Differential Diagnosis of Edema
Transcript of Differential Diagnosis of Edema
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Differential Diagnosis of Differential Diagnosis of EdemaEdemaJillian Caster PT DPT WCC CLTChatham University Grand Rounds11/10/16
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ObjectivesObjectivesAt the conclusion of this course
you will be able to ◦Effectively evaluate and diagnose
causes of edema◦Rule out/in red flag causes of edema
and appropriately refer◦Effectively treat edema
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EdemaEdemaWhat is edema?
◦Definition: Edema is a palpable swelling produced by expansion of the interstitial fluid volume
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PathophysiologyPathophysiologyOver filtrationIncreased
capillary hydraulic pressure
Reduced capillary oncotic pressure
Increased capillary permeability
Reduced drainageVenous
insufficiencyLymphatic
insufficiencyIncreased
interstitial oncotic pressure
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CausesCauses• Systemic– Allergic reaction– Cardiac disease– Hepatic disease– Malnutrition – Sleep Apnea– Pregnancy/
premenstrual– Renal disease– Pulmonary
hypertension– Idiopathic edema– Medication
• Localized– Acute injury– Cellulitis– Chronic Venous
Insufficiency– Compartment
Syndrome– Complex Regional
Pain Syndrome– DVT & Post
Thrombotic Syndrome
– Lipedema– Lymphedema– May Thurner
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EvaluationEvaluation• History • Medication• Onset• Unilateral or
bilateral• Positional changes
in edema• Coloring and skin
texture• Pitting or non-pitting• History of wounds• Stemmer sign• Weight
PainTemperatureStrength and mobilityJugular vein
distentionSOBIrregular heart
rhythmLung cracklesWells RuleBlood Work
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Red FlagsRed Flags• Red Flags– SOB and coughing– Tachypnea, tachycardia– Irregular heat beat– Ascites– Periorbital edema– Abnormal Labs– Acute onset– Redness– Warmth– Pain– Fever– + Wells
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Red FlagsRed FlagsNumbness and tinglingPulslessnessAcute injuryProximal swelling distribution
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Wells RuleWells Rule
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StemmerStemmer’’ssPositive Negative
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Pitting Edema ScalePitting Edema Scale
Grade Definition1+ 2mm or less
disappears immediately
2+ 2-4 mmfew second rebound
3+ 4-6 mm10-12 second rebound
4+ 6-8 mm> 20 second rebound
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Case 1Case 165 year old male
with bilateral LE edema present for 10 years; former smoker; retired bus driver
PMH: obesity, retinopathy, CHF, CAD, HTN, hyperlipidemia, aortic valve disease and replacement, CABG, sleep apnea, CKD, CVA, DM type 2, skin CA
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Case 1Case 1
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Case 1 HistoryCase 1 History• Bilateral• Chronic• 3+ Pitting edema• Obesity • Cardiac disease• Sleep apnea • CKD• CVA• Medication
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Evaluation & Special TestsEvaluation & Special TestsReduction with elevationBrawny, hemosiderin stainingHistory of wounds
◦ Large amount of exudate-Stemmer’sDull achinessVitals WNLAmbulates community distances with
minimal difficulty use of RWWell nourished4/5 strength in L LE DF/PF, Quads, Hams,
hip flexors otherwise LE MMT= WFL
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What can we rule out?What can we rule out?LymphedemaLipedemaDependent edema
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DiagnosisDiagnosisCVI
◦ Low viscosity/ protein poor
◦ Pitting edema◦ Chronic◦ Bilateral ◦ Achy/ heaviness◦ Volume reduction
overnight ◦ Possible
varicosities
◦ Hemosiderin staining
◦ Inverted champagne bottle
◦ Ulcerations◦ - Stemmer’s
CKDCardiac
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TreatmentTreatmentWound care: absorbent dressingsABIVascular TestingShort stretch multilayer
compression bandagesCompression garments: 30-
40mmHgLE elevationTherapeutic exercise
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ABIABIHighest systolic ankle / Highest
systolic Brachial1.0 < Normal0.8-0.99 Abnormal0.5-0.8 Compromised< 0.5 Severe PAD- Do not compress!
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Case 2Case 266 y.o. Female
with 30 year history of bilateral LE edema; works as CNA
PMH: obesity, cataract repair, hyperlipidemia, HTN, CKD II, bilateral knee arthritis, DM type 2, hypothyroidism
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Case 2Case 2
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Case 2 HistoryCase 2 History• Bilateral • Chronic• 2+ Pitting edema• Obesity• Cardiac disease• CDK Stage II• Bilateral knee arthritis• Hypothyroidism
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Evaluation & Special TestsEvaluation & Special TestsEdema is stable with positional
changesNo wounds+ Stemmer’s10# weight gainNo painNormal Temp and skin coloringAreas of fibrosis and papillomasBil LE strength WNLAmbulates unlimited distances no ADVitals WNL
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What can we rule out?What can we rule out?Venous insufficiencyLipedemaDependent edemaMedicationMalnutrition
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DiagnosisDiagnosisLymphedema
◦ Protein rich swelling◦ Chronic◦ Painless◦ Unilateral or
Bilateral◦ Stage I – Stage II
Pitting◦ Stage II – III non
pitting◦ Fibrosis
◦ Hyperkeratotic skin
◦ Squared of toes◦ + Stemmers
CKD
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Squared off toes Fibrosis & Hyperkeratosis
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LymphedemaLymphedemaPrimary
◦ Milroy’s Birth-2 years
◦ Meigs 2-35 years
◦ Lymphedema Tarda 35+
Secondary◦ Tumor◦ Surgery◦ Radiation◦ Infection◦ Filariasis◦ Venous
Insufficiency Bilateral Phlebolymphostatic
edema
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TreatmentTreatmentABICDT
◦MLD◦Short stretch compression bandages
Therapeutic exerciseFlat knit custom compression
garments
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Case 3Case 382 y.o. female; 3
month history of bilateral LE swelling; retired secretary; former smoker; limited ambulation
PMH: HTN, CAD, CHF, A-fib, GERD, bowel obstruction, CKD, gout, bipolar disorder, hysterectomy, thyroidectomy
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Case 3Case 3
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Case 3 HistoryCase 3 HistoryBilateralChronic4+ Pitting edema
◦CHF, A-fib, HTN, CAD◦CKD◦Medication◦Malnutrition◦Dependent edema◦Gout◦Hysterectomy
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Evaluation & Special TestsEvaluation & Special Tests Increased edema in dependent positionNormal skin color and tempNo Hx of non healing wounds- Stemmers 10# weight loss in 1 monthNo pain associated with edemaMin A for sit <> stand; ambulates with RW
household distances and uses W/C long distances
Bilateral LE weakness Jugular vein distention Irregular hear rhythmSOB
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What can we rule out?What can we rule out?CVILymphedemaLipedemia
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DiagnosisDiagnosisCHF
◦Chronic◦Bilateral ◦Pitting◦Jugular vein distention◦Gallop rhythm◦C/O dyspnea
CKDDependentMalnutrition
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TreatmentTreatmentRefer to cardiologist/kidney
specialistNutrition consultLight compression garments
once medically managedEducation on elevating LEs
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Case 4Case 443 y.o. female
with negative history of LE edema; woke up on 2 days ago with a red, swollen LE; typical, active life style, works as an elementary school teacher
PMH: HTN, LBP
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Case 4Case 4
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Case 4 HistoryCase 4 HistoryUnilateral edema Acute symptoms3+ Pitting
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Evaluation & Special TestsEvaluation & Special TestsNo change in edema with elevationRedness with irregular borders, warmth7/10 pain in R LENo woundsOnchomychosis-Stemmer’s signTemp: 99.1, BP: 137/88, HR: 92, SpO2:
98%Strength and mobility WNL- Well’s
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What can we rule out?What can we rule out?LymphedemaLipedemaCVICardiacKidneyLiverDVTBaker’s Cyst
CRPSCompartment
SyndromeMay ThurnerMalnutritionDependentIdiopathic
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CellulitisCellulitisUnilateral Acute onsetPainfulRedWarmthSystemic
symptoms◦ Fever◦ malaise◦ achiness
PittingWoundsOnychomycosis
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CellulitisCellulitisAntibioticsRefer Pt to ERMultilayer short stretch
compression
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Everything else to keep in Everything else to keep in mindmindLipedema
◦Chronic, bilateral, pitting◦Abnormal fat distribution from ankles
to hips◦Treat with CDT and flat knit garments
DVT◦Acute, unilateral, pitting◦Painful with palpation, redness,
warmth, + Wells◦Refer to ER
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Everything else to keep in Everything else to keep in mindmindCRPS
◦Chronic, unilateral, pitting◦Sweating, pallor, irregular hair growth◦Hx of traumatic injury◦Therapeutic exercise, refer for medical
managementRuptured Baker’s Cyst
◦Acute, unilateral, pitting◦Redness, warmth, trickling feeling◦Hx of knee complications◦Rest, elevation, compression
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Everything else to keep in Everything else to keep in mindmindPulmonary Hypertension
◦Chronic, bilateral, pitting◦History of sleep apnea◦Refer to cardiologist
Idiopathic edema◦Chronic, bilateral, pitting◦Females <50, menstruating, weight gain
through day, c/o hand and face edema, obesity, depression
◦Refer- Spironolactone ◦Compression garments if tolerated
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Everything else to keep in Everything else to keep in mindmindDependent edema
◦Chronic, unilateral or bilateral, pitting◦Paralysis, reduced strength, dependent
position◦Hx of CVA, MS etc◦Short stretch compression, compression
garmentsMedication
◦Chronic, bilateral, pitting◦Occurs with use of medication◦Refer for change in medication or compression
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MedicationMedicationClass Specific MedicationAntidepressants MAOIs, trazodoneAntihypertensives Beta blockers, Ca++ blockers,
clonidine, hydralazine, methyldopa, minoxidil
Antivirals ZoviraxChemotherapeutics Cyclophosphamide,
cyclosporine, cytosine arabinoside, mithramycin
Cytokines G-CSF, GM-CSF, interferon alfa, interluken-2 and 4
Hormones Androgen, corticosteroids, estrogen, progesterone, testosterone
NSAIDs Celebrex, ibuprofen
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Everything else to keep in Everything else to keep in mindmindCompartment Syndrome
◦Acute, unilateral, pitting◦Pain, redness, paresthesia, pulse◦ER referral
May Thurner◦Chronic, unilateral, pitting◦Left iliac vein is compressed by the
right iliac artery◦Refer to vascular surgeon◦Compression following surgery
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Everything else to keep in Everything else to keep in mindmindMalnutrition
◦ Chronic, bilateral, pitting◦ Interstitial oncotic pressure is higher than
capillary oncotic pressure drawing fluid out◦ Typically older individuals, refer for blood work,
nutrition consult◦ Compression
Kidney disease◦ Chronic, bilateral, pitting◦ Reduced protein levels in blood causing
interstitial oncotic pressure is higher than capillary oncotic pressure drawing fluid out
◦ Refer to nephrologist, conservative compression, garments
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Everything else to keep in Everything else to keep in mindmindLiver disease
◦Chronic, bilateral, pitting◦Ascites, jaundice, spider hemangiomas◦Reduced protein circulating, portal vein
hypertension, refer for blood work and liver specialist
Post thrombotic syndrome◦Chronic, unilateral or bilateral, pitting◦History of DVT causing deep venous
insufficiency◦Blood clotting disorder◦Wound care, compression, refer for
vascular testing and vascular surgeon
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148-160. Sterns, RH. (2016) Clinical manifestations and diagnosis of edema in
adults. Available from UpToDate.com. Accessed on 10 October 2016. World Union of wound healing societies initiative (2012). Compression in
venous leg ulcers: A consensus document. Principles of Best Practice. Trayes, KP. (2013) Edema: Diagnosis and Management. Am Fam
Physician 88(2): 102-110. Norton, S. Norton School of Lymphatic Therapy Course Manual. Diagnosis
& Therapy. Norton School of Lymphatic Therapy 2013. Banu, A. (2007) Lymphoedema- Up to Now- Review. Mædica A Journal of
Clinical Medicine 2(1) 25-32. Hogan, M (2007) Medical-Surgical Nursing (2nd ed.). Salt Lake City:
Prentice Hall Zuther, J., Norton, S. Lymphedema Management: The Comprehensive
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