an approach to a child with oedema
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An approach to a child with
oedema
Pushpa Raj Sharma
Professor of Child HealthInstitute of Medicine
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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
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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.
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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.
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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
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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
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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?
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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
The most likely diagnosis is
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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
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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?
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Third case: further investigation Bilateral edema and
tender Rhypochondrium.
Ultrasound of theabdomen:
Thickened Gall Bladderwall
Mucocoele
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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.
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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?
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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.
The most likely diagnosis is
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