23 yrs old female pt came with the complaints of bilateral pedal edema for the past 8 yrs..how to approach this case?

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Edema is either due to increased hydrostatic pressure or due to decreased osmotic pressure. Affection of different systems can cause edema. 1. Renal system: Acute nephritis, nephrotic syndrome, CKD. 2. CVS: right sided heart failure or CCF. 3.Endocrine system: Hypothyroidism. 4. Chronic liver disease 5. GIT: Protein losing enteropathy. 7. Severe anemia with hypoproteinemia. 8. Angioneurotic edema. Accordingly we need to do investigations. Renal system : BUN, s.creatinine, urine routine and microscopic examination, 24 hour urinary protein estimatio,USG:KUB. CVS: CXR PA view, ecg, 2D echocardiography. Endocrinology: serum TSH Liver pathology: LFT, USG abdomen, PT. Complement C2 and C4 estimation. Other routine tests: CBC and serum electrolytes. Besides all these clinical examination is very important. All the vitals sign along with head toe examination. High BP with anemia with edema suggestive of renal pathology. Need to look for signs of stigmata of liver failure such as ascites, sparse axillary and spider angioma and features of portal hypertension. Search for sign and symptoms of hypothyroidism such as weight gain ,dry and coarse skin, hoarseness, constipation etc. Considering her age we need to think of collagen vascular disease such as SLE as lupus nephritis can present with edema. Taking her age and clinical scenario, provisional diagnosis: 1.Nephrotic syndrome, 2. Acute nephritis progressing to nephrotic range of proteinuria. 3. Hypothyroidism 4. Lupus nephritis. 5. CLD secondary to glycogen storage disease. 6. Protein energy malnutrition with severe hypoalbuminemia. 7. Severe anemia with hypoproteinemia. Please rectify me if I'm wrong. Waiting for discussion. Thank you.

excellent approach Dr. arnab sir. .Thanks for giving more important to clinical examination. .that gives more clue
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It could be a case of: "Cyclical Odema/Periodic Odema & the fluid retention Syndrome". It is a poorly understood Syndrome occurring exclusively in women who complain of intermittent swelling of face,trunk,limbs,ankle & feet.There is evidence of increased capillary permeability leading to extravasation of fluid from vascular compartment with secondary Retention of sodium & water through renin angiotensin aldosterone pathway. Diagnosis is established by excluding cardiac,renal,hypoproteinemic & Obstructive Causes of odema by appropriate investigations. The most characteristic feature is diurnal weight gain of > 1.4 kg in a day as per THORN's criteria for diagnosis. This condition seems to be an exaggeration of normal fluid retention mechanism of body Risk Factors: Such odema is found associated with: 1.Obesity 2.Diabetes Mellitus 3.Hypothyroidism 4.Psychological Abnormality Reference David W.Denning etal " The relationship between normal fluid retention in women & idiopathic Odema. Postgraduate. Med. J.(1990) 66, 363-366.

Thanks.
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patient had history since 8 years and almost normal.investigations . so these diagnosis nephrotic synd or ccf unlikely.

ask pt. for fever with chill when swelling is occurred it may be Elephantitis or osmeticly do lymphengiography

Had it been a case of venous insufficiency there would have been skin changes like chronic venous stasis ulcers

investigation required Doppler for iliac veins, thyroid profile, renal function test,

Hypothyroidism Obesity Physiological abnormalities

congratulations for the correct answered persons. .Dr. alok mantri sir. Dr. amandeep Singh sir and Dr. santosh sir. .final diagnosis. .lymphedema preacox. ..but .correct answer I'm going to select is Dr. arnab sir. For very best approach for this case. .because we r daily seeing this finding. .Thank you so much for all

Thanks for presenting such a nice case sir. Had never seen it before.
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Dear Dr. Suresh .... Thanks for presenting this case.... Kindly send the complete workup details of this patient labelled as Lymphoedema Praecox....it shall benefit all readers...interesting case in which all tests done so far have been reported as normal......

Thank you so much for ur appreciation and sharing sir. .surely ill post all the details. .
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I would recommend to first get a urine routine and rule out nephrotic syndrome. Then evaluate for ccf, hypoalbuminemia and hypothyroid. So urine routine, liver and renal function tests and clin exam and echo to rule out valvular heart diseases or ccf

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