Bedside Diagnostic Challenge – 47-year-old woman with bilateral leg swelling

Paul Griner, MD, MACPBedside Diagnostic Challenge, Family Medicine, Internal Medicine

Diagnostic Case - 47 yo woman with leg swelling

Test your bedside diagnostic skills with this free clinical case question.


A 47-year-old-woman presents with the complaint of bilateral leg swelling of 2 week’s duration. She states that she had been in good health until about a month ago when she had a sore throat and low- grade fever for a few days. She then felt well until becoming aware of swelling of her feet at the end of the day. Approximately two weeks ago, the swelling increased gradually until it rose to the knees and did not regress overnight. She has had no other symptoms. Her past health has been satisfactory with no serious illnesses or operations. She takes no medications, does not smoke and has a “few beers” on weekends.

Physical examination reveals a healthy appearing woman with:

  • Temperature of 99.20 F
  • Blood Pressure of 136/70 mmHg
  • Pulse of 78 and regular
  • Respirations of 15 breaths per minute
  • There are no abnormal findings on examination of the lungs, heart, or abdomen.
  • There is 3+ soft pitting edema of both legs to the knees without pain or tenderness.
  • You notice an abnormality of the fingernails.


Based on the diagnostic value of careful examination …

Which of the following nail abnormalities should raise the likelihood that the patient has a nephrotic syndrome?

Answer Options:

Koilonychia (spooned nails)

Splinter hemorrhages

Clubbing of the nails

Muehrcke’s lines

Answer Explanation & References:

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About Bedside Diagnostic Challenge:

Except for Hospitalists, Emergency Medicine physicians, and Interventional Cardiologists, most internists will spend the bulk of their professional time with patients in an office setting.

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About the Author:

Paul Griner MD, MACP graduated from the University of Rochester School of Medicine and completed his residency at the Massachusetts General Hospital, Boston, MA. He has served the University of Rochester School of Medicine as Chief Resident in Medicine and as Professor, Department of Medicine. He has served as a Senior Lecturer at Harvard Medical School and consultant at the Massachusetts General Hospital where he introduced a mentoring program for the faculty of General Internal Medicine. Dr. Griner is board certified in internal medicine.