1. An approach to a child with oedema
Dr.Nada Ali

2. 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

3. 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.

4. 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

5. 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

6. 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 RBC/hpf WBC/hpf 2-5 RBC casts/hpf 2-5 Granular casts/hpf
What is the most likely diagnosis?

7. 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

8. Third case 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
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.

9. 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?

10. Third case: further investigation
Bilateral edema and tender R hypochondrium.
Ultrasound of the abdomen:
Thickened Gall Bladder wall
Mucocoele

11. 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.

12. Fourth case What is the diagnosis? 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?