an approach to a child with oedema pushpa raj sharma professor of child health institute of medicine
TRANSCRIPT
An approach to a child with oedema
Pushpa Raj Sharma
Professor of Child Health
Institute of Medicine
Oedema: accumulation excess interstitial fluid Increased hydrostatic pressure
Acute nephritic syndromeCongestive cardiac failure
Decreased plasma oncotic pressureProtein calorie malnutrition, Nephrotic syndrome; protein loosing enteropathy
Increased capillary leakageAllergy, sepsis, angiooedema.
Impaired venous flowVanacaval obstruction, hepatic vein obstruction
Impaired lymphatic flowCongenital lymphedema, Wuchereria bancrofti infection
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.
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.
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
First case 4 year old girl, who
recently recovered from a sore throat, was brought to the OPD with symptoms of swelling of both feet. Physical examination reveals edema around the eyes and the ankle. A routine urinalysis reveals the following results.
The most likely diagnosis is
Urine examination
Chemical/Physical Analysis Color:Yellow’ Blood:Moderate;Clarity:Hazy;pH:6.5
Glucose:Negative;Protein:300mg/dL;Ketones:Negative Specific Gravity:1.015 ;Nitrite:Negative Microscopic Analysis
20-50 RBC/hpf 10-20 WBC/hpf 2-5 RBC casts/hpf 2-5 Granular casts/hpf
What is the most likely diagnosis?
Second case 5 year male child Swelling first noticed
around eyes. No history of shortness
of breath; fever; cough; jaundice; umbilical infection; no dark colored urine.
Height: 110cms; Wt: 18kg; liver not enlarged; Ascites present
The most likely diagnosis is
Third case
!2 year male from Pokhara; arrived after traveling by bus for 12 hours.
History of fever Upper abdominal pain Dark colored urine No past history of sore
throat, rash, joint pain diarrhea, 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
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?
Third case: further investigation Bilateral edema and
tender R hypochondrium.
Ultrasound of the abdomen: Thickened Gall Bladder
wall Mucocoele
Third case :Final diagnosis and pathophysiology Edema: increased hydrostatic pressure due
to gravitational effect from prolonged leg hanging.
R. Hypochondrium pain and fever: cholecystitis and mucocele of gall bladder (ultrasound supported)
Edema subsided on the next day after admission.
Fourth case
5 year male child Swelling started from limb :
one month No history of cough,
shortness of breath, cyanosis, jaundice, dark colored urine, umbilical infection.
Persistent diarrhea +. Irritable; wt: 6 kg; Ht:
100cms. Serum protein: 1.5G/dL; Urine normal
What is the diagnosis?What is the diagnosis?
Fourth case 6 year female child Swelling both feet for
10 days. History: shortness of
breath off and on for1 year, joint pain; palpitation; low urine output; fever with rigor
Tachypnoea; pyrexial, propped-up; raised JVP, enlarged liver and spleen; urine shows RBC.
The most likely diagnosis is