🧪 MOCK OSCE · FCPS, MCPS, MD PAEDIATRICS ⏱ 10 min · NEPHROLOGY · NEPHROTIC SYNDROME

Nephrotic Syndrome · Short Case

Candidate task: perform focused examination on a child with generalized body swelling / suspected nephrotic syndrome.
Then discuss differential diagnosis, investigations, management & follow‑up.
Pre‑exam Protocol
⏤ Wash, Warm, Introduce, Position, Expose, Approach ▾

Standard pre‑examination protocol – must be demonstrated:

🖐 Wash hands with sterilizing solution.
🔥 Warm hands and stethoscope.
👋 Introduce yourself to child & parent.
🧍 Position child: supine, then sitting (if possible).
👕 Exposure — fully expose for systematic exam, warm environment.
➡️ Approach from the right side.
✔ CPSP marker: Pre‑exam Protocol is observed and scored.
1. Clinical Examination (≈6 min)
02 General Look (Inspection from end of bed) ▾

Key observations – “Nephrotic Syndrome / generalized swelling” clues:

  • Facial appearance: periorbital puffiness (worse in morning), moon facies (steroid therapy).
  • Generalized edema: pitting edema of legs, sacrum, scrotum/labia, abdominal wall.
  • Respiratory: tachypnoea, shallow breathing (pleural effusion, ascites).
  • Skin: pallor, stretch marks, striae (steroid use), cellulitis (infection risk).
  • Abdominal distension: ascites, hepatomegaly (congestion).
  • Growth: weight gain (fluid), poor linear growth (chronic).
👁 Red flags: anasarca, respiratory compromise, hypertension, gross hematuria → complicated nephrotic syndrome.
03 Systemic Examination (CVS, Resp, Abdomen, Neurological) ▾

Systematic examination – identify aetiology & complications:

  • Cardiovascular: HR, BP (hypertension common), JVP (raised if overload), pericardial rub (rare).
  • Respiratory: reduced air entry at bases (pleural effusion), crackles (pulmonary oedema if overload).
  • Abdomen: ascites (shifting dullness, fluid wave), hepatomegaly (congestive), splenomegaly (if systemic).
  • Neurological: headache, visual changes (hypertension), confusion (encephalopathy).
  • Genitalia: scrotal or labial swelling (common in nephrotic syndrome).
🔍 Key: hypertension + edema + proteinuria → nephritic/nephrotic overlap.
04 General Physical Exam (Hands → Face → Chest → Abdomen → Limbs) ▾

Systematic examination – identify aetiology & complications:

  • Hands: pallor (anaemia), leukonychia, peripheral cyanosis.
  • Face: periorbital puffiness, malar flush (SLE), moon face (steroids).
  • Chest: respiratory rate, use of accessory muscles, dullness at bases (effusion).
  • Abdomen: ascites, organomegaly, shifting dullness, fluid thrill.
  • Limbs: pitting edema (sacrum, ankles, shins), muscle wasting (chronic).
  • Skin: striae, bruising (steroid), cellulitis (infection), purpura (HSP).
  • Blood pressure: hypertension (common in nephrotic syndrome).
📏 Anthropometry: weight, length/height, head circumference – plot growth.
05 Developmental Assessment & Associated Signs ▾

Assess:

  • Motor milestones: delayed if chronic illness, weakness (hypokalemia).
  • Speech & language: may be normal; dysarthria if hypertension encephalopathy.
  • Feeding: poor appetite, vomiting (uraemia), salt aversion.
  • Behaviour: irritability, lethargy (electrolyte imbalance, uraemia).
  • School performance: may be affected by frequent hospitalisations, steroid side effects.
🧠 Red flags: severe hypertension, encephalopathy, acute kidney injury → urgent referral.

📋 Case Presentation – (fill in during exam)

This is a _____-year-old _____ child, referred for _____ (generalized swelling / periorbital puffiness / anasarca). On examination, the child appears _____ (well / unwell / in distress), with _____ (pitting edema / ascites / pleural effusion). Weight: _____ percentile, Height: _____ percentile. Blood pressure: _____ (normal / elevated). Cardiovascular: _____ (tachycardia / normal). Respiratory: _____ (shallow / reduced air entry / crackles). Abdomen: _____ (ascites / hepatomegaly / normal). Skin: _____ (striae / bruising / cellulitis / purpura). GPE: _____ (pallor / oedema / normal). Neurological: _____ (alert / confusion / headache).

2. Viva Discussion (≈4 min)
06 Viva · Differential, Investigations, Management, Follow‑up ▾
🔹 Differential Diagnosis

• Minimal Change Nephrotic Syndrome (MCNS)
• Focal Segmental Glomerulosclerosis (FSGS)
• Membranous Nephropathy
• Membranoproliferative GN (MPGN)
• IgA Nephropathy / HSP Nephritis
• Lupus Nephritis (SLE)
• Post-infectious GN
• Congenital Nephrotic Syndrome
• Secondary: HIV, hepatitis B/C, malaria
• Heart failure, liver disease, protein-losing enteropathy

🔹 Investigations – Diagnosis

• Urinalysis: heavy proteinuria (3+ / 4+), microscopic hematuria (20%).
• Spot urine protein/creatinine ratio: >2 (nephrotic range).
• Serum albumin: <2.5 g/dL.
• Serum cholesterol: elevated (>200 mg/dL).
• Serum creatinine & BUN: usually normal (prerenal if volume depleted).
• Complement C3/C4: normal (MCNS), low (MPGN, SLE, post-infectious).
• 24-hour urine protein: >40 mg/m²/hr.

🔹 Investigations – Aetiology

• ANA, anti-dsDNA: lupus nephritis.
• Hepatitis B/C serology, HIV, VDRL.
• C3, C4, CH50: complement levels.
• ASOT, anti-DNase B: post-streptococcal GN.
• Renal biopsy: if steroid-resistant, atypical age (<1 or >12 years), persistent hematuria, low C3.

🔹 Investigations – Exclude Others

• Renal ultrasound: exclude CKD, hydronephrosis, renal vein thrombosis.
• Chest X-ray: pleural effusion, cardiomegaly.
• Blood culture: rule out sepsis / peritonitis.
• Tuberculosis screen (TST/IGRA): before immunosuppression.
• Genetic testing: congenital NS, familial FSGS.

🔹 Investigations – Rule Out Complications

• Serum electrolytes: Na, K (hyponatremia, hyperkalemia).
• Coagulation profile: hypercoagulable state (DVT, renal vein thrombosis).
• Lipid profile: hypercholesterolemia.
• Infection screen: peritonitis (ascitic tap if suspected).
• Growth monitoring: weight, height, BMI (steroid effects).

🔹 Management – Across Organ Systems

Edema / Fluid

Salt restriction (<1.5g/day), fluid restriction (if hyponatremia). Diuretics (furosemide) with caution. IV albumin + furosemide in severe anasarca (nephrologist).

Immunosuppression

Prednisone 60 mg/m²/day (or 2 mg/kg/day) for 4-6 weeks, then alternate-day taper. Steroid-sparing: cyclophosphamide, cyclosporine, mycophenolate, rituximab (steroid-dependent/resistant).

Infection Prevention

Pneumococcal vaccination (PCV13, PPSV23), influenza annually. Prophylactic penicillin in some centres. Treat infections aggressively (peritonitis, cellulitis, sepsis).

Thromboembolism

Monitor for DVT, renal vein thrombosis. Anticoagulation if thrombotic event. Treat with heparin, warfarin (nephrologist guidance).

Nutrition & Growth

High-quality protein (1.5-2 g/kg/day), calcium/vitamin D supplementation. Monitor growth, manage steroid-induced obesity with diet/exercise.

Psychosocial

Family education about home urine dipstick, signs of relapse, complications. Support for steroid side effects, body image, school attendance.

📈 Prognosis

  • MCNS: 90% steroid-responsive; excellent long-term survival.
  • FSGS: 20% steroid-responsive; 50% ESRD in 5-10 years if resistant.
  • MPGN / Membranous: variable; may progress to ESRD.
  • Congenital NS: poor prognosis; may require dialysis/transplantation.
  • Relapse: frequent in MCNS (80%); decreases with age.
  • Steroid resistance: higher risk of progression to CKD.

📋 Follow‑up Schedule

  • Initial episode: daily home urine dipstick; weekly clinic visits.
  • Relapse: as per initial, with steroid taper.
  • Frequent relapses / steroid-dependent: monthly to 3-monthly reviews.
  • Long-term: 6-monthly to annually for BP, growth, urine, renal function.
  • Transition: to adult nephrology at 16-18 years.
💡 Examiner expectation: logical differential (primary vs secondary), systematic investigation (urine, blood, imaging), and a management plan with corticosteroids, supportive care, and steroid-sparing agents. Know the complications (infection, thrombosis, AKI) and prognosis by histological type.
📚 Visit paeds.online for more CPSP resources
Mock OSCE · Nephrotic Syndrome · Based on Nelson, Wyne‑Harris & Pediatric Clinical Advisor