Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Hematology > Approach to patient with oedema > Flashcards

Approach to patient with oedema Flashcards

1
Q

What is the definition of oedema?

A

clinically apparent increase in interstitial fluid volume

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the relevant hx to take in a patient with oedema

A

How long is the duration of the oedema?

  • Acute: think of DVT, ruptured Baker’s cyst, infection, compartment syndrome
  • Chronic (>72 hrs)

Is the edema painful?

  • Pain 🡪 red flag
  • Think of DVT, compartment syndrome, cellulitis, necrotising fasciitis, baker’s cyst, reflex sympathetic dystrophy
  • CVI may have low grade aching

Any diurnal variation?

  • Improve overnight? Think of venous cause > lymphatic cause
  • Intermittence? – common premenstrual symptom (treatment is not necessary)

Any history suggestive of systemic disease: cardiac, liver or renal?

Any history of pelvic or abdominal malignancy or radiation therapy?

Any intake of drugs associated with edema formation?

Pitting

  • Non pitting: lymphedema, (pretibial) myxoedema
  • Pitting: HF, CRF, Nephrotic Syndrome, CLD, Idiopathic edema

Travel history: Filariasis 🡪 travel to Malaysia, Indonesia, India 🡪 walking barefoot

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are the basic investigations conducted for patients with edema?

A
  1. FBC
  2. Urinalysis
  3. Serum creatinine, albumin
  4. TSH
  5. ECG
  6. Chest X Ray
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the basic investigations conducted for patients with edema if there are clinical suspicions?

A
  • DVT: D dimer, venous duplex scan
  • Cardiac disease: BNP, 2DEcho
  • Liver disease: ALT, AST, ALP, bilirubin, albumin, PT, US liver
  • Renal disease: UFeme, 24 hour urine protein, US kidneys
  • Pelvic malignancy: CT scan of abdomen and pelvis
  • CVI: Venous reflux study
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the differentials to acute unilateral LL swelling?

A

Cellulitis: erythematous, warm and tender limb, often associated with fever and raised inflammatory markers

Necrotising Fasciitis: systemic toxicity

DVT

  • Environmental: Recent surgery, prolonged bed rest, travel
  • Previous Hx of DVT
  • Coagulopathies, HRT, OCP use
  • Ai Diseases, APLS (DVT + Recurrent Miscarriages)
  • Diffusely swollen, warm, erythematous and tender leg. There may be low grade fever.

Compartment Syndrome (6Ps: Pain Pallor Poikilothermia Paraesthesia Paralysis Pulselessness)

Ruptured Baker’s cyst (history of rheumatoid arthritis, osteoarthritis, meniscal injury)

Ruptured medial head of gastronemius (history of sudden foot dorsiflexion)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the differentials to chronic unilateral LL swelling?

A

Chronic venous insufficiency: An aching, swollen leg worse at the end of the of the day, with varicose veins and venous skin changes.

Bilateral lymphedema: cutaneous and subcutaneous thickening

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the differentials to bilateral LL swelling with elevated JVP?

A

Congestive cardiac failure

Chronic kidney disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the differentials to bilateral LL swelling with normal JVP and low albumin?

A

Cirrhosis

Nephrotic syndrome

Protein losing enteropathy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the differentials to bilateral LL swelling with normal JVP and low albumin?

A

Thyroid

Drug induced edema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

[Bilateral edema] What are the common drugs associated with edema formation?

A

NSAIDs/ ACE-Is

  • reduce GFR
  • NSAIDs 🡪 inhibition of renal vasodilatory prostaglandins 🡪 increased renal sodium reabsorptio

Vasodiators

  • Calcium channel blockers
  • Hydralazine
  • Clonidine
  • Alpha blockers

OHGAs: rosiglitazone, pioglitazone (stimulate sodium reabsorption)
- Increases GLUT protein exp on muscle cells; induce insulin sensitisation

Steroids: glucocorticoids, anabolic steroids, estrogens and progestins 🡪 increases risk of DVT and thrombotic event

Cyclosporin

Methotrexate
- hepatotoxic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

[Bilateral edema] What are the clinical features pointing towards congestive cardiac failure?

How can it be worked up?

A
  • Chest pain, palpitations, SOB, exertional dypsnea, orthopnea and paroxysmal nocturnal dypsnea
  • Ischemic risk factors (HTN, HLD, DM, Smoking)
  • History of CAD/IHD, valvular heart disease, arrhythmias
  • acute precipitant of worsening fluid overload e.g. new MI, uncontrolled arrhythmia, non compliance to fluid restruction or intercurrent infection
  • CXR: cardiomegaly +/- pulmonary edema
  • ECG: prior infarction (e.g. q waves, poor R wave progression)
  • elevated NT- proBNP levels and echocardiac evidence of reduced ejection fraction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

[Bilateral edema] What are the clinical features pointing towards CKD, nephrotic syndrome?

A

Acute onset swelling, Frothy urine

History of renal disease, risk factors (DM, HTN)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

[Bilateral edema] What are the clinical features pointing towards hepatic (CLF)?

A

Jaundice

History of alcohol, drug abuse, hepatitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

[Bilateral edema] What are the clinical features pointing towards myxedema ?

A

Myxedema – a non-pitting edema

  • Due to deposition of GAGs in the dermis 🡪 draws water in
  • A dermatological change seen in Hypothyroidism (eg: Hashimoto’s Thyroiditis, long standing hypothyroid)
  • Hence a/w cold intolerance, weight gain, constipation, lethargy, dry skin

Pretibial Myxedema

  • Refers to Myxedema in the LL (the only form of myxedema in Hyperthyroid patient)
  • Hallmark of Grave’s
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

[Bilateral edema] What are the clinical features pointing towards pulmonary hypertension?

A 
Sleep apnea (STOPBANG)
Chronic lung disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

[Bilateral edema] What are the clinical features pointing towards hypoalbumin?

A

Diarrhoea (protein losing enteropathy)

Malnutrition

17
Q

[Unilateral edema, acute onset] What are the clinical features pointing towards DVT?

A

Swelling, pain, warmth (tenderness)

Edema, erythema: These findings can be found in v obvious pts, but in non obv patients, we look for at the gastrocnemius tendon (disappears in DVT)

Pulmonary embolism 🡪 fSOB
- Wells score ≥3 indicates likely DVT

Localized upper extremity edema may occur with upper extremity venous thrombosis

  • Feeling of fullness in the fingers or difficulty with finger rings feeling “too tight”
  • Can be spontaneous or catheter induced

Risk factors

  • Taking os steroids: Combined OCP or HRT
  • Immobilisation (eg. Plaster or paresis)
  • Long distance travel
  • Bedridden > 3 days
  • Active cancer
  • Pregnancy
  • Previous DVT/Family Hx
  • Major surgery within 4 weeks
18
Q

[Unilateral edema, acute onset] What are the clinical features pointing towards compartment syndrome?

A

6 Ps – Pain (tenderness), pulselessness(late sign), paraesthesia (pins & needles or even numbness), paralysis (late sign), pallor, poikilothermia

Aetiology: Trauma, burns, tight splints/casts, LL fracture, crush injury

19
Q

[Unilateral edema, acute onset] What are the clinical features pointing towards cellulitis?

A

Erythema, warmth, fever, tenderness of the leg swelling

Discrete area of symptoms

Aetiology
- Bacterial infection of the subcutaneous fat tissue via
trauma, penetrating injury, sepsis
- Can progress to necrotising fasciitis / abscess

20
Q

[Unilateral edema, acute onset] What are the clinical features pointing towards necrotising fasciitis?

A

Stage I presentation initially similar to cellulitis (+ presence of tenderness)

Stage II & III: blistering, skin necrosis, anaesthesia, crepitus

Risk factors: DM, peripheral vascular disease, IV drug use, alcoholism, surgery, abscess, immunosuppression

Infection: MRSA, Group A Strep (eg: Strep Pyogenes)

21
Q

[Unilateral edema, acute onset] What are the clinical features pointing towards baker’s cyst?

A

Swelling, pain (tenderness), warmth, erythema

What? Also known as a popliteal cyst 🡪 a benign swelling of the semimembranosus behind the knee

Aetiology: History of RA, OA, meniscal injury

22
Q

[Unilateral edema, chronic onset] What are the clinical features pointing towards pelvic mass?

A

LOA, LOW

Previous pelvic cancer

PV (per-vaginal) bleeding (post-menopausal or intermenstrual)

23
Q

[Unilateral edema, chronic onset] What are the clinical features pointing towards reflex sympathetic dystrophy?

A

AKA: Syndrome of pain (tenderness), swelling, vasomotor dysfunction post trauma / surgery

Presents with Painful extremity

24
Q

[Unilateral & bilateral edema, chronic onset] What are the clinical features pointing towards lymphedema

A

Previous lymph node dissection or radiotherapy, filariasis

Lead to fluid accumulation within tissue due to impaired drainage

Skin becomes darkened and thickened (cobblestone appearance)

  • Thickening occurs in cutaneous and subcutaneous tissues + cutaneous fibrosis
  • Leads to +ve Kaposi-Stemmer sign = skin on the dorsum of the second toe cannot be pinched as a fold by the fingers. This can also be performed on any other part of the body.
  • When positive, it confirms the presence of peripheral lymphedema

Hyperkeratosis + Brawny Induration of the skin

  • In Developed Countries: Most common reason: Axillary LN dissection (breast cancer) & Axillary/Inguinal LN dissection (melanoma)
  • In Developing Countries: Most common reason is Filiriasis – a parasitic disease caused by an infection with roundworms which occupy Lymphatics
25
Q

[Unilateral & bilateral edema, chronic onset] What are the clinical features pointing towards chronic venous insufficiency?

A

Skin changes (haemosiderin pigmentation, atrophy, hair loss, varicose/stasis eczema, varicose veins, ulceration)

Elderly patient, F>M, family hx, obesity, pregnancy, previous DVT or vein harvesting

Painless however will cause pain when DVT reoccurs

26
Q

What would you examine for generally in a patient with oedema?

A
  1. Body mass index: obesity associated with chronic venous insufficiency (CVI)
  2. Distribution of edema
  3. tenderness: DVT, cellulitis
  4. Pitting or non pitting
  5. Signs of systemic disease: heart failure, liver disease, renal failure
  6. Presence of varicose veins or stasis eczema suggestive of CVI
  7. Hyperkeratosis with brawny induration suggestive of lymphadema
  8. Kaposi- Stemmer’s sign: suggestive of lymphadema
27
Q

What is Well’s score?

A

Risk factors

  • Active cancer (or treated within 6 months): +1
  • Paralysis of recent lower limb immobilisation: + 1
  • Bedridden > 3 days or surgery within 4 weeks: +1

Physical findings

  • Swelling of entire leg: +1
  • Calf swelling > 3 cm, compared to the normal leg: +1
  • Pitting edema, greater than the normal leg: +1
  • Localised tenderness along the deep venous system: +1
  • Collateral superficial veins (not varicose veins): +1

Differential: Alternative differential as likely or more likely than DVT (-2)

Hematology (19 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions