Systemic Examination

1. Environmentgeneral appearance
2. Handsarms faceneck chest
3. Abdomenbacklegs
4. Urine

Genitalia Examination

1. Penis
2. Scrotum: insppalptranslucency
3. Spermatic cord

Environment

• Dialysis tubes in flesh.
• Dialysis bags.
• Catheter.

General appearance

• Hydration level: under (ARF).
• Skin pigmentation (kidney excretion problems).
• Hyperventilation (acidosis).
• Hiccupping (uremia).
• Twitchingspasms (hypocalcemiaN2 retention). 

Hands

• Nails: leuconychia [white transverse bands]Muehrcke's nails [whitepaired lines near fingernail tip] (nephrotic syndrome's hypoalbuminemia).
• Nails: others (do later).
• Palmar creases: pallor (anemia).
• Wrists: shunts from prior dialysis.

Arms

• Scratch marks (2° hyperparathyroid).
• Uremic frost [white powder on skin] (chronic renal failure).
• Peripheral neuropathy (chronic renal failure 2° to diabetes).
• Bone tenderness (low vit D).
• Blood pressure (HTN 2° to chronic renal failure).
• Postural hypotension if applicable (ARF).

Faceneck

• Eyes: jaundiceanemia.
• Eyes: fundi (diabetes). See FundiExamination.
• Mouth: fetor.
• Mouth: ulcersinfections.
• Face: rash (SLEsystemic sclerosis).

Chest

• Heart: CHF.
• Heart: hypertension.
• Heart pericarditis.
• Lung: pulmonary edema.

Abdomen

• Scars: nephrectomy [may need to roll pt. on side]kidney transplant.
• Distension (APKD/ Wilm's tumor [young]nephrotic syndromeascitiesdialysis).
• Palpate kidneys.
• Palpate enlarged bladder.
• Palpate hepatomegalysplenomegaly (APKD).
• Palpate AAAso can DDx from renal stenosis on auscultation.
• Assess ascites. See Ascites.
• Percuss enlarged bladder.
• Auscultate renal bruit: above umbilicus 2cm lateral to midlinethen inflanks (renal artery stenosis).

Back

• Ask if tenderness in back.
• Sacral edema (CHFnephrotic syndrome).
• Gently strike base of spine with fist for tenderness (renal osteomalacia2hyperparathyroidism).
• Gently do Murphy's kidney punch in renal angle for tenderness (kidneyinfection).

Legs

• Edema.
• Peripheral vascular dz (chronic renal failure 2° to diabetes).
• Injured toes from diabetes (chronic renal failure 2° to diabetes).
• Purpura.
• Toes: tophi (gout).

Urine

• See Urinalysis Reference.

Penis

• Gloves on.
• Retract foreskin if indicated.
• Rashesulcerationsswellingslesionswarts.
• Urethral meatus:
  • Meatus is patent
  • Meatus is in normal location.
  • No extra openings (hypospadias).
• Look for discharge:
  • Bloody.
  • Purulent.
  • Smegma [cheese-like substance] under foreskin.
• If dischargecompress penis to excrete some into jar for analysis.
• Tell pt. to cough (stress incontinence).

Scrotum: inspect

• Pt. standing up.
• Asymmetry is normal: L lower than R.
• Note size (mumps)position.
• Rashesulcerationsswellingslesions.
• Look for discharge:
  • Bloody.
  • Purulent.
• Tell pt. to cough (stress incontinence).

Scrotum: palpate

• Similar sizeconsistency for R and L.
• Smoothnessfirmness.
• Absent testicle causes:
  • Undescended [look in inguinal canal].
  • Surgical removal.
• Masses. See Testicular MassesReference.
• If mass palpatedDr tries to get above it. If unablelikely an inguinalhernia.

Scrotum: translucency

• Perform if a mass was palpated.
• Turn off lights.
• Hold light up to posterior of swellingand test for translucency:
  • Opaque: solid mass.
  • Translucent: cystic.
• Examine whether separate from the testis.
• See Testicular Masses Reference.

Spermatic cord

• Palpate from epididymis to superficial inguinal ring.
• Locate both R and L ductus deferens within scrotum.

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