Symptom: Ankle Swelling

Initial Grading Reminder

CTCAE grading of limb edema:

Grade 1 (Mild): 5-10% inter-limb discrepancy; swelling or obscuration of anatomic architecture on close inspection
Grade 2 (Moderate): >10-30% inter-limb discrepancy; readily apparent obscuration of anatomic architecture; obliteration of skin folds; limiting instrumental ADLs
Grade 3 (Severe): >30% inter-limb discrepancy; gross deviation from normal anatomic contour; limiting self-care ADLs

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Do you have any joint, kidney, or cardiac problems? Have you ever had a deep venous thrombosis (blood clot)? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly? Is the swelling persistent or just at the end of the day? Is it one or both ankles? Is it painful? Have you ever had this before?

One ankle and/or pain would be more consistent with arthralgia/arthritis or DVT. Both ankles would be more consistent with kidney (nephritis) or cardiotoxicity.

Grade the symptom

Ask the patient:

How bad is the swelling? Is your ankle usually swollen? Can you see your ankle(s)? Are you having trouble getting your regular shoes on?  Can you flex your foot up and down without it being painful or uncomfortable? Is the skin tight/tense? Are you able to carry out your normal activities?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Can you put weight on your ankle(s)?

Are you having any changes in urination? Are you swollen elsewhere? Do you have any nausea, vomiting? Are you confused or foggy? Any shortness of breath/dyspnea on exertion?

Any new or worsening fatigue? Does your heart feel like it is racing or skipping a beat? Are you having chest pain?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

  • Click Here for Telephone Triage

    Suggested Intervention

    If the swelling is moderate or severe, the patient should be seen within 1 day. If there is new or worsening shortness of breath or any chest pain is also present, the patient needs to be seen immediately.

  • Click Here for In-Office Triage

    Nursing Assessment of Potential Causes

    Nephritis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Does the patient look ill?
    • Has there been change in urination?
      • Urine color?
      • Frequency?
    • How much fluid is the patient taking in?
    • Are associated symptoms present?
      • Nausea?
      • Headache?
      • Malaise?
      • Lung edema?
    • Are there symptoms indicative of:
      • Urinary tract infection?
      • Pyelonephritis?
      • Worsening CHF?
    • Are symptoms limiting ADLs?
    • Current or recent use of nephrotoxic medications (prescribed and OTC), other agents?
      • NSAIDs
      • Antibiotics
      • Contrast media or other nephrotoxic agents (contrast dye, aminoglycosides, PPI)?
    • Laboratory abnormalities (elevated creatinine, electrolyte abnormalities)
    • Urinalysis abnormalities (casts)
    • Abdominal or pelvic disease that could be causing symptoms
    • Prior history of renal compromise?
    • Other immune-related adverse effects?
    • Presence of current or prior immune-mediated toxicities, including rhabdomyolysis
    • Is patient volume depleted?

    Arthralgias and Arthritis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Does the patient appear unwell?
    • Is gait affected?
    • Obvious swollen or deformed joint(s)?
    • Is the patient having trouble getting up and down stairs?
    • Have symptoms worsened?
    • Are symptoms limiting ADLs?
    • Are symptoms increasing the patient’s risk for fall? Other safety issues?
    • Associated symptoms?
      • Fatigue (new or worsening)
    • Is there a pre-existing autoimmune dysfunction?
    • Is there a history of prior orthopedic injury, DJD, OA, RA?
    • Other immune-related adverse effects
    • Three subtypes of inflammatory arthritis associated with checkpoint inhibitors:
      1. Polyarthritis similar to rheumatoid arthritis
      2. True reactive arthritis with conjunctivitis, urethritis, and oligoarthritis
      3. Subtype similar to seronegative spondyloarthritis with inflammatory back pain and predominantly larger joint involvement

    Cardiotoxicity - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient look unwell?
    • Fatigued?
    • Diaphoretic?
    • SOB or in respiratory distress?
    • Is there leg edema?
    • Change in energy level?
    • SOB or DOE?
    • Leg edema?
    • Palpitations?
    • Changes in BP?
    • Dizziness or syncope?
    • What exacerbates or improves symptoms?
    • Any new prescribed or OTC meds? Illicit substances?
    • Any underlying cardiac disease (CAD, MI, or other)?
    • What exacerbates or improves symptoms?
    • Prior radiation therapy?
    • Determine specific toxicity and related grade (if applicable)
    • Other related symptoms: hypotension, syncope, chest pain, DOE, SOB, palpitations, edema, etc.
    • Impact of symptoms on QOL/performance status
    • Changes in cardiac function: ECG changes, decreased EF, elevated cardiac enzymes (troponin, CK)
    • Assess other changes in oxygen saturation, BP, lung function

    Differential Diagnosis

    What do you suspect is the cause of the ankle swelling?