A 12-year-old female is sent by her primary care physician to see a rheumatologist for a pediatric rheumatology consultation because she was found to have 3+ proteinuria and anemia (Hgb 8.9) after a routine physical exam. A repeat urinalysis on first morning urine specimen had 3+ proteinuria and 1+ blood. Additionally, her antinuclear antibody (ANA) test was 1:2560.
The patient is accompanied to the rheumatologist’s office by her mother, who reports that the child has been more fatigued than normal in the past six months and has had recurring fevers up to 38.60o C approximately one to three times per week for the past two weeks. Her mother also reports that the child has lost five pounds since her previous well-child exam.
The patient has had periorbital edema in the mornings for the past month, which the mother attributed to “allergies.” The patient also reports that her socks often leave indentations above her ankles when she removes them at night, and she reports generalized musculoskeletal pain on most days, which she rated at a 6 on a Faces Scale of 0–10. She especially has pain and stiffness in her hands and sometimes her rings are “too tight,” especially in the morning. The patient has had an intermittent raised red rash across her cheeks for the past three months, which is more prominent when she is outdoors in sunlight, and her mother reports that the child’s hair has been thinning, but denied patchy alopecia.
The patient also reports new-onset, daily frontal and parietal headaches for the past two weeks, which do not wake her from sleep. She rates headaches at 10 on Faces Scale 0–10. Her headaches are sometimes associated with dizziness or photophobia, but she denies nausea or photophobia at this time.
The mother reports that the child seems to be more forgetful recently and that her teachers have reported that she has not been completing her school assignments. The patient reports that she sometimes has difficulty remembering her school assignments. The mother denies that the patient has exhibited any other behavior changes.
The patient also denies oral or nasal ulcers, visual disturbances, swollen or tender lymph nodes, Raynaud’s phenomenon, chest pain, dyspnea, cough, epistaxis, unusual bruising, dysuria, insomnia, tremors, seizures, hallucinations, abdominal pain, vomiting, diarrhea, constipation, or hematochezia.
The patient was premenarche and is not on any prescribed medications, but takes Tylenol for headaches or musculoskeletal pain with occasional relief. She has no known allergies.
