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Symptoms and Signs – Differential Diagnosis of Hyperkalemia
PSEUDOHYPERKALEMIA
• Hemolyzed specimen
• Severe thrombocytosis (platelet count >106 mL)
• Severe leukocytosis (white blood cell count >105 mL)
• Fist clenching during phlebotomy
EXCESSIVE POTASSIUM INTAKE (OFTEN IN SETTING OF IMPAIRED EXCRETION)
• Potassium replacement therapy
• High-potassium diet
• Salt substitutes with potassium
• Potassium salts of antibiotics
DECREASED RENAL EXCRETION
• Potassium-sparing diuretics (e.g., spironolactone, triamterene,
amiloride)
• Renal insufficiency
• Mineralocorticoid deficiency
• Hyporeninemic hypoaldosteronism (diabetes mellitus [DM])
• Tubular unresponsiveness to aldosterone (e.g., systemic lupus erythematosus [SLE], multiple myeloma, sickle cell disease)
• Type 4 renal tubular acidosis (RTA)
• Angiotensin-converting enzyme (ACE) inhibitors
• Heparin administration
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Trimethoprim-sulfamethoxazole
• β-Blockers
• Pentamidine
REDISTRIBUTION (EXCESSIVE CELLULAR RELEASE)
• Acidemia (each 0.1 decrease in pH increases the serum potassium by 0.4 to 0.6 mEq/L). Lactic acidosis and ketoacidosis cause
minimal redistribution.
• Insulin deficiency
• Drugs (e.g., succinylcholine, markedly increased digitalis level,
arginine, β-adrenergic blockers)
• Hypertonicity
• Hemolysis
• Tissue necrosis, rhabdomyolysis, burns
• Hyperkalemic periodic paralysis
PSEUDOHYPERKALEMIA
• Hemolyzed specimen
• Severe thrombocytosis (platelet count >106 mL)
• Severe leukocytosis (white blood cell count >105 mL)
• Fist clenching during phlebotomy
EXCESSIVE POTASSIUM INTAKE (OFTEN IN SETTING OF IMPAIRED EXCRETION)
• Potassium replacement therapy
• High-potassium diet
• Salt substitutes with potassium
• Potassium salts of antibiotics
DECREASED RENAL EXCRETION
• Potassium-sparing diuretics (e.g., spironolactone, triamterene,
amiloride)
• Renal insufficiency
• Mineralocorticoid deficiency
• Hyporeninemic hypoaldosteronism (diabetes mellitus [DM])
• Tubular unresponsiveness to aldosterone (e.g., systemic lupus erythematosus [SLE], multiple myeloma, sickle cell disease)
• Type 4 renal tubular acidosis (RTA)
• Angiotensin-converting enzyme (ACE) inhibitors
• Heparin administration
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Trimethoprim-sulfamethoxazole
• β-Blockers
• Pentamidine
REDISTRIBUTION (EXCESSIVE CELLULAR RELEASE)
• Acidemia (each 0.1 decrease in pH increases the serum potassium by 0.4 to 0.6 mEq/L). Lactic acidosis and ketoacidosis cause
minimal redistribution.
• Insulin deficiency
• Drugs (e.g., succinylcholine, markedly increased digitalis level,
arginine, β-adrenergic blockers)
• Hypertonicity
• Hemolysis
• Tissue necrosis, rhabdomyolysis, burns
• Hyperkalemic periodic paralysis
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Symptoms and Signs – Differential Diagnosis of Acquired Hypercoagulable State
ANTIPHOSPHOLIPID ANTIBODY SYNDROME
• Most common cause of acquired thrombophilia
• Can present as arterial or venous thrombosis, recurrent pregnancy loss, and adverse pregnancy outcomes
• Thromboembolic events occur in up to 30% of population; high risk of recurrent thrombosis (up to 70% reported).
HYPERHOMOCYSTEINEMIA
• Can be inherited (most commonly an autosomal recessive mutation in methylene tetrahydrofolate reductase gene) but more frequently acquired; folate, vitamin B6, or vitamin B12 deficiency accounts for two thirds of cases. Other acquired causes include renal disease, hypothyroidism, malignant disease, smoking, and certain medications.
• May be associated with venous thromboembolism (VTE), atherosclerotic disease (cardiovascular, cerebrovascular, and peripheral vascular), and possibly adverse pregnancy outcomes
CONDITIONS ASSOCIATED WITH INCREASED RISK OF THROMBOSIS
• Prior thrombosis
• Trauma
• Medical illness: heart failure, respiratory failure, infection, diabetes mellitus, obesity, nephrotic syndrome, inflammatory bowel disease, paroxysmal nocturnal hemoglobinuria, sickle cell anemia
• Pregnancy (sixfold increased risk of VTE), post partum, OC use (fourfold increased risk, higher risk with third-generation OCs), transdermal contraceptive patch, HRT (twofold increased risk), tamoxifen, raloxifene
• Immobilization, travel
• Surgery (especially orthopedic), central venous catheters
• Hyperviscosity syndromes
• Myeloproliferative disorders
• Malignancy: disease or treatment related
• Heparin-induced thrombocytopenia and thrombosis
• Smoking
ANTIPHOSPHOLIPID ANTIBODY SYNDROME
• Most common cause of acquired thrombophilia
• Can present as arterial or venous thrombosis, recurrent pregnancy loss, and adverse pregnancy outcomes
• Thromboembolic events occur in up to 30% of population; high risk of recurrent thrombosis (up to 70% reported).
HYPERHOMOCYSTEINEMIA
• Can be inherited (most commonly an autosomal recessive mutation in methylene tetrahydrofolate reductase gene) but more frequently acquired; folate, vitamin B6, or vitamin B12 deficiency accounts for two thirds of cases. Other acquired causes include renal disease, hypothyroidism, malignant disease, smoking, and certain medications.
• May be associated with venous thromboembolism (VTE), atherosclerotic disease (cardiovascular, cerebrovascular, and peripheral vascular), and possibly adverse pregnancy outcomes
CONDITIONS ASSOCIATED WITH INCREASED RISK OF THROMBOSIS
• Prior thrombosis
• Trauma
• Medical illness: heart failure, respiratory failure, infection, diabetes mellitus, obesity, nephrotic syndrome, inflammatory bowel disease, paroxysmal nocturnal hemoglobinuria, sickle cell anemia
• Pregnancy (sixfold increased risk of VTE), post partum, OC use (fourfold increased risk, higher risk with third-generation OCs), transdermal contraceptive patch, HRT (twofold increased risk), tamoxifen, raloxifene
• Immobilization, travel
• Surgery (especially orthopedic), central venous catheters
• Hyperviscosity syndromes
• Myeloproliferative disorders
• Malignancy: disease or treatment related
• Heparin-induced thrombocytopenia and thrombosis
• Smoking
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Symptoms and Signs – Differential Diagnosis of Hypercoagulable State, Associated Disorders
• Systemic lupus erythematosus in association with the presence of a lupus anticoagulant or antiphospholipid antibodies
• Malignant neoplasm
• Disease related: includes migratory superficial thrombophlebitis (Trousseau’s syndrome), nonbacterial thrombotic endocarditis,thrombosis associated with chronic DIC, thrombotic
microangiopathy
• Treatment related: associated with the administration of various chemotherapeutic agents (asparaginase, mitomycin, someadjuvant chemotherapeutic agents for treatment of breast cancer,thalidomide or lenalidomide in conjunction with high doses of dexamethasone)
• Infusion of prothrombin complex concentrates
• Nephrotic syndrome
• Heparin-induced thrombocytopenia
• Myeloproliferative disorders
• Paroxysmal nocturnal hemoglobinuria
• Systemic lupus erythematosus in association with the presence of a lupus anticoagulant or antiphospholipid antibodies
• Malignant neoplasm
• Disease related: includes migratory superficial thrombophlebitis (Trousseau’s syndrome), nonbacterial thrombotic endocarditis,thrombosis associated with chronic DIC, thrombotic
microangiopathy
• Treatment related: associated with the administration of various chemotherapeutic agents (asparaginase, mitomycin, someadjuvant chemotherapeutic agents for treatment of breast cancer,thalidomide or lenalidomide in conjunction with high doses of dexamethasone)
• Infusion of prothrombin complex concentrates
• Nephrotic syndrome
• Heparin-induced thrombocytopenia
• Myeloproliferative disorders
• Paroxysmal nocturnal hemoglobinuria
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Symptoms and Signs – Differential Diagnosis of Hypercortisolemia
• Stress
• Pregnancy
• Loss of normal diurnal variation
• Iatrogenic
• Ectopic adrenocorticotropic hormone (ACTH) production (e.g., small cell carcinoma of lung)
• Chronic renal failure
• Adrenal or pituitary hyperplasia or adenomas
• Stress
• Pregnancy
• Loss of normal diurnal variation
• Iatrogenic
• Ectopic adrenocorticotropic hormone (ACTH) production (e.g., small cell carcinoma of lung)
• Chronic renal failure
• Adrenal or pituitary hyperplasia or adenomas
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Symptoms and Signs – Differential Diagnosis of Hyperemesis Gravidarum
• Pyelonephritis
• Pancreatitis
• Hepatitis
• Cholecystitis
• Pyelonephritis
• Pancreatitis
• Hepatitis
• Cholecystitis
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Symptoms and Signs – Differential Diagnosis of Hypereosinophilia
• Warfarin sensitivity
• Urticaria
• Radiation therapy
• Pernicious anemia
• Pemphigus
• Parasitic infestations (trichinosis, aspergillosis, hydatidosis)
• Non-Hodgkin’s lymphoma
• Myeloproliferative disorders
• L-Tryptophan ingestion
• Inflammatory bowel disease (IBD)
• Hodgkin’s disease
• Eosinophilic nonallergic rhinitis
• Drug reactions
• Collagen-vascular diseases
• Bronchial asthma
• Angioneurotic edema
• Allergy
• Acute hypereosinophilic syndrome
• Warfarin sensitivity
• Urticaria
• Radiation therapy
• Pernicious anemia
• Pemphigus
• Parasitic infestations (trichinosis, aspergillosis, hydatidosis)
• Non-Hodgkin’s lymphoma
• Myeloproliferative disorders
• L-Tryptophan ingestion
• Inflammatory bowel disease (IBD)
• Hodgkin’s disease
• Eosinophilic nonallergic rhinitis
• Drug reactions
• Collagen-vascular diseases
• Bronchial asthma
• Angioneurotic edema
• Allergy
• Acute hypereosinophilic syndrome
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Symptoms and Signs-Differential Diagnosis of Hypergastrinemia
• Rheumatoid arthritis (RA)
• Pyloric obstruction
• Hypochlorhydria due to atrophic gastritis, gastric carcinoma,pernicious anemia
• Hyperplasia of antral G cells
• Gastrinoma (Zollinger-Ellison syndrome)
• Decreased gastrin release inhibition from medications (proton pump inhibitors [PPIs], H2 receptor antagonists), vagotomy
• Chronic renal failure
• Rheumatoid arthritis (RA)
• Pyloric obstruction
• Hypochlorhydria due to atrophic gastritis, gastric carcinoma,pernicious anemia
• Hyperplasia of antral G cells
• Gastrinoma (Zollinger-Ellison syndrome)
• Decreased gastrin release inhibition from medications (proton pump inhibitors [PPIs], H2 receptor antagonists), vagotomy
• Chronic renal failure
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Symptoms and Signs – Differential Diagnosis of Hyperglycemia
• Stress
• Myocardial infarction (MI)
• Infections
• Impaired glucose tolerance
• Hemochromatosis
• Glucagonoma
• Drugs (glucocorticoids, diuretics [thiazides, loop diuretics])
• Diabetes mellitus (DM)
• Cushing’s syndrome
• Cerebrovascular accident (CVA)
• Acute pancreatitis
• Acromegaly
• Stress
• Myocardial infarction (MI)
• Infections
• Impaired glucose tolerance
• Hemochromatosis
• Glucagonoma
• Drugs (glucocorticoids, diuretics [thiazides, loop diuretics])
• Diabetes mellitus (DM)
• Cushing’s syndrome
• Cerebrovascular accident (CVA)
• Acute pancreatitis
• Acromegaly
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Symptoms and Signs – Differential Diagnosis of Hyperhidrosis
CORTICAL
• Emotional
• Familial dysautonomia
• Congenital ichthyosiform erythroderma
• Epidermolysis bullosa
• Nail-patella syndrome
• Jadassohn-Lewandowsky syndrome
• Pachyonychia congenita
• Palmoplantar keratoderma
HYPOTHALAMIC
Drugs
• Antipyretics
• Emetics
• Insulin
• Meperidine
Exercise
Infection
• Defervescence
• Chronic illness
Metabolic
• Debility
• Diabetes mellitus (DM)
• Hyperpituitarism
• Hyperthyroidism
• Hypoglycemia
• Obesity
• Porphyria
• Pregnancy
• Rickets
• Infantile scurvy
Cardiovascular
• Heart failure
• Shock
Vasomotor
• Cold injury
• Raynaud’s phenomenon
• Rheumatoid arthritis (RA)
Neurologic
• Abscess
• Familial dysautonomia
• Postencephalitic
• Tumor
Miscellaneous
• Chédiak-Higashi syndrome
• Compensatory
• Phenylketonuria (PKU)
• Pheochromocytoma
• Vitiligo
MEDULLARY
• Physiologic gustatory sweating
• Encephalitis
• Granulosis rubra nasi
• Syringomyelia
• Thoracic sympathetic trunk injury
SPINAL
• Cord transection
• Syringomyelia
CHANGES IN BLOOD FLOW
• Arteriovenous fistula
• Klippel-Trénaunay syndrome
• Glomus tumor
• Blue rubber bleb nevus syndrome
CORTICAL
• Emotional
• Familial dysautonomia
• Congenital ichthyosiform erythroderma
• Epidermolysis bullosa
• Nail-patella syndrome
• Jadassohn-Lewandowsky syndrome
• Pachyonychia congenita
• Palmoplantar keratoderma
HYPOTHALAMIC
Drugs
• Antipyretics
• Emetics
• Insulin
• Meperidine
Exercise
Infection
• Defervescence
• Chronic illness
Metabolic
• Debility
• Diabetes mellitus (DM)
• Hyperpituitarism
• Hyperthyroidism
• Hypoglycemia
• Obesity
• Porphyria
• Pregnancy
• Rickets
• Infantile scurvy
Cardiovascular
• Heart failure
• Shock
Vasomotor
• Cold injury
• Raynaud’s phenomenon
• Rheumatoid arthritis (RA)
Neurologic
• Abscess
• Familial dysautonomia
• Postencephalitic
• Tumor
Miscellaneous
• Chédiak-Higashi syndrome
• Compensatory
• Phenylketonuria (PKU)
• Pheochromocytoma
• Vitiligo
MEDULLARY
• Physiologic gustatory sweating
• Encephalitis
• Granulosis rubra nasi
• Syringomyelia
• Thoracic sympathetic trunk injury
SPINAL
• Cord transection
• Syringomyelia
CHANGES IN BLOOD FLOW
• Arteriovenous fistula
• Klippel-Trénaunay syndrome
• Glomus tumor
• Blue rubber bleb nevus syndrome
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Symptoms and Signs – Differential Diagnosis of Hydrocele
• Epididymitis
• Inguinoscrotal hernia
• Spermatocele
• Testicular tumor
• Varicocele
• Epididymitis
• Inguinoscrotal hernia
• Spermatocele
• Testicular tumor
• Varicocele
