellulitis, inflammation, trauma, chronic venous insufficiency) or systemic causes (heart failure or cor pulmonale). It can also be due to a pelvic mass which increases hydrostatic pressure by obstructing venous return.
  • Reduced colloid osmotic pressure in the microvasculature: due to hypoalbuminaemia secondary to nephrotic syndrome, liver cirrhosis or severe malnutrition.
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Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

  • Demonstrating empathy in response to patient cues: both verbal and non-verbal.
  • Active listening: through body language and your verbal responses to what the patient has said.
  • An appropriate level of eye contact throughout the consultation.
  • Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
  • Making sure not to interrupt the patient throughout the consultation.
  • Establishing rapport (e.g. asking the patient how they are and offering them a seat).
  • Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
  • Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

  • “What’s brought you in to see me today?”
  • “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand on their presenting complaint if required:

  • “Ok, can you tell me more about the leg swelling?”
Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.

History of presenting complaint

Gather further details about the patient’s leg swelling using the SOCRATES acronym.


The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain but can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.


Ask if the leg swelling is unilateral (if so, which leg) or bilateral:

  • “Are both legs swollen, or just one leg?”

In bilateral swelling, the legs may be swollen to different degrees.

Unilateral leg swelling

Causes of unilateral leg swelling include:

  • Deep vein thrombosis (DVT): occlusion or partial occlusion by thrombus of one of the veins in the leg
  • Superficial thrombophlebitis (STP): occlusion or partial occlusion by thrombus of a superficial leg vein (most commonly the saphenous vein); the swelling is localised to the affected vein, which can help to distinguish it from the more generalised swelling seen with DVT
  • Cellulitis: infection of the soft tissues (most commonly affects the leg below the knee). The infecting organism (most commonly Streptococcus pyogenes or Staphylococcus aureus) may be introduced via an open wound on the leg or foot, or from splits in the skin caused by tinea pedis (athlete’s foot)
  • Baker’s cyst: accumulation of synovial fluid in the popliteal space can cause calf pain and swelling when it ruptures; it is a non-serious condition but is difficult to distinguish clinically from a DVT
  • Dysfunction of the lymphatic system (affecting one leg): may be congenital, or secondary to malignancy affecting the lymph nodes, surgical removal of inguinal lymph node(s), or trauma.
  • Inflammatory reactions: insect bites and stings
  • Trauma (can be minimal): soft tissue injury, ruptured Achilles tendon
Bilateral leg swelling

Causes of bilateral leg swelling include:

  • Congestive cardiac failure and cor pulmonale
  • Chronic venous insufficiency: incompetent valves in the veins of the legs cause venous reflux and persistent elevation of pressure in the veins
  • Dysfunction of the lymphatic system (affecting both legs): may be congenital or secondary to malignancy affecting the lymph nodes, surgical removal of inguinal lymph node(s), or trauma.
  • Increased hydrostatic pressure: can be caused by a pelvic mass (e.g. ovarian tumour); the size of the uterus from the second trimester of pregnancy onwards has a similar effect
  • Conditions which cause hypoalbuminaemia, such as nephrotic syndrome, liver cirrhosis and severe malnutrition
  • Decreased mobility may cause dependent oedema due to reduced fluid passage through the lymphatic system
  • Medications: calcium channel blockers (e.g. amlodipine) cause decreased lymphatic drainage; non-steroidal anti-inflammatory drugs (NSAIDs) cause fluid and salt retention


Clarify how and when the swelling developed:

  • “When did the leg swelling start?”
  • “Did it start suddenly or develop slowly?

The onset of leg swelling may suggest different underlying causes:

  • Onset over minutes to hours is seen with inflammatory reactions and trauma
  • Onset over hours to a few days is suggestive of DVT/STP, cellulitis or rupture of a Baker’s cyst
  • Onset over weeks to months indicates more chronic pathology, such as hypoalbuminaemia, heart failure or cor pulmonale, chronic venous insufficiency, lymphatic dysfunction, or a pelvic mass.


Ask about the specific characteristics of the leg swelling:

  • Is the swelling pitting (a dimple remains after the skin is pressed with a finger) or non-pitting?

Chronic venous insufficiency and chronic lymphoedema cause fibrosis and non-pitting oedema, while other causes are associated with pitting oedema.


Ask about the progression of the leg swelling:

  • “Where in the leg did the swelling first start?”
  • “Did the leg swelling start in a specific place?”
  • “Has the swelling moved anywhere else?”

Swelling starting at the knee and moving distally into the calf and foot suggests a ruptured Baker’s cyst. Other knee pathology, such as arthritis of any type, gout or pseudogout can also cause swelling which moves down into the lower leg due to gravity.

Swelling starting in the foot or lower leg and moving proximally (possibly as high as the thigh) is seen with DVT, lymphatic dysfunction, pelvic mass, heart failure/cor pulmonale, chronic venous insufficiency hypoalbuminaemia, oedema secondary to immobility and medication side effects. Pathology in the joints of the foot or ankle (e.g. arthritis, gout, ruptured Achilles tendon) can also cause swelling that moves up into the leg.

Swelling which starts in a localised area and spreads outwards is seen in cellulitis, STP, trauma and inflammatory reactions.

Associated symptoms

Ask if there are other symptoms which are associated with the leg swelling:

  • “Are there any other symptoms associated with the leg swelling?” 

Specifically, ask about pain in the leg:

  • Acute pain suggests cellulitis, DVT/STP, a ruptured Baker’s cyst, or an inflammatory reaction
  • Chronic, aching pain and heaviness occur in chronic venous insufficiency
  • Other causes of leg swelling are painless

Other important associated symptoms to ask about include:

  • Erythema is seen in cellulitis, DVT/STP, ruptured Baker’s cyst and inflammatory reactions
  • Itching suggests a reaction to a bite or sting
  • Fever suggests cellulitis (septic arthritis should also be considered if the swelling originated around a joint)
  • Weight loss, back pain and urinary urgency may suggest a pelvic malignancy; in women, there may be abnormal vaginal bleeding or discharge
  • Shortness of breath, particularly when lying flat, is seen in heart failure and cor pulmonale
  • Patients may report frothy urine in nephrotic syndrome due to proteinuria, and more generalised oedema
  • In liver cirrhosis, other symptoms may include jaundice, ascites and easy bruising

Time course

Clarify how the leg swelling changes over time:

  • “Is the swelling there all the time, or does it come and go?”

Exacerbating or relieving factors

Ask if anything makes the leg swelling worse or better:

  • “Does anything make the leg swelling worse?”
  • “Does anything make the leg swelling better?”

Swelling which improves with elevation of the legs (e.g. whilst the patient is in bed overnight) suggests the primary problem is excess interstitial fluid. If the swelling is constant, this indicates a problem with lymphatic drainage.

Ask whether the swelling has coincided with the initiation of new medications.  



Wells score for DVT

When a DVT is suspected, the two-level DVT Wells score is used to assess the condition’s pre-test probability and guide further investigations. The score should not be used for pregnant women or those in the first six weeks postpartum, as these patients should all be referred for same-day assessment.

Clinical feature Points
Active cancer (currently receiving treatment or treatment within 6 months or palliative) 1
Paralysis, paresis or recent plaster immobilisation 1
Recently bedridden (3 days or more), or major surgery within the last 3 months 1
Localised tenderness along the distribution of the deep venous system 1
Entire leg swollen 1
Calf swelling at least 3cm larger than the asymptomatic side 1
Pitting oedema in the symptomatic leg 1
Collateral superficial veins (non-varicose) 1
Previously documented DVT 1
An alternative diagnosis is at least as likely as DVT -2

* if both legs are symptomatic, the more symptomatic leg should be used

Remember the rule of 3s:

  • Bedridden for 3 days
  • Surgery in the last 3 months
  • Leg 3cm larger

A DVT is considered likely if the score is two points or more and unlikely if the score is one point or fewer.

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideasconcerns, and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more naturalpatient-centred, and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.


Explore the patient’s ideas about the current issue:

  • “What do you think the problem is?”
  • “What are your thoughts about what is happening?”
  • “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”


Explore the patient’s current concerns:

  • “Is there anything, in particular, that’s worrying you?”
  • “What’s your number one concern regarding this problem at the moment?”
  • “What’s the worst thing you were thinking it might be?”


Ask what the patient hopes to gain from the consultation:

  • “What were you hoping I’d be able to do for you today?”
  • “What would ideally need to happen for you to feel today’s consultation was a success?”
  • “What do you think might be the best plan of action?


Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.

Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.


Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far“Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next“Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”

Systemic enquiry

systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

Some examples of symptoms you could screen for in each system include:

  • Systemic: fever, unintentional weight loss
  • Cardiovascular: chest pain, palpitations
  • Respiratory: shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea
  • Gastrointestinal: features of liver disease (e.g. jaundice, abnormal bruising, abdominal distension) or pelvic malignancy (abdominal bloating, pain, change in bowel habit)
  • Genitourinary: frothy urine (nephrotic syndrome), urinary urgency and/or frequency (pelvic mass); in women, ask about abnormal vaginal bleeding or discharge

Past medical history

Ask if the patient has any medical conditions: 

  • “Do you have any medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”

Ask if the patient has previously undergone any surgery (e.g. lower limb surgery, pelvic surgery, cancer surgery):

  • “Have you ever previously undergone any operations or procedures?”
  • “When was the operation/procedure, and why was it performed?”

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Examples of relevant medical conditions

Relevant medical conditions in the context of leg swelling include:

  • History of DVT/PE: may increase the risk of further thrombotic events; past DVT is also a cause of chronic venous insufficiency
  • Cardiovascular disease, such as myocardial infarction (increases the risk of heart failure)
  • Chronic respiratory conditions, such as COPD (increases risk of cor pulmonale)
  • Peripheral vascular disease or varicose veins
  • Malignancy, including surgery for any previous malignancy.
  • Conditions which increase the risk of infection (e.g. diabetes mellitus)
  • Musculoskeletal conditions, such as arthritis, gout and pseudogout
  • Liver disease
  • Renal disease
  • Eating disorders (risk of malnutrition)


Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications, document the medication namedosefrequencyform and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”
  • “Do you think your leg swelling started after you began taking any of your current medications?”
Medication examples

Medications which increase the risk of DVT include:

Amlodipine, prescribed for hypertension, commonly causes oedema of the lower limbs.

NSAIDS (e.g. ibuprofen and naproxen) cause salt and fluid retention, leading to peripheral oedema

Quinolone antibiotics (e.g. ciprofloxacin) increase the risk of tendon rupture.

Medications which increase the risk of infection include corticosteroids (e.g. prednisolone) and disease-modifying anti-rheumatic drugs (e.g. methotrexate).

Medications which patients may already be taking for leg swelling include:

  • Anticoagulants for previous thromboembolic events (e.g. rivaroxaban, apixaban or warfarin)
  • Loop diuretics for oedema (e.g. furosemide, bumetanide)

Family history

Ask the patient if there is any family history of lymphoedema, malignancy, venous thromboembolism (DVT/PE) or cardiovascular disease.

  • “Do any of your parents or siblings have any medical conditions?” 

Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic factors).

If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death:

  • “I’m really sorry to hear that, do you mind me asking how old your dad was when he died?”
  • “Do you remember what medical condition was felt to have caused his death?”

Social history

General social context

Explore the patient’s general social context including:

  • the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
  • who else the patient lives with and their personal support network
  • what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
  • if they have any carer input (e.g. twice daily carer visits)


Record the patient’s smoking history, including the type and amount of tobacco used.

Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk profile:

  • pack-years = [number of years smoked] x [average number of packs smoked per day]
  • one pack is equal to 20 cigarettes

See our smoking cessation guide for more details.

Smoking increases the risk of DVT, cardiovascular disease and chronic venous insufficiency.


Record the frequencytype and volume of alcohol consumed on a weekly basis.

See our alcohol history taking guide for more information.

Excess alcohol consumption increases the risk of liver cirrhosis.

Recreational drug use

Ask the patient if they use recreational drugs and if so, determine the type of drugs used and their frequency of use. Intravenous drug use is a risk factor for DVT.

Fluid intake

Patients with poor fluid intake are at increased risk of DVT due to dehydration.


Ask about the patient’s current occupation and how their symptoms impact their ability to perform their role.

Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


  • BMJ Best Practice. Assessment of peripheral oedema. Available from: [LINK]
  • NICE CKS. Superficial thrombophlebitis. Available from: [LINK]
  • NICE CKS. Deep vein thrombosis. Available from: [LINK]


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