What are the key components of a focused physical examination (PE) for a patient with glomerulonephritis (inflammation of the glomeruli)?

Focused Physical Examination for Glomerulonephritis

A focused physical examination in glomerulonephritis must systematically assess for volume overload, hypertension, and systemic disease manifestations, as these directly impact morbidity and mortality. 1, 2

Vital Signs Assessment

• Measure blood pressure carefully as hypertension is a cardinal feature of nephritic syndrome and predicts progression; target BP goals vary by proteinuria level (≤130/80 mmHg if proteinuria <1 g/day; ≤125/75 mmHg if >1 g/day) 1
• Document temperature to identify infection-related glomerulonephritis or complications from immunosuppression 1
• Assess for oliguria as this is a critical predictor of end-stage renal disease and mortality 3

Volume Status and Edema

• Examine for peripheral edema, particularly pedal and periorbital edema, which indicates sodium and water retention from renal impairment 1, 4
• Assess for signs of fluid overload including pulmonary edema and pleural effusions, as pulmonary hemorrhage is a warning sign of rapidly progressive glomerulonephritis 2
• Calculate BMI as obesity can contribute to hyperfiltration injury in secondary forms 1

Cardiovascular Examination

• Auscultate for new or changed cardiac murmurs to identify endocarditis-associated glomerulonephritis 1
• Assess for signs of heart failure (elevated JVP, S3 gallop, rales) as this is a significant predictor of mortality 3

Skin and Mucous Membranes

• Examine skin for characteristic lesions including purpura (vasculitis), malar rash (lupus), or active impetigo/cellulitis (infection-related GN) 1
• Look for signs of active infection at skin or tonsil sites, particularly in suspected post-infectious glomerulonephritis 1

Abdominal Examination

• Palpate for splenomegaly which may indicate endocarditis-associated glomerulonephritis 1

Respiratory Assessment

• Auscultate lungs for crackles or signs of pulmonary hemorrhage, as respiratory failure is a significant mortality predictor and suggests ANCA-associated vasculitis or anti-GBM disease 2, 3

Neurological Examination

• Assess mental status and level of consciousness to identify uremic encephalopathy or complications from severe hypertension 4

Critical Pitfalls to Avoid

• Do not delay treatment while waiting for biopsy if clinical presentation and serology strongly suggest rapidly progressive disease, particularly in ANCA-associated vasculitis 2
• Do not miss signs of infection before initiating immunosuppression, as infections are the most frequent complication and mortality predictor 2, 3
• Do not overlook subtle signs of volume overload in patients with preserved renal function, as early intervention prevents progression 4