What physical exam should be conducted for a suspected case of nephrotic syndrome in a child presenting with generalized edema and tea-colored urine?

Physical Examination for Suspected Nephrotic Syndrome in a 7-Year-Old Child

A thorough physical examination for a 7-year-old child with suspected nephrotic syndrome should focus on assessing the extent of edema, blood pressure, and signs of complications, with special attention to the characteristic distribution of fluid accumulation.

Initial Assessment

• Vital Signs:

  • Blood pressure measurement (hypertension may be present)
  • Heart rate (tachycardia may indicate hypovolemia)
  • Respiratory rate (increased with pleural effusions)
  • Temperature (to rule out infection)

• Growth Parameters:

  • Height/length
  • Weight (to document baseline and track fluid changes)
  • BMI calculation 1

Edema Assessment

• Distribution of Edema:

  • Periorbital edema (typically most noticeable in the morning)
  • Dependent pitting edema (ankles, sacrum, genitalia - more prominent later in day)
  • Abdominal examination for ascites:
    • Shifting dullness
    • Fluid wave
    • Abdominal distention
  • Scrotal/labial edema
  • Generalized anasarca in severe cases 1

• Quantification of Edema:

  • Grade edema on a scale (1+ to 4+)
  • Measure abdominal girth if ascites present
  • Document extent and distribution 1

Cardiovascular Examination

• Heart:

  • Auscultation for gallop rhythm (volume overload)
  • Assessment for muffled heart sounds (pericardial effusion)
  • Cardiac ultrasound if concerned for effusions or left ventricular mass 1

• Vascular Assessment:

  • Examine central and peripheral pulses
  • Assess jugular venous pressure
  • Evaluate for signs of thrombosis (limb swelling, pain) 1

Respiratory Examination

• Lung Assessment:
  • Auscultation for decreased breath sounds (pleural effusions)
  • Percussion for dullness at lung bases
  • Signs of respiratory distress (increased work of breathing)
  • Ultrasound of pleural space if effusions suspected 1

Abdominal Examination

• Liver and Spleen:

  • Palpate for hepatomegaly or splenomegaly
  • Assess for tenderness

• Kidneys:

  • Palpate for kidney size and tenderness
  • Assess for costovertebral angle tenderness 1

Neurological Examination

• Complete Neurological Assessment:
  • Mental status
  • Cranial nerves
  • Motor and sensory function
  • Deep tendon reflexes
  • Signs of cerebral edema or thrombosis 1

Skin Examination

• Skin Assessment:
  • Skin integrity (risk of breakdown with severe edema)
  • Signs of infection (cellulitis is common with edema)
  • Rashes (may indicate underlying systemic disease)
  • Striae from rapid stretching due to edema 1

Additional Focused Examinations

• Ophthalmological Examination:

  • Look for signs of hypertensive retinopathy
  • Evaluate for lens opacities (steroid-induced cataracts in chronic cases)

• Genital Examination:

  • Assess for edema
  • Rule out structural abnormalities 1

Special Considerations

• Volume Status Assessment:

  • Signs of hypovolemia (tachycardia, poor capillary refill, cool extremities)
  • Signs of hypervolemia (elevated JVP, crackles in lungs)
  • This distinction is critical for management decisions 2

• Evaluation for Complications:

  • Signs of infection (common complication)
  • Signs of thromboembolism (limb pain, respiratory distress)
  • Nutritional status assessment 3

Pitfalls to Avoid

1. Do not miss hypertension - blood pressure must be measured with an appropriately sized cuff
2. Do not overlook signs of infection - children with nephrotic syndrome are immunocompromised
3. Do not confuse cardiac versus renal edema - distribution patterns differ
4. Do not miss thrombotic complications - maintain high suspicion for thromboembolism
5. Do not forget to examine all potential sites of fluid accumulation - including pleural and pericardial spaces 1

Remember that tea-colored urine with generalized edema strongly suggests glomerular disease, and the physical examination findings should be interpreted alongside urinalysis showing proteinuria (>2+ by dipstick), possibly with red blood cell casts and deformed red blood cells 1.

Ultrasound of the abdomen and pleural space should be considered as part of the complete evaluation to assess kidney echogenicity and size, and to detect ascites, effusions, or thrombosis 1, 4.

Physical examination findings should guide the urgency of management and the need for additional diagnostic testing, including kidney biopsy in selected cases.