Differentials
Common
Essential hypertension
History
often asymptomatic; headaches, visual disturbance, nosebleeds, or neurological symptoms possible
Exam
may have signs of end organ damage; heave due to left ventricular hypertrophy, retinopathy, functional deficit following stroke; lack of signs to suggest a secondary cause
1st investigation
- ECG:
normal, evidence of previous MI or left axis deviation with left ventricular hypertrophy
- urea/creatinine:
normal, or elevated with renal impairment
- serum cholesterol:
variable
- random blood glucose:
>8 mmol/L on non-fasting sample suggestive of comorbid diabetes and fasting blood sugar advised
- urinalysis:
may be normal
More
Other investigations
Renal artery stenosis
History
often asymptomatic; headaches, visual disturbance, nosebleeds, or neurological symptoms possible; difficult-to-treat hypertension; peripheral vascular disease; may present with flash pulmonary oedema
Exam
bruit over the abdomen
1st investigation
- plasma renin activity:
elevated
Other investigations
- renal angiogram:
narrowing of renal artery
- renal MRI:
narrowing of renal artery
Chronic kidney disease
History
known renal impairment; usually asymptomatic; may present with headaches, visual disturbances, neurological deficits (e.g., transient ischaemic attack or stroke), or nose bleeds, fatigue, nausea, anorexia; difficult-to-treat hypertension suggests possible renal cause[67]
Exam
features of chronic renal failure: oedema, arteriovenous fistulae, pale conjunctiva secondary to anaemia
1st investigation
- urinalysis:
albuminuria, casts in the urine
- urea/creatinine:
elevated creatinine and urea
- renal ultrasound:
small kidneys
Other investigations
Obstructive uropathy
History
variable depending on cause; may report previous urethral instrumentation, flank pain with nephrolithiasis, hesitancy, frequency, and poor stream with prostatic enlargement
Exam
variable; enlarged prostate on rectal examination, flank tenderness with renal calculi
1st investigation
- renal ultrasound:
may show hydronephrosis or small kidneys with resultant chronic renal failure
- urea/creatinine:
elevated creatinine
Other investigations
- non-contrast CT pyelogram:
demonstrates renal calculi if present
Obstructive sleep apnoea/hypopnoea syndrome
History
sleeping for long periods of time, loud snoring, excessive daytime sleepiness, restless sleep, erectile dysfunction, morning headaches, GORD, and weight gain. Total score of ≥11 on Epworth sleepiness scale supports the diagnosis.
Exam
maxillomandibular abnormalities, macroglossia
1st investigation
Other investigations
- fibre-optic endoscopy:
may see nasal polyps or tumours, or hypertrophic lingual tonsils
Obesity hypoventilation syndrome
History
obesity (BMI ≥30 kg/m²), dyspnoea, nocturia, lower extremity oedema, excessive daytime sleepiness, fatigue, loud disruptive snoring, witnessed apnoeas, waking headaches, unexplained polycythaemia
Exam
mild hypoxemia awake, with significant hypoxaemia when asleep, awake daytime hypercapnia
1st investigation
Other investigations
- polysomnography:
demonstrates hypoventilation, particularly during REM sleep
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Uncommon
Coarctation of aorta
History
often asymptomatic; headaches, visual disturbance, nosebleeds, or neurological symptoms possible; cold legs, sweating
Exam
disparity in the blood pressure readings between both arms (left arm typically 20 mmHg lower than the right arm), radio-femoral delay, systolic or continuous murmurs over lateral chest wall, absence of pedal pulses
1st investigation
- ECG:
left ventricular hypertrophy
- echocardiogram:
left ventricular hypertrophy ± bicuspid aortic valve
More - chest x-ray:
widening of left subclavian border, double bulge above and below the usual site of the aortic knuckle, rib notching due to collaterals
Other investigations
- MRI scan of aorta:
coarctation is clearly defined and used to plan further management
Pre-eclampsia
History
pregnant woman, >20 weeks' gestation, usually >32 weeks' gestation, can be asymptomatic, may have facial or limb swelling, may have epigastric pain that radiates to the back
Exam
newly elevated blood pressure >140/90 mmHg on 2 readings 6 hours apart, may have facial or limb pitting oedema
1st investigation
Other investigations
- fetal ultrasound:
variable depending on severity; fetal biometry may reveal fetal growth restriction
- coagulation screen:
typically normal
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Glomerulonephritis
History
nausea, malaise, weight loss, fever, features of underlying aetiology (e.g., arthralgia)
Exam
oedema with nephrotic features, hypervolaemia, signs of underlying aetiology; skin rash
1st investigation
- urinalysis:
dysmorphic red blood cells, sub-nephrotic proteinuria, and active sediment
- 24-hour urine collection:
proteinuria is generally <3.5 g/day
Other investigations
- renal biopsy:
characteristic findings on light and immunofluorescence microscopy
Nephrotic syndrome
Polycystic kidney disease
History
haematuria, headaches, abdominal pain, elevated blood pressure often presenting feature in young patients (20 to 34 years); family history of polycystic kidneys, or intracranial aneurysm, or subarachnoid haemorrhage
Exam
palpable kidneys; hepatomegaly, inguinal, incisional, and para-umbilical hernias are not uncommon
1st investigation
- renal ultrasound:
30 years of age: at least 2 unilateral or bilateral cysts; 30-59 years of age: 2 cysts in each kidney; >60 years of age: 4 cysts in each kidney
- urinalysis:
proteinuria, increased urinary albumin excretion, and haematuria are common
More
Other investigations
Phaeochromocytoma
History
usually asymptomatic; may present with headaches, visual disturbances, neurological deficits (e.g., transient ischaemic attack or stroke), or nose bleeds; symptoms of the hyper-adrenergic state: palpitations, panic attacks, cold clammy skin, pallor, abdominal cramps[79]
Exam
no specific findings, features of hypertension-mediated organ damage possible
1st investigation
- urinary catecholamines, vanillylmandelic acid, and metanephrins:
levels twice the laboratory reference range are suggestive
- plasma metanephrins:
levels twice the laboratory reference range are suggestive
More
Other investigations
- CT or MRI of adrenals:
localisation of lesion if presence suggested by initial tests
Hyperaldosteronism
History
usually asymptomatic (patients are typically normokalaemic); if serum potassium is low: headaches, tiredness, nocturia, paraesthesiae, muscle cramps, palpitations
Exam
no specific findings, features of hypertension-mediated organ damage possible
1st investigation
Other investigations
- CT or MRI of adrenals:
localisation of adenoma/tumour
- adrenal vein sampling:
aldosterone to cortisol ratio >2 between sides suggestive of aldosterone-secreting tumour
Cushing's disease/syndrome
History
psychiatric symptoms, weight gain, hirsutism, easy bruisability, decreased libido
Exam
supraclavicular fullness due to fat deposition, facial plethora, violaceous striae
1st investigation
- late-night salivary cortisol:
elevated
- 1 mg overnight dexamethasone suppression test:
>50 nanomol/L (1.8 microgram/dL)
More - 24-hour urinary free cortisol:
>50 micrograms/24 hours
Other investigations
Hyperthyroidism
History
heat intolerance, sweating, weight loss, palpitations, tremor
Exam
tachycardia, proptosis, exophthalmos, cardiac flow murmur
1st investigation
- thyroid-stimulating hormone:
suppressed
More - serum free T4:
elevated above normal range
- serum free or total T3:
elevated above normal range
Other investigations
Hypothyroidism
History
weight gain, lethargy, depression, constipation
Exam
dry skin, bradycardia, thick tongue, eyelid oedema
1st investigation
- serum thyroid-stimulating hormone:
elevated above normal range
- free serum T4:
below normal range
Other investigations
Hyperparathyroidism
History
fatigue, anxiety, depression, bone pain, paraesthesiae, myalgia
Exam
band keratopathy (deposition of calcium just inside the iris on eye examination), fibro-osseous jaw tumours on palpation (uncommon)
1st investigation
- serum calcium:
elevated
More - serum PTH levels:
normal or elevated
Other investigations
Chronic alcohol excess
History
central nervous system excitability on withdrawal of alcohol, dependency behaviour, tolerance; social, economic, or legal problems
Exam
jaundice, hepatomegaly, evidence of cirrhosis; spider nevi, ascites
1st investigation
- diagnostic interview:
Structured Clinical Interview for DSM (SCID) can be administered by non-clinicians and can replace a psychiatric interview; at least 2 of the 11 DSM-5 criteria for alcohol-use disorder must be present
- gamma glutamyl transferase, alanine aminotransferase, and aspartate aminotransferase:
elevated
Other investigations
Medication
History
chronic use of non-steroidal anti-inflammatory drugs or current use of oral contraceptives, glucocorticoids, ciclosporin, atypical antipsychotics, or vascular endothelial growth factor receptor tyrosine kinase inhibitors
Exam
no specific examination findings
1st investigation
- trial discontinuation of medication:
elevated blood pressure resolves
More
Other investigations
Illicit drug use
History
history of use of vasoactive illicit drug (e.g., cocaine, metamfetamine) and/or non-compliance with prescribed medications; nervousness, restlessness, tremors, anxiety, irritability; hostility and exaggerated strength; headache; abdominal pains; hallucinations, convulsions, delirium, unconsciousness, seizures
Exam
constricted or dilated pupils, cold extremities, tachycardia; nervousness, restlessness, tremors, anxiety, and irritability; rise in body temperature/hyperthermia; enhanced reflexes; irregular respiration
1st investigation
Other investigations
'White-coat hypertension'
History
asymptomatic, elevated blood pressure readings in clinic but normal readings at home or outside hospital environment
Exam
no evidence of end organ damage as hypertension is not sustained outside clinical environment
1st investigation
- 24-hour blood pressure monitoring:
normal
More
Other investigations
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