Check the vital signs.

An elevated blood pressure may indicate acute or chronic renal disease. A rapid pulse or tachypnea could indicate volume overload and hence renal failure.

Assess overall appearance.

Puffiness and pallor can be a sign of acute fluid retention as might be seen in acute post-infectious glomerulonephritis. Marked edema can be a sign of nephrotic syndrome.

Check the eye grounds.

Hypertension could cause hemorrhages or exudates. Extreme photophobia could be seen with cystinosis. Alport’s syndrome is associated with ocular abnormalities (cataracts, keratoconus and spherophakia).

Check hearing.

Alport’s syndrome is associated with the onset of hearing loss in the range of 4000 to 8000 Hz. (audiometry required).

Check ears, nose and throat.

Skin tags, clefts and otic pits may be associated with congenital abnormalities of the kidneys. Enlarged, enflamed tonsils could be seen with acute post-infectious glomerulonephritis.

Auscultate chest carefully.

Rales and rhonchae can be a sign of volume overload and hence acute post-infectious glomerulonephritis or chronic glomerulonephritis. A pleuritic rub can be associated with lupus erythematosis.

Auscultate the heart carefully.

A pericardial rub can be a sign of lupus. A gallop can be a sign of volume overload. Remember that post-infectious glomerulonephritis and rheumatic heart disease may be seen in the same patient.

Palpate the abdomen carefully.

A mass can be an enlarged kidney due to obstruction or a neoplasm. Bilaterally enlarged kidneys can represent autosomal dominant or recessive polycystic kidney disease. An enlarged liver can represent congestion and volume overload. Enlarged livers may be seen with autosomal recessive polycystic kidney disease. Ascites is often seen with nephrotic syndrome.

Examine the genitalia.

Edema of the vulva, prepuce and scrotum can be a sign of ascites. Renal anomalies can be seen with undescended testes and hypospadias. Ambiguous genitalia may be associated with renal anomalies.

Evaluate the neurological status.

Hypertensive encephalopathy can present as confusion or excitability. Lupus can present as a cerebritis and hence the patient is encephalopathic.