# A puffy face for a week in a 4-year-old: a paediatric swelling case to work up

> A paediatrics case for medical students: a 4-year-old whose eyes have been puffy every morning for a week, now with swollen legs and scrotum, two weeks after a cold. What to ask, examination, first tests and the differential.

- Pediatrics · Intermediate · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/4-year-old-boy-whose-face-has-been-puffy-for-a-week
- Work up this patient: https://www.medikarya.in/case-studies/4-year-old-boy-whose-face-has-been-puffy-for-a-week

## How the patient presents

A mother brings her son because his eyes have been puffy every morning for a week, and now his legs and scrotum are swollen too. He had a cold two weeks ago.

## Why a puffy face and swelling in a young child matters

Puffy eyes in the morning in a child are easily put down to allergy, but swelling that spreads means fluid is collecting somewhere, and the urine is the first place to look. A dipstick for protein and blood, the blood pressure and the urine output separate the main causes.

## What to ask in the history

- When the swelling started, where, and how it has spread
- How much urine he passes; its colour (red or cola-coloured) and whether it is frothy
- A recent sore throat or skin infection
- Breathlessness, a swollen tummy, abdominal pain, fever
- Diet, appetite and weight change
- Allergies, insect bites, new foods
- Previous episodes
- Family history of kidney disease; medicines

## Red flags

- High blood pressure, headache, fits or changes in vision
- Very little urine
- Red or cola-coloured urine
- Breathlessness
- Abdominal pain with fever
- Cold hands and feet, fast pulse or dizziness despite the swelling
- A painful swollen limb or other sign of a clot

## What to examine

- Weight, compared with any recent weight
- Blood pressure with the right cuff size, pulse, capillary refill
- Swelling: face, legs, sacrum, scrotum; fluid in the abdomen or chest
- Abdomen: tenderness
- Throat and skin for infection
- Signs of liver or heart disease

## First investigations

- Urine dipstick for protein and blood
- Urine protein-to-creatinine ratio and microscopy (red cells, casts)
- Serum albumin, creatinine, electrolytes
- Cholesterol, full blood count
- Complement (C3) and streptococcal antibodies if there is blood in the urine or high blood pressure
- Further tests as the findings direct

## Differential diagnosis of a puffy face and swelling in a young child

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Not the kidney

- Allergic swelling (angioedema)
- Protein loss from the gut or poor nutrition
- Liver disease
- Heart failure

### The kidney

- Nephrotic syndrome
- Acute nephritis, for example after a streptococcal infection
- Other glomerular disease

## Common mistakes

- Calling it an allergy and giving antihistamines without testing the urine.
- Measuring the blood pressure with the wrong cuff, or not at all.
- Missing a child who is short of fluid inside the blood vessels even though he looks swollen.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.