سيمنارات

An approach to a child with oedema

Dr.Nada Ali Prof. pediatrics

Oedema: accumulation excess interstitial fluid

Increased hydrostatic pressure Acute nephritic syndrome Congestive cardiac failure Decreased plasma oncotic pressure Protein calorie malnutrition, Nephrotic syndrome; protein loosing enteropathy Increased capillary leakage Allergy, sepsis, angiooedema. Impaired venous flow Vanacaval obstruction, hepatic vein obstruction Impaired lymphatic flow Congenital lymphedema, Wuchereria bancrofti infection

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

The most likely diagnosis is

Urine examination

Chemical/Physical Analysis Color:Yellow’ Blood:Moderate;Clarity:Hazy;pH:6.5Glucose:Negative;Protein:300mg/dL;Ketones:NegativeSpecific Gravity:1.015 ;Nitrite:NegativeMicroscopic 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

12 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: 40C 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: 12 kg; Ht: 100cms. Serum protein: 1.5G/dL; Urine normal
What is the diagnosis?