A 16-Month-Old Girl With Cough and Proteinuria

Melanie Malloy, MD, PhD; Sage W. Wiener, MD

Disclosures

December 10, 2015

Physical Examination and Workup

Upon physical examination, the child is ill-appearing but nontoxic. Her skin is warm and mildly sweaty. She cries during examination but is consolable.

Her vital signs are as follows:

  • Rectal temperature—99.1°F

  • Blood pressure—115/75 mm Hg

  • Heart rate—90 beats/min

  • Respiratory rate—35 breaths/min

Figure 1.

The patient has marked periorbital swelling. Her tympanic membranes are clear bilaterally. She has no conjunctival injection or discharge. She has no dental abnormalities. The oropharynx is not erythematous. The patient has no neck masses and no lymphadenopathy. The patient has a normal S1 and S2 with no murmurs. The chest wall is nontender. She is tachypneic with diminished breath sounds bilaterally and a dry cough. No wheezing or rales are observed. The abdominal examination reveals it to be soft and nontender, with no masses or hepatosplenomegaly and normal bowel sounds. Costovertebral angle tenderness is not observed.

The extremities show a pink discoloration to the hands and feet and 2+ bilateral pitting edema to the ankles (Figure 1). The patient moves all extremities spontaneously and has free range of motion globally. No bony deformities are noted. The patient is alert. She is able to ambulate with assistance from her mother; however, the mother notes that the patient seems "off balance." The neurologic examination is significant for globally decreased deep tendon reflexes. Sensory examination reveals normal light touch and pinprick.

Urinalysis shows 2+ protein but is negative for leukocyte esterase, nitrites, red blood cells, white blood cells, and bacteria. Complete blood count and basic metabolic panel results are within normal limits. Chest imaging shows diffuse ground glass opacities but no focal consolidation and no effusion.

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