35/F
Chief Complaint: Generalized Edema
What is your concept/perception of generalized edema?
Swelling all the whole body caused by water retention
What are “cues” for the presence of generalized edema?
Swelling of the face, especially the periorbital areas
Ascites
Bilateral pedal edema
If there is only swelling of the face, there is no ascites and bilateral pedal edema, is generalized edema present?
No
If there is only ascites, there is no swelling of the face and bilateral pedal edema, is generalized edema present?
No
If there is only bilateral pedal edema, there is no swelling of the face and ascites, is generalized edema present?
No
If there is ascites and bilateral pedal edema, there is no swelling of the face, is generalized edema present?
No
If there is swelling of the face and bilateral pedal edema, is generalized edema present?
Yes
How do you distinguish generalized edema from generalized obesity?
Pitting in edema Non-pitting in obesity
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What are the body system/organ that may be involved in patients with generalized edema?
Renal system
Nutritional system - hypoproteinemia
Cardiovascular system
Hepatic system
Endocrine system - hypothyroidism
Which among the systems mentioned above, if afflicted, usually present more with generalized edema rather than localized edema?
Renal system
Nutritional system
Endocrine system
Among the 3 systems mentioned above, rank them as to prevalence in a 35-year-old female patient?
Renal system
Endocrine system
Nutritional system
What will you do now to diagnose the patient’s health problem?
Check if generalized edema is really present by looking for the “cues” for generalized edema.
Swelling of the face with evident periorbital edema and bilateral pedal edema are present.
Although the abdomen is globular, no definite fluid wave can be elicited. With a presumptive diagnosis of generalized edema being present, what will you do now in terms of clinical diagnosis?
Determine the etiology of the generalized edema.
Whether it is acute or chronic.
Whether it is due to problems in the renal system, endocrine system, or nutritional system.
How do you determine whether the generalized edema is acute or chronic?
By asking for the noticeable onset.
Less than one month - acute????????
More than one month - chronic
You ask for the onset, the answer is 3 months. Is this acute or chronic in onset?
Chronic.
What are more common causes of acute generalized edema? Give systems involved and cite specific disorders and diseases.
Vascular system - parenteral fluid overload
What are the “cues” for renal system involvement, endocrine system involvement, and nutritional system involvement in patients with chronic generalized edema?
Patient volunteers the following information:
5 mos - intermittent exertional dyspnea, easy fatigability upon doing light household work that is relieved by short pauses.
- difficulty in urination associated with flank pain.
3 mos - generalized swelling
- whitish lesions in oral cavity
- noted to be pale
1 mos - bouts of nausea and vomiting
2 wks - dyspnea and orthopnea
- persistent bouts of nausea and vomiting
- increased swelling of both lower extremities
Based on the above data, do you have “cues” as to the cause of the chronic generalized edema?
Yes or No? Why?
Yes - possibly renal system involvement because of the presence of difficulty in urination
Are there other data that you need to be more definite that the renal system is the cause of the chronic generalized edema? Yes or No? If yes, what?
Yes - more in-depth investigation for urinary difficulty.
Exact nature of the urinary difficulty.
Pain on urination?
Change in the volume of urine output?
Change in the color of urine?
Change in the character of the urine?
Pattern - Intemittent? Progressive?
You inquire further on the urinary difficulty and you got the following information:
Pain on urination? Occasional
Change in the volume of urine output? Yes. Marked decrease to about 500 cc/day
Change in the color of urine? Before it had been reddish.
Change in the character of the urine? None
Pattern - Intemittent? Progressive? Progressive decrease in urine output
Are you now more definite that renal system is involved?
Yes or No? Why?
Yes - the progressive decrease in output and at 500/cc per day and presumptive “hematuria”
are reliable cues for a renal system involvement.
Do you need to investigate on the endocrine and nutritional system as the possible causes? Yes or No? Why? How?
Yes. To give additional assurance that my diagnosis of renal problem is correct.
I will look for signs of hypothyroidism - palpate the thyroid and check for any abnormality.
Since in the presence of cues for alternative diagnosis which is renal problem, I can withhold
investigation on the nutritional system problem. This is quite unlikely and beside
there are no reliable clinical cues.
The thyroid gland is not palpable. Is this a cue for a thyroid problem? Yes or No? Why?
No. A normal thyroid gland is usually not palpable. In the presence of a palpable thyroid gland, I will suspect a thyroid pathology. Although hypothyroidism can be associated with a nonpalpable gland, such as caused by agenesis, the symptoms should have occurred at an earlier age, say at birth.
Does the patient has renal failure with a urine output of 500cc/day and generalized edema? Yes or No?
Why?
Yes. Average urine output should be about 1500cc/day????.
Output at 500 cc/day is considered oliguria.
At 1000 cc/day????
If the patient has a chronic renal failure, what are the more possible causes in the Philippines?
Chronic glomurulonephritis
Chronic pyelonephritis
Diabetic nephropathy
Hypertensive Nephrosclerosis
What are cues for each entity?
Patient gives the following data after you inquire on the above cues. You do not know how to do an ophthalmoscopy.
History of hematuria one year ago
No history of intermittent urinary tract infection
History of being treated for diabetes mellitus 4 years ago
No known history of hypertension
With these data, what is your most likely diagnosis as to the cause of the chronic renal failure? Why?
Diabetic nephropathy - because of the past treatment of diabetes mellitus (presumptively present)
What is your second most likely cause of the chronic renal failure?
ROJ@17nov6