edema Kirila Flashcards
Determine symptoms that the patient presents with/complains of/admits to on review of systems, that correlate with edema or an underlying cause
- Leg swelling – unilateral vs bilateral and extent • Dyspnea
• Orthopnea
• Paroxysmal Nocturnal Dyspnea
• Chest pain, indigestion
• Weight changes – gain or loss
• Skin, hair, nail changes
• GI changes suggesting malabsorption or thyroid disorder • Frothy urine – may indicate proteinuria
Distinguish edema from tissue swelling
Definitions – Edema
• Abnormally large amounts of fluid in intercellular spaces – various types and classifications
• Localized such as due to venous obstruction or lymphatic obstruction
• Generalized as seen with systemic causes such as heart failure and renal
disease – however may be first apparent in lower extremities due to gravity
• May be classified according to region as in Ascites regarding fluid in the peritoneal cavity, Hydrothorax with fluid in the pleural cavity or Hydropericardium (aka pericardial effusion) in the pericardial sac
• Anasarca: massive generalized edema
Definitions – Swelling
• Transient abnormal enlargement or increased volume of a body part or body area – seen with increased engorgement in tissues due to increased blood volume in dilated vessels
• Transient eminence or elevation – such as seen with local inflammatory reaction to insect bites or immunization injections
Pitting vs non-pitting edema
- Non-pitting:
- No appreciable indentation when pressure applied
- Due to underlying metabolic disease such as thyroid (Myxedema) or lymphatic system disease
- Can be associated with warm weather
• Pitting –
-associated with underlying organ dysfunction • Heart
• Kidney • Liver
Distinguish among Lymphedema, Lipedema, and other types of edema and potential combinations
Lymphedema: impaired fluid return in the lymphatic system due to hereditary or secondary causes including crush injuries and tropical infections (filarial)
- Lipidema: fat cells grow and proliferatefluid retention around the cells
- Can be localized or generalized as seen with morbid obesity
Differentiate location and distribution of edema based on patient’s history in addition to physical findings on exam
Most commonly first noticed in lower extremities due to gravity or periphery (hands and feet) due to decreased venous return for a variety of reasons
• Helpful if patient’s baseline weight is known prior to onset of edema
• Signs of CHF (Congestive Heart Failure) • Exertional dyspnea
• Orthopnea
• Paroxysmal dyspnea
• S3 on cardiac exam
• Bilateral crackles on lung exam
Generate a differential diagnosis for edema focusing on the potentially life-threatening and the most common
- Congestive Heart Failure: clinical diagnosis which may be acute exacerbation of CHF superimposed on long-standing stable chronic CHF
- Underlying causes include myocardial ischemia/infarction
- Pulmonary edema is the advanced form of CHF
- If dyspnea is primary symptom, consider pulmonary embolism or pneumonia
- Nephrotic syndrome
- Venous stasis, dependent edema due to gravity/sedentary activity
Differential Diagnosis (Diff Dx)
- Bilateral leg edema – venous or lymphatic causes
- Venous obstruction
- DVT (Deep Vein Thrombosis) can be bilateral or unilateral
- Pelvic or retroperitoneal lymphadenopathy or mass (even profound constipation can have a mass-like effect)
- Venous insufficiency
- Lymphatic obstruction (Lymphedema) – primary or secondary
- Unilateral limb edema
- Same as bilateral above
- Lymphedema secondary to neoplasm, surgery, radiation, tuberculosis, filariasis • Cellulitis
- Baker cyst
Determine extrinsic factors that are contributing to edema
Sodium intake – increased salt intake causes increased water retention
• Sedentary lifestyle
• Gravity causes increased dependent fluid accumulation • Decreased venous return due to sub-optimal muscle use
• Increased calorie intake • Weightgain
• Decreased venous return
• NSAID (Non-Steroidal Anti-Inflammatory Drug) use especially high doses &/or
prolonged use – can result in Acute Interstitial Nephritis and Nephrotic Syndrome
• Other medications (see differential diagnosis slides)
• Excess alcohol intake
• Cirrhosis and liver failure resulting in ascites
Prioritize diagnostic testing to evaluate edema
complete history and physical CMP TSH CBC CRX-PA ECG Echo BNP ANP
Revise differential diagnosis of edema based on changes in patient presentation and/or results of diagnostic testing
- If diagnostics inconclusive, may need to revisit H&P
- Consider additional lab
- Antinuclear antibody for possible underlying rheumatologic process • Hepatitis B and C serology
- Serum and urine protein electrophoresis
- Renal ultrasound
- Possible renal biopsy
