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Edema (ºÎ±â, ºÎÁ¾)

The Root of Ambulatory Care (¿Ü·¡ Áø·á Áöħ¼­) Àüü ¸ñ·Ï º¸±â
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The Root of Ambulatory Care

The Root of Ambulatory Care

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KEYWORDS: ..ºÎÁ¾Àº Á¶Á÷°£¾×ÀÌ ºñÁ¤»óÀûÀ¸·Î ÃàÀûµÇ¾î ÀÖ´Â »óŸ¦ ¸»Çϸç, ÈçÈ÷ ½Åü Áß dependent partÀÎ legs¿¡ È£¹ßÇÑ´Ù. 1. Onset? Measured in hours to days : Acute onset - eg. Celluitis, DVT, Compartment syndrome etc Chronic onset - eg. Systemic process, Medication, Chronic venous insufficiency, Lymphedema 2. Clinical course? Intermittent vs constant 3. Pain? Painful - eg. Cellulitis, Ruptured gastronemius, Ruptured Baker¡¯s cyst, Compartment syndrome, DVT Painless - eg. Systemic causes, Lymphedema 4. Associated systemic Symptoms? Fever and chills - Cellulitis, Lymphangitis, or Venous thrombosis Dyspnea, orthopnea, paroxysmal noctural dyspnea - Cardiac origin Recent streptococcal sore throat, recurrent cystitis, hypertension, changes in ocular fundi, U/A, BUN/Cr and Albumin abnormality - Renal pathogenesis Hepatitis, alcoholism, axillary hair loss, palmar erythema, Icterus, spider telangiectasia, Hepatomegaly, splenomegaly, Ascites, abnormal LFT - Hepatic origin 5. Medications? Antidepressants - Monoamine oxidase inhibitors Anti-hypertensive drugs - ¥âblocker, CCB, Clonidine, Diazoxide, Guanethidine, Hydralazine, Methyldopa, Minoxidil, Reserpine Hormone agent - Corticosteroids, Estrogen, Progesterone, Testosterone NSAIDs Edema Key Questions 6. Endocrine diseases? - Cushing¡¯s syndrome,Thyroid dysfunction (pretibial myxedema) 7. Other conditions? - Pregnancy, Salt overload, Sudden cessation of laxative, Diuretic abuse etc ..Àü½ÅÀû ºÎÁ¾Àº °ÉÀ» ¼ö ÀÖ´Â °æ¿ì´Â ÇÏÁö¿¡, ħ»ó »ýȰ¸¸ ÇÏ´Â °æ¿ì´Â õ°ñºÎ ºÐ¿¡ Àß »ý±ä´Ù. ..The distribution of edema (generalized/localized) is useful in diagnosis. Common causes of generalized edema - ½ÉÀåÁúȯ Congestive heart failure Constrictive pericarditis Restrictive cardiomyopathy - °£°æÈ­ - ½ÅÀåÁúȯ Renal failure Nephrotic syndrome Common causes of Localized edema - Inflammatory disease - Injury : thermal, immune, infectious, mechanical - Occlusion of localized vein or lymphatic drainage 1. Chest radiograph 2. U/A (including microscopic) 3. Biochemistry profile (LFT, albumin, total protein, BUN/Cr) 7 The Root of ambulatory care Key tests Key treatments Edema Fig 1. Diagnostic approach to edema 1. Removal of underlying disease 2. Restriction of sodium intake : < 500mg/day 3. Diuretics : Weight loss by diuretics should be limited to 1~1.5kg/day ..Diuretics´Â ´ÜÁö ¹Ì¿ëÀûÀÎ ¸ñÀûÀ¸·Î »ç¿ëÇØ¼­´Â ¾ÈµÈ´Ù. ÀÌ´¢Á¦´Â aldosteroneÀÇ »ý¼ºÀ» ÀÚ±ØÇÏ¸ç ¿©¼ºÀÇ ÁÖ±âÀû ºÎÁ¾À» ¾ÇÈ­½Ãų ¼ö ÀÖ´Ù. ..AlbuminÅõ¿©´Â Áõ»ó°³¼±ÀÇ È¿°ú°¡ ÀϽÃÀûÀ̾ Ä¡·á·Î¼­ÀÇ Àǹ̴ ¹Ì¾à ÇÏ´Ù. ..º¸°íÀÚ¿¡ µû¶ó À̰ßÀº ÀÖÀ¸³ª, idiopathic cyclic edemaÄ¡·á¿¡ ÀÖ¾î ACE inhibitors°¡ ¶§¶§·Î È¿°úÀûÀÌ´Ù. (e.g,Captopril 25~50mg bid-tid) Diuretics ó¹æ¿¹ - ¿ïÇ÷¼º ½ÉºÎÀü 1. Furosemide 40mg 1/2T-1T qd or bid Spironolactone 25mg 1/2T-1T qd Edema Localized edema? Albumin < 2.5g/dL Heart failure Renal failure Severe malnutrition Cirrhosis Nephrotic syndrome Azotemia Active urine sediment Increased JVD (jugular venous distension) Decreased CO (cardiac output) Consider : Drug-induced : Steroids, Estrogens, Vasodilators, Hypothyroidism Inflammatory disease/Local Injury (thermal, lmmune, infectious, mechanical) Occlusion of localized vein or lymphatic drainage No No No No Yes Yes Yes Yes 9 The Root of ambulatory care Diuretics ó¹æ¿¹ - ½ÅÁõÈıº 1. Furosemide 40mg 1/2T-1T & Spironolactone 25mg 1/2T-1T qd or bid (Á¤»ó½Å ±â´É½Ã) 2. Furosemide 40mg 1T-2T qd or bid (½ÅºÎÀü½Ã) Diuretics ó¹æ¿¹ - °£°æº¯ 1. Spironolactione 25mg 1/2T-1T bid or tid Overdiuresis may result in hyponatremia, hypokalemia, and alkalosis, which may worsen hepatic encephalopathy. Common ¢º Volume depletion ¢º Prerenal azotemia ¢º Potassium depletion ¢º Hyponatremia-thiazide ¢º Metabolic alkalosis ¢º Hypercholesterolemia ¢º Hyperglycemia-thiazides ¢º Hyperkalemia-K£« sparing ¢º Hypomagnesemia ¢º Hyperuricemia ¢º Hypercalcemia-thiazides ¢º GI complaints ¢º Rash-thiazides Uncommon ¢º Interstitial nephritis-thiazides, furosemide ¢º Pancreatitis-thiazides ¢º Loss of hearing-loop diuretics ¢º Anemia,leukopenia, thrombocytopeniathiazides Âü°í ¹®Çå Ralph Weber : Leg edema,in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 287-289 ÃÖÁöÈ£ : ºÎÁ¾, in °¡Á¤ÀÇÇÐ ÀÓ»óÆí. ¼­¿ï, °èÃø¹®È­»ç, 2002, P 614-618 Joshua H. Barash,M.D. : Edema, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D.(ed).United States of America, The McGrwa-Hill Companies, Inc., 2005, P 132-136 Glenn Chertow, M.D. : Edema, in Harrison's Manual of Medicine, 16th ed, Dennis L. Kasper, M.D., M.A., Eugene Braunwald, M.D., M.A., M.D., ScD., Anthony S. Fauci, M.D., ScD., Stephen L. Hauser, M.D., Dan L. Longo, M.D., J. Larry Jameson, M.D., PhD. (ed). United States of America, The McGrwa-Hill Companies, Inc., 2005, P 194-196 Martin S. Lipsky,M.D.,Mitchell S. King,M.D. : Edema, in Blueprints in Family Medicine. Massachusetts, Blackwell Publishing, 2003, P 94-96