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Symptoms and Signs – Differential Diagnosis of Hypoalbuminemia
• Severe burns
• Rapid IV hydration
• Protein-losing enteropathies (inflammatory bowel disease [IBD])
• Prolonged immobilization
• Pregnancy
• Poor nutritional status
• Nephrotic syndrome
• Neoplasia
• Lymphomas
• Liver disease
• Hypervitaminosis A
• Chronic inflammatory diseases
• Chronic glomerulonephritis
• Severe burns
• Rapid IV hydration
• Protein-losing enteropathies (inflammatory bowel disease [IBD])
• Prolonged immobilization
• Pregnancy
• Poor nutritional status
• Nephrotic syndrome
• Neoplasia
• Lymphomas
• Liver disease
• Hypervitaminosis A
• Chronic inflammatory diseases
• Chronic glomerulonephritis
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Symptoms and Signs – Differential Diagnosis of Hypoaldosteronism
Pseudohypoaldosteronism: renal unresponsiveness to aldosterone. In this condition, both renin and aldosterone levels are elevated.Pseudohypoaldosteronism can be caused by medications (spironolactone), chronic interstitial nephritis, systemic disorders (systemic lupus erythematosus, amyloidosis), or primary mineralocorticoid resistance.
Pseudohypoaldosteronism: renal unresponsiveness to aldosterone. In this condition, both renin and aldosterone levels are elevated.Pseudohypoaldosteronism can be caused by medications (spironolactone), chronic interstitial nephritis, systemic disorders (systemic lupus erythematosus, amyloidosis), or primary mineralocorticoid resistance.
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Symptoms and Signs – Differential Diagnosis of Hypocalcemia
• Renal insufficiency: hypocalcemia caused by:
• Increased calcium deposits in bone and soft tissue secondary to increased serum PO4−3 level
• Decreased production of 1,25-dihydroxyvitamin D
• Excessive loss of 25-OHD (nephrotic syndrome)
• Hypoalbuminemia: each decrease in serum albumin (g/L) will decrease serum calcium by 0.8 mg/dL but will not change free (ionized) calcium.
• Vitamin D deficiency
• Malabsorption (most common cause)
• Inadequate intake
• Decreased production of 1,25-dihydroxyvitamin D (vitamin D–
dependent rickets, renal failure)
• Decreased production of 25-OHD (parenchymal liver disease)
• Accelerated 25-OHD catabolism (phenytoin, phenobarbital)
• End-organ resistance to 1,25-dihydroxyvitamin D
• Hypomagnesemia: hypocalcemia caused by
• Decreased parathyroid hormone (PTH) secretion
• Inhibition of PTH effect on bone
• Pancreatitis, hyperphosphatemia, osteoblastic metastases: hypocalcemia is secondary to increased calcium deposits (bone, abdomen).
• Pseudohypoparathyroidism: autosomal recessive disorder characterized by short stature, shortening of metacarpal bones, obesity, and mental retardation; the hypocalcemia is secondary to congenital end-organ resistance to PTH.
• Idiopathic hypoparathyroidism, surgical removal of parathyroids (e.g., neck surgery)
• “Hungry bones syndrome”: rapid transfer of calcium from plasma into bones after removal of a parathyroid tumor
• Sepsis
• Massive blood transfusion (as a result of ethylenediaminetetraacetic acid [EDTA] in blood)
• Renal insufficiency: hypocalcemia caused by:
• Increased calcium deposits in bone and soft tissue secondary to increased serum PO4−3 level
• Decreased production of 1,25-dihydroxyvitamin D
• Excessive loss of 25-OHD (nephrotic syndrome)
• Hypoalbuminemia: each decrease in serum albumin (g/L) will decrease serum calcium by 0.8 mg/dL but will not change free (ionized) calcium.
• Vitamin D deficiency
• Malabsorption (most common cause)
• Inadequate intake
• Decreased production of 1,25-dihydroxyvitamin D (vitamin D–
dependent rickets, renal failure)
• Decreased production of 25-OHD (parenchymal liver disease)
• Accelerated 25-OHD catabolism (phenytoin, phenobarbital)
• End-organ resistance to 1,25-dihydroxyvitamin D
• Hypomagnesemia: hypocalcemia caused by
• Decreased parathyroid hormone (PTH) secretion
• Inhibition of PTH effect on bone
• Pancreatitis, hyperphosphatemia, osteoblastic metastases: hypocalcemia is secondary to increased calcium deposits (bone, abdomen).
• Pseudohypoparathyroidism: autosomal recessive disorder characterized by short stature, shortening of metacarpal bones, obesity, and mental retardation; the hypocalcemia is secondary to congenital end-organ resistance to PTH.
• Idiopathic hypoparathyroidism, surgical removal of parathyroids (e.g., neck surgery)
• “Hungry bones syndrome”: rapid transfer of calcium from plasma into bones after removal of a parathyroid tumor
• Sepsis
• Massive blood transfusion (as a result of ethylenediaminetetraacetic acid [EDTA] in blood)
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Symptoms and Signs – Differential Diagnosis of Hypocapnia
• Pulmonary embolism
• Pulmonary disease (asthma, interstitial fibrosis)
• Pregnancy
• Pneumonia, pneumonitis
• Pain
• Metabolic acidosis
• Medications (salicylates, β-adrenergic agonists, progesterone, methylxanthines)
• Hyperventilation
• High altitude
• Hepatic failure
• Fever, sepsis
• Congestive heart failure (CHF)
• CNS lesions
• Pulmonary embolism
• Pulmonary disease (asthma, interstitial fibrosis)
• Pregnancy
• Pneumonia, pneumonitis
• Pain
• Metabolic acidosis
• Medications (salicylates, β-adrenergic agonists, progesterone, methylxanthines)
• Hyperventilation
• High altitude
• Hepatic failure
• Fever, sepsis
• Congestive heart failure (CHF)
• CNS lesions
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Symptoms and Signs – Differential Diagnosis of Hypochloremia
• Vomiting
• Thiazide diuretic administration
• Syndrome of inappropriate antidiuretic hormone (SIADH)
• Salt-losing nephritis
• Primary aldosteronism
• Gastric suction
• Diarrhea
• Diaphoresis
• Diabetic ketoacidosis (DKA)
• Continuous infusion of D5W
• Congestive heart failure (CHF)
• Burns
• Addison’s disease
• Vomiting
• Thiazide diuretic administration
• Syndrome of inappropriate antidiuretic hormone (SIADH)
• Salt-losing nephritis
• Primary aldosteronism
• Gastric suction
• Diarrhea
• Diaphoresis
• Diabetic ketoacidosis (DKA)
• Continuous infusion of D5W
• Congestive heart failure (CHF)
• Burns
• Addison’s disease
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Symptoms and Signs – Differential Diagnosis of Hypochondriasis
• Underlying medical condition, such as multiple sclerosis, hypothyroidism, or systemic lupus erythematosus (SLE)
• Somatization disorder
• Body dysmorphic disorder (restricted to a circumscribed concern about appearance)
• Factitious disorder or malingering
• Generalized anxiety disorder with health concerns as one worry among many others
• Major depressive disorder with health concerns occurring only during depressive episodes
• Psychosis, such as may occur with depression or schizophrenia
• Underlying medical condition, such as multiple sclerosis, hypothyroidism, or systemic lupus erythematosus (SLE)
• Somatization disorder
• Body dysmorphic disorder (restricted to a circumscribed concern about appearance)
• Factitious disorder or malingering
• Generalized anxiety disorder with health concerns as one worry among many others
• Major depressive disorder with health concerns occurring only during depressive episodes
• Psychosis, such as may occur with depression or schizophrenia
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Symptoms and Signs – Differential Diagnosis of Hypogonadism
HYPERGONADOTROPIC HYPOGONADISM
• Hormone resistance (androgen, luteinizing hormone [LH] insensitivity)
• Gonadal defects (e.g., Klinefelter’s syndrome, myotonic dystrophy)
• Drug induced (e.g., spironolactone, cytotoxins)
• Alcoholism, radiation induced
• Mumps orchitis
• Anatomic defects, castration
HYPOGONADOTROPIC HYPOGONADISM
• Pituitary lesions (neoplasms, granulomas, infarction, hemochromatosis, vasculitis)
• Drug induced (e.g., glucocorticoids)
• Hyperprolactinemia
• Genetic disorders (Laurence-Moon-Biedl syndrome, Prader-Willi
syndrome)
• Delayed puberty
• Other: chronic disease, nutritional deficiency, Kallmann’s syndrome, idiopathic isolated LH or follicle-stimulating hormone (FSH) deficiency
HYPERGONADOTROPIC HYPOGONADISM
• Hormone resistance (androgen, luteinizing hormone [LH] insensitivity)
• Gonadal defects (e.g., Klinefelter’s syndrome, myotonic dystrophy)
• Drug induced (e.g., spironolactone, cytotoxins)
• Alcoholism, radiation induced
• Mumps orchitis
• Anatomic defects, castration
HYPOGONADOTROPIC HYPOGONADISM
• Pituitary lesions (neoplasms, granulomas, infarction, hemochromatosis, vasculitis)
• Drug induced (e.g., glucocorticoids)
• Hyperprolactinemia
• Genetic disorders (Laurence-Moon-Biedl syndrome, Prader-Willi
syndrome)
• Delayed puberty
• Other: chronic disease, nutritional deficiency, Kallmann’s syndrome, idiopathic isolated LH or follicle-stimulating hormone (FSH) deficiency
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Symptoms and Signs – Differential Diagnosis of Hypoimmunoglobulinemia
• IgM: congenital deficiency, lymphocytic leukemia, nephrotic syndrome
• IgG: congenital or acquired deficiency, lymphocytic leukemia, phenytoin, methylprednisolone, nephrotic syndrome, proteinlosing enteropathy
• IgE: hypogammaglobulinemia, neoplasm (breast, bronchial, cervical), ataxia-telangiectasia
• IgA: nephrotic syndrome, protein-losing enteropathy, congenital deficiency, lymphocytic leukemia, ataxia-telangiectasia, chronic sinopulmonary disease
• IgM: congenital deficiency, lymphocytic leukemia, nephrotic syndrome
• IgG: congenital or acquired deficiency, lymphocytic leukemia, phenytoin, methylprednisolone, nephrotic syndrome, proteinlosing enteropathy
• IgE: hypogammaglobulinemia, neoplasm (breast, bronchial, cervical), ataxia-telangiectasia
• IgA: nephrotic syndrome, protein-losing enteropathy, congenital deficiency, lymphocytic leukemia, ataxia-telangiectasia, chronic sinopulmonary disease
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Symptoms and Signs – Differential Diagnosis of hypokalemia
• β-Adrenergic agonists (e.g., terbutaline), decongestants, bronchodilators, theophylline, caffeine
• Vitamin B12 therapy for megaloblastic anemias, acute leukemias
• Renal tubular acidosis (RTA): distal (type 1) or proximal (type 2)
• Postobstruction diuresis, diuretic phase of tyrosinase-negative oculocutaneous albinism (ATN)
• Osmotic diuresis (e.g., mannitol)
• Magnesium deficiency
• Insulin administration
• Increased renal excretion secondary to medications: diuretics, including carbonic anhydrase inhibitors (e.g., acetazolamide); amphotericin B; high-dose sodium penicillin, nafcillin, ampicillin, or carbenicillin; cisplatin; aminoglycosides, corticosteroids, mineralocorticoids, foscarnet sodium
• Increased mineralocorticoid activity (primary or secondary aldosteronism), Cushing’s syndrome
• Inadequate dietary intake (e.g., anorexia nervosa)
• Hypokalemic periodic paralysis: rare familial disorder manifested by recurrent attacks of flaccid paralysis and hypokalemia
• High dietary sodium intake, excessive use of licorice
• GI loss: vomiting, nasogastric suction, diarrhea, laxative abuse, villous adenoma, fistulas
• Diabetic ketoacidosis (DKA), ureteroenterostomy
• Cutaneous loss (excessive sweating)
• Correction of digoxin intoxication with digoxin antibody fragments (Digibind)
• Chronic metabolic alkalosis from loss of gastric fluid (increased renal potassium secretion)
• Cellular shift (redistribution) and undetermined mechanisms
• Bartter’s syndrome: hyperplasia of juxtaglomerular cells leading to increased renin and aldosterone, metabolic alkalosis, hypokalemia, muscle weakness, and tetany (seen in young adults)
• Barium poisoning, toluene intoxication, verapamil intoxication, chloroquine intoxication
• Alkalosis (each 0.1 increase in pH decreases serum potassium by 0.4 to 0.6 mEq/L)
• β-Adrenergic agonists (e.g., terbutaline), decongestants, bronchodilators, theophylline, caffeine
• Vitamin B12 therapy for megaloblastic anemias, acute leukemias
• Renal tubular acidosis (RTA): distal (type 1) or proximal (type 2)
• Postobstruction diuresis, diuretic phase of tyrosinase-negative oculocutaneous albinism (ATN)
• Osmotic diuresis (e.g., mannitol)
• Magnesium deficiency
• Insulin administration
• Increased renal excretion secondary to medications: diuretics, including carbonic anhydrase inhibitors (e.g., acetazolamide); amphotericin B; high-dose sodium penicillin, nafcillin, ampicillin, or carbenicillin; cisplatin; aminoglycosides, corticosteroids, mineralocorticoids, foscarnet sodium
• Increased mineralocorticoid activity (primary or secondary aldosteronism), Cushing’s syndrome
• Inadequate dietary intake (e.g., anorexia nervosa)
• Hypokalemic periodic paralysis: rare familial disorder manifested by recurrent attacks of flaccid paralysis and hypokalemia
• High dietary sodium intake, excessive use of licorice
• GI loss: vomiting, nasogastric suction, diarrhea, laxative abuse, villous adenoma, fistulas
• Diabetic ketoacidosis (DKA), ureteroenterostomy
• Cutaneous loss (excessive sweating)
• Correction of digoxin intoxication with digoxin antibody fragments (Digibind)
• Chronic metabolic alkalosis from loss of gastric fluid (increased renal potassium secretion)
• Cellular shift (redistribution) and undetermined mechanisms
• Bartter’s syndrome: hyperplasia of juxtaglomerular cells leading to increased renin and aldosterone, metabolic alkalosis, hypokalemia, muscle weakness, and tetany (seen in young adults)
• Barium poisoning, toluene intoxication, verapamil intoxication, chloroquine intoxication
• Alkalosis (each 0.1 increase in pH decreases serum potassium by 0.4 to 0.6 mEq/L)
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Symptoms and Signs – Differential Diagnosis of Hypomagnesemia
• Renal tubular acidosis (RTA)
• Redistribution: hypoalbuminemia, cirrhosis, administration of insulin and glucose, theophylline, epinephrine, acute pancreatitis, cardiopulmonary bypass
• Parenteral therapy without magnesium
• Miscellaneous: sweating, burns, prolonged exercise, lactation, “hungry bones” syndrome
• Inadequate dietary intake (e.g., alcoholics)
• Endocrine disturbances (diabetic ketoacidosis [DKA], hyperaldosteronism, hyperthyroidism, hyperparathyroidism), syndrome of inappropriate antidiuretic hormone (SIADH), Bartter’s syndrome, hypercalciuria, hypokalemia
• Diuretics
• Diuretic phase of acute tubular necrosis (ATN)
• Defective GI absorption (malabsorption)
• Cisplatin, alcohol, cyclosporine, digoxin, pentamidine, mannitol, amphotericin B, foscarnet, methotrexate
• Chronic diarrhea, villous adenoma, prolonged nasogastric suction, fistulas (small bowel, biliary)
• Antibiotics (gentamicin, ticarcillin, carbenicillin)
• Renal tubular acidosis (RTA)
• Redistribution: hypoalbuminemia, cirrhosis, administration of insulin and glucose, theophylline, epinephrine, acute pancreatitis, cardiopulmonary bypass
• Parenteral therapy without magnesium
• Miscellaneous: sweating, burns, prolonged exercise, lactation, “hungry bones” syndrome
• Inadequate dietary intake (e.g., alcoholics)
• Endocrine disturbances (diabetic ketoacidosis [DKA], hyperaldosteronism, hyperthyroidism, hyperparathyroidism), syndrome of inappropriate antidiuretic hormone (SIADH), Bartter’s syndrome, hypercalciuria, hypokalemia
• Diuretics
• Diuretic phase of acute tubular necrosis (ATN)
• Defective GI absorption (malabsorption)
• Cisplatin, alcohol, cyclosporine, digoxin, pentamidine, mannitol, amphotericin B, foscarnet, methotrexate
• Chronic diarrhea, villous adenoma, prolonged nasogastric suction, fistulas (small bowel, biliary)
• Antibiotics (gentamicin, ticarcillin, carbenicillin)
