Physical Exam Key Points

1. Vital signs. BP measurement is essential to detect nephritis.

2. Skin. Observe for facial swelling; and for pitting edema of legs and sacral area if patient is nonambulatory. Look for vasculitic rash and sores on the buccal mucosa. If lupus is suspected, check lymph nodes.

3. Lungs. If patient has generalized edema, carefully listen for crackles and rhonchi as signs of pulmonary edema.

4. Abdomen. Evaluate for possible ascites; look for fluid waves and percuss for fluid shift.

5. Joints. Thorough exam of joints is necessary if lupus or HSP is suspected.

B. Laboratory Data. In young children with typical nephrotic syndrome, extensive workup beyond routine laboratory studies (CBC, creatinine, and serum albumin) is not needed.

1. Urinalysis. RBCs can be present in 20-30% of patients with MCD. Hyaline casts alone have little significance, but granular and cellular casts (typically both red and white cell casts) indicate glomerulonephritis.

2. CBC. Anemia alone may indicate glomerulonephritis. Anemia with schistocytes and thrombocytopenia is expected in HUS. Leukopenia, usually with anemia and sometimes with thrombocytopenia, is frequent finding in lupus. HSP does not have characteristic findings on CBC.

3. Serum chemistry. Occasionally, elevated BUN and creatinine can be seen in MCD (if patient has severe edema and renal hypoperfusion). These findings, however, usually point to FSGS or glomerulonephritis. Hypoalbuminemia (< 3 g/dL) and high cholesterol indicate nephrotic syndrome.

4. Serum serology. Low C3 is expected in lupus, APIGN, and MPGN. Moderately elevated ANA (1:80-1:160) is frequently seen without vasculitis, but higher titers should raise the suspicion of lupus.

5. ESR. In the presence of hypoalbuminemia, ESR is moderately elevated, but values > 100 must be considered highly suspicious for systemic vasculitis.

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