Symptoms, signs, and differential diagnosis





2.1 Edema


2.1.1 Renal























Probable Diagnosis Symptoms/Signs Diagnostic Procedures
Nephrotic syndrome


  • Facial swelling



  • Swelling of the arms and legs, especially the ankles and feet



  • Pleural effusions



  • Foamy urination



  • Weight gain (water retention)




  • Urine protein/Cr ratio or 24-hour urine protein



  • BUN



  • Serum Cr



  • Serum albumin



  • CrCl or eGFR



  • UA with sediment microscopy



  • Serum and urine protein electrophoresis



  • HIV, anti-PLA2R (for membranous nephropathy) and hepatitis antibodies



  • Renal biopsy

Nephritic syndrome (e.g., acute glomerulonephritis)


  • Peripheral or periorbital edema



  • Hematuria



  • Oliguria



  • Headache, secondary to hypertension



  • Shortness of breath or dyspnea on exertion, secondary to heart failure



  • Possible flank pain, secondary to stretching of the renal capsule




  • UA and urinary sediment for protein, RBCs, acanthocytes, WBCs, casts (e.g., RBC casts)



  • Serum electrolytes, BUN, Cr



  • Serological tests for C3, C4, ASLO, ANCA, anti-GBM, and hepatitis antibodies



  • Serum and urine protein electrophoresis



  • Renal US and renal biopsy

CKD


  • Swelling: generalized (fluid retention), ankle, foot, and leg



  • High blood pressure



  • Nausea or vomiting



  • Loss of appetite



  • Metallic taste in mouth



  • Flank pain



  • Hyperkalemia, metabolic acidosis



  • Urination changes: oliguria, anuria, nocturia (excessive urination at night)



  • Fatigue




  • Blood tests: Cr, BUN, electrolytes, CBC, calcium, phosphate, albumin



  • CrCl or eGFR



  • Urine tests: 24-hour urinary protein or urine protein to Cr ratio



  • Serum and urine protein electrophoresis



  • Arterial or venous blood gas, if serum bicarbonate is low



  • Renal US



  • Renal biopsy if indicated and kidneys are not contracted and small



  • Abdominal CT scan or MRI when indicated by US findings


ASLO , antistreptolysin O; ANCA , anti-neutrophil cytoplasmic autoantibody; BUN , blood urea nitrogen; C3 , C3 complement; C4 , C4 complement; CBC , complete blood count; CKD , chronic kidney disease; Cr , creatinine; CrCl , creatinine clearance; eGFR , estimated glomerular filtration rate; GBM , glomerular basement membrane; PLA2R , phospholipase-A2 receptor; RBCs , red blood cells; UA , urinalysis; US , ultrasound; WBCs , white blood cells.


2.1.2 Cardiovascular



















Probable Diagnosis Symptoms/Signs Diagnostic Procedures
Congestive heart failure (CHF)


  • Swelling (edema) of the ankles and legs or abdomen



  • Basilar lung crackles



  • S3 gallop



  • Dyspnea (shortness of breath)



  • Cough



  • Fatigue, weakness, faintness



  • Loss of appetite



  • Palpitations



  • Swollen (enlarged) liver or abdomen



  • Neck veins distended



  • Nocturia (increased urination at night)



  • Weight gain




  • ECG



  • Echocardiogram (echo)



  • Chest X-ray



  • Cardiac catheterization and angiography, if indicated



  • Blood test: BNP level

Cardiomyopathy (largely similar to CHF)


  • Shortness of breath or dyspnea with physical exertion



  • Chest pain



  • Fatigue (tiredness)



  • Swelling in the ankles, feet, legs, abdomen, and veins in the neck



  • Dizziness, fainting



  • Lightheadedness



  • Arrhythmias (irregular heartbeats)



  • Heart murmurs




  • Physical examination (tachypnea, tachycardia, hypertension or hypotension, hypoxia, JVD, pulmonary edema (lung crackles and/or wheezes), S3 gallop



  • BNP



  • Chest X-ray, MRI



  • Cardiac catheterization


BNP , Brain natriuretic peptide; CHF , congestive heart failure; ECG , electrocardiogram; JVD , jugular venous distension.


2.1.3 Endocrine























Probable Diagnosis Symptoms/Signs Diagnostic Procedures
Cushing syndrome


  • Round, red, full face (moon face)



  • Cervical fat pads



  • Comedones (acne)



  • Purplish pink stretch marks (abdominal striae)



  • Fatigue, headache, weak muscles



  • High blood pressure, high blood sugars, hypokalemia



  • Polydipsia and polyuria



  • Loss of libido, depression




  • Clinical evaluation



  • Serum and salivary cortisol level, ACTH levels



  • Dexamethasone suppression test



  • 24-hour urinary measurement for cortisol



  • Abdominal CT or MRI scan of adrenal glands and MRI of pituitary gland



  • Bone density test

Hypothyroidism


  • Puffy face and hands, and swelling of the legs



  • Increased sensitivity to cold



  • Fatigue or feeling slowed down



  • Joint or muscle pain



  • Coarse hair or brittle fingernails



  • Dry skin



  • Muscle cramps




  • Clinical evaluation



  • TFTs



  • TRH test



  • MRI of the brain

Hyperthyroidism (see 2.2 Hypertension )

ACTH , Adrenocorticotropic hormone; TFTs , thyroid function tests; TRH , thyroid releasing hormone.


2.1.4 Others



















Probable Diagnosis Symptoms/Signs Diagnostic Procedures
Cirrhosis


  • Swelling or fluid buildup of the legs (edema) and in the abdomen (ascites)



  • Confusion or problems thinking (hepatic encephalopathy)



  • Loss of appetite



  • Nausea and vomiting



  • Nosebleeds or bleeding gums



  • Pale or clay-colored stools



  • Small, red, spider-like blood vessels on the skin (spider angiomas)



  • Yellow color in the skin, mucus membranes, or eyes (jaundice)



  • Impotence, loss of libido




  • Clinical history (alcoholism, obesity, hepatitis B or C, type 2 diabetes)



  • CBC, LFTs



  • Abdominal US



  • CT or MRI of the abdomen, hepatic fibrosis scan



  • Endoscopy to check abnormal variceal veins in the esophagus or stomach



  • Liver biopsy confirming cirrhosis/etiology



  • Levels of AFP



  • Wilson’s disease, hemochromatosis studies, if indicated

Preeclampsia


  • Swelling of face or legs



  • Severe headaches



  • Hypertension



  • Hyperreflexia



  • Blurry vision, flashing lights, or floaters



  • Vomiting, pain in the upper abdomen



  • Decrease in urine output




  • CBC with differential and platelet count



  • Check for proteinuria



  • 24-hour urine collection for CrCl and total protein



  • Fetal US



  • sFLT-1 level or sFLT-1:PIGF ratio when diagnosis is unclear



  • LFTs (acute fatty liver of pregnancy)


AFP , Alpha-fetoprotein; CBC , complete blood count; CrCl , creatinine clearance; LFTs , liver function tests; US , ultrasound.


2.2 Hypertension



























Probable Diagnosis Symptoms/Signs Diagnostic Procedures
CKD (see 2.1.1 Renal )
Hyperthyroidism


  • High blood pressure



  • Difficulty concentrating



  • Fatigue



  • Frequent bowel movements



  • Goiter (visibly enlarged thyroid gland) or thyroid nodules



  • Heat intolerance



  • Increased appetite



  • Increased sweating



  • Itching (overall)



  • Lack of menstrual periods



  • Nausea and vomiting



  • Pounding, rapid, or irregular pulse



  • Protruding eyes (exophthalmos)




  • Clinical evaluation



  • TFTs, thyroid scan



  • Radioactive iodine uptake



  • Blood glucose (hyperglycemia)

Cushing syndrome (see 2.1.3 Endocrine )
Primary hyperaldosteronism (Conn’s syndrome)


  • Hypertension



  • Muscle weakness



  • Polydipsia



  • Polyuria



  • Hypokalemia




  • Blood test: plasma aldosterone/renin ratio



  • 24-hour urinary excretion of aldosterone test



  • Serum electrolytes for hypokalemia, metabolic alkalosis



  • Saline suppression test of aldosterone



  • MRI of adrenal glands



  • Adrenal vein sampling (to distinguish adenoma from bilateral hyperplasia)



  • Spironolactone therapeutic trial

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Sep 9, 2023 | Posted by in NEPHROLOGY | Comments Off on Symptoms, signs, and differential diagnosis

Full access? Get Clinical Tree

Get Clinical Tree app for offline access