PCNL or kidney trauma. Open surgery may be necessary if other measures fail. B) Treat the cause Atallah A. Shaaban Basic Urology 44 General Examination Note the general appearance while talking. Hands and radial pulse. Face and mouth. Neck. Chest and heart. Lower limbs (edema, circulation, loco-motor functions and neurological). Abdominal examination. Scrotum. Pelvic examination. Height and weight (BMI). Urinalysis.

Examination of the face: 1- Uremia: - Sallow complexion (a dirty brown appearance or uremic tinge) due to impaired excretion of urochromes and anemia. - Hyperventilation: metabolic acidosis. - Hiccup. - Uremic fetor: ammoniacal fish breath due to breakdown of urea in saliva. - Eyes: Anemia. Jaundice. Atallah A. Shaaban Basic Urology 45

Band keratopathy: calcium deposition beneath the corneal epithelium in line with the inter-palpebral fissure due to excessive calcium replacement or hyperparathyroidism. - Muscle twitches due to tetany and epilepsy. - Subcutaneous nodules (calcium phosphate). 2- Cushing's syndrome: - Moon face. - Plethora. - Acne. - Hirsutism. - Buffalo hump. 3- Tuberous sclerosis: familial - Adenoma sebaceum. - Mental retardation. - Epilepsy. - Renal hamartoma (angiomyolipoma).

Complexion: 1- Pallor: - The normal conjunctiva is red pink in the palpebral part and creamy in the sclera. This difference is absent in significant anemia. - The palmar skin creases and nail beds are inspected.

2-Jaundice: - Yellowish pigmentation of the skin, sclera and mucous membranes due to increased bilirubin - Best appreciated in natural daylight. Atallah A. Shaaban Basic Urology 46 3-Cyanosis - Bluish discoloration of the skin and mucous membranes due to increased deoxygenated hemoglobin in blood. - Central cyanosis: blue tongue& periphery: Chronic obstructive pulmonary disease. Massive pulmonary embolism. Cyanotic congenital heart disease. Polycythemia. Met- and sulph-hemoglobinemia. - Peripheral cyanosis: blue fingers and toes: All causes of central cyanosis. Exposure to cold. Reduced cardiac output (shock, left ventricular failure). Peripheral vascular obstruction.

Examination of the neck: Inspection: - Sit the patient with the head looking straight ahead.