An Approach to a Child With Oedema

8/2/2019 An Approach to a Child With Oedema

1/14

An approach to a child with

oedema

Pushpa Raj Sharma

Professor of Child HealthInstitute of Medicine


2/14

Oedema: accumulation excess interstitial fluid Increased hydrostatic pressure

Acute nephritic syndromeCongestive cardiac failure

Decreased plasma oncotic pressure

Protein calorie malnutrition, Nephrotic syndrome; proteinloosing enteropathy

Increased capillary leakageAllergy, sepsis, angiooedema.

Impaired venous flowVanacaval obstruction, hepatic vein obstruction

Impaired lymphatic flowCongenital lymphedema, Wuchereria bancrofti infection


3/14

Entry questions and

threading questions

Sensitivity

Specificity

Understandable

Open ended

Leading

Short

Acceptable

Entry questions:

Enters into the organ/system

Threading question Enters into the specific

aetiology.


4/14

Examples for formulation of questions

Localized oedema

Insect bite; trauma; skin infections

Kwashiorkar (bilateral pedal)

Superior vanacaval obstruction

Lymphatic obstruction Orthostatic

Generalized oedema

Renal:periorbital; hematuria; hypertension;symptoms of collagen disease (rash, joint pain);frothy urine; symptoms of uraemia (vomiting,nausea, pallor), convulsion, low urine output.


5/14

Examples for formulation of questions

Cardiac: orthopnoea, joint pain; palpitation;giddiness; fainting episodes; bluish episodes;

Protein energy malnutrition: low calorie and

protein in the diet for long; precipitating factors(persistent diarrhea, chronic illnesses)

Hepatic: Jaundice; ascites; prominent abdominal

veins; neonatal umbilical sepsis; spleenomegaly;purpura

Collagen diseases: fever, rash, joint pain, pallor


6/14

First case

4 year old girl, whorecently recovered froma sore throat, wasbrought to the OPDwith symptoms of

swelling of bothfeet. Physicalexamination revealsedema around the eyes

and the ankle. Aroutine urinalysisreveals the followingresults.

The most likely diagnosis is


7/14

Urine examination

Chemical/Physical AnalysisColor:YellowBlood:Moderate;Clarity:Hazy;pH:6.5

Glucose:Negative;Protein:300mg/dL;Ketones:Negative

Specific Gravity:1.015 ;Nitrite:Negative Microscopic Analysis

20-50 RBC/hpf10-20 WBC/hpf

2-5 RBC casts/hpf2-5 Granular casts/hpf

What is the most likely diagnosis?


8/14

Second case 5 year male child

Swelling first noticedaround eyes.

No history of shortnessof breath; fever; cough;

jaundice; umbilicalinfection; no darkcolored urine.

Height: 110cms; Wt:

18kg; liver notenlarged; Ascitespresent



9/14

Third case

!2 year male fromPokhara; arrived aftertraveling by bus for 12hours.

History of fever

Upper abdominal pain

Dark colored urine

No past history of sorethroat, rash, joint paindiarrhea, trauma.

Comfortably lying flat in

bed Oral temp: 102.0

Respiratory rate: 28.min

Bilateral pedal edema, non

tender

Absence of Jaundice

Weight: 38 Kg.

Chest: normal Abdomen: Tender R hypo.

No free fluid


10/14

Third case: Normal blood count

Urine: routine normal Liver function: normal

X-ray chest: normal

What causes we have excluded?Increased hydrostatic pressure?

Decreased plasma oncotic pressure?

Increased capillary leakage?Impaired venous flow?

Impaired lymphatic flow?


11/14

Third case: further investigation Bilateral edema and

tender Rhypochondrium.

Ultrasound of theabdomen:

Thickened Gall Bladderwall

Mucocoele


12/14

Third case :Final diagnosis and

pathophysiology

Edema: increased hydrostatic pressure dueto gravitational effect from prolonged leghanging.

R. Hypochondrium pain and fever:cholecystitis and mucocele of gall bladder

(ultrasound supported)

Edema subsided on the next day after admission.


13/14

Fourth case

5 year male child

Swelling started from limb :one month

No history of cough,

shortness of breath,cyanosis, jaundice, darkcolored urine, umbilicalinfection.

Persistent diarrhea +. Irritable; wt: 6 kg; Ht:

100cms. Serum protein:1.5G/dL; Urine normal

What is the diagnosis?


14/14

Fourth case 6 year female child

Swelling both feet for10 days.

History: shortness ofbreath off and on for1

year, joint pain;palpitation; low urineoutput; fever with rigor

Tachypnoea; pyrexial,propped-up; raised

JVP, enlarged liver andspleen; urine showsRBC.


Documents

An Approach to a Child With Oedema