Systemic Examination

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

Genitalia Examination

1. External genitalia
2. SpeculumPap smear
3. Internal genitalia

Environment

• Dialysis tubes in flesh [urine].
• Dialysis bags [urine].
• Catheter [urine].
• Table: baby congratulation cards.

General appearance

• Weight: anorexic (amenorrhoea) or obese (polycystic ovary).
• Hydration level: under (ARF) [urine].
• Skin pigmentation (kidney excretion problems) [urine].
• Hyperventilation (acidosis) [urine].
• Hiccupping (uremia) [urine].
• Twitchingspasms (hypocalcemiaN2 retention) [urine]. 

Hands

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

Arms

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

Faceneck

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

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) [urine.
• Gently do Murphy's kidney punch in renal angle for tenderness (kidneyinfection).

Legs

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

Urine

• See Urinalysis Reference.

• Woman with emptied bladder.
• In lithotomy position [on backlegs apartknees bent]or L lateralposition if cannot.
• Gloves on.

External genitalia

• Rashesulcerationsswellingslesions.
• Separate labia with forefinger and thumbexamine clitoris.
• Look for discharge:
  • Bloody.
  • Purulent.
• Tell pt. to bear down: look for prolapse (cystocelerectocele).
• Tell pt. to cough (stess incontinence).
• Palpate Bartholin's glands [posterior of labia major] (palpable =Bartholin cyst/ abcess).
• If exam normal so fartell pt.

Speculum

• Do speculumpap smear before manual examination to avoid contamination
• Lubricatewarm bivalve speculum.
• Screw speculum until won't rattle. Grip like a gun.
• One hand separates labiaother hand inserts speculum in upwards directionwith blades closed.
• Open bladesinspect vagina and cervix.
• If exam normal so fartell pt.

Pap smear

• With speculum distended.
• Insert spatula against cervical osrotate it 360°.
• Optionallyinsert a brush to obtain some endocervical cells.
• Use other end of spatula on vaginal wall for homonal assessment.
• Smear samples on slides.
• If Trichomonas or thrushsmear on wet slides. If gonorrheaobtainculture.
• Close speculum as it is withdrawnso prevent trapping cervix.

Internal genitalia

• Lubricate indexmiddle finger if necessary.
• Left hand separates labia with index fingerthumb.
• Insert index then middle finger into vaginalocate cervix: sizeshapepositiontendernessmobility.
• Palpate fornices.
• Palpate ovaries (palpable = mass).
• Bimanual: fingers upand push other hand down back on pubic symphysis.
• With bimanualpalpate uterus: ante- or retrovertedas well asproperties.
  • Large nodular (fibroids).
  • Smooth enlargement (pregnantsubmucous fibroidsadenomyosis).

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