ribs and pulling the ribcage forward (Fig. 6.16B), or ask
the patient to roll towards you and on to their right side
• Feel along the left costal margin and percuss over the
lateral chest wall. The normal spleen causes dullness to
percussion posterior to the left mid-axillary line beneath
There are many causes of splenomegaly (Box 6.13).
Massive enlargement in the developed world is usually due
to myeloproliferative disease or haematological malignancy;
worldwide, malaria is a common cause.
Important causes of hepatosplenomegaly include lymphoma
or myeloproliferative disorders, cirrhosis with portal hypertension,
amyloidosis, sarcoidosis and glycogen storage disease.
Ascites is the accumulation of intraperitoneal fluid (see Fig. 6.6).
• With the patient supine, percuss from the midline out to
the flanks (Fig. 6.17). Note any change from resonant to
dull, along with areas of dullness and resonance.
ascites the note then becomes resonant.
Fig. 6.18 Eliciting a fluid thrill.
110 • The gastrointestinal system
characteristics, and attempt to differentiate between direct and
• Examine the groin with the patient standing upright.
• Inspect the inguinal and femoral canals and the scrotum
• Ask the patient to cough; look for an impulse over the
femoral or inguinal canal and scrotum.
• Identify the anatomical relationships between the bulge,
the pubic tubercle and the inguinal ligament to distinguish
a femoral from an inguinal hernia.
• Palpate the external inguinal ring and along the inguinal
canal for possible muscle defects. Ask the patient to
cough and feel for a cough impulse.
• Now ask the patient to lie down and establish whether the
• If so, press two fingers over the internal inguinal ring at the
mid-inguinal point and ask the patient to cough or stand
up while you maintain pressure over the internal inguinal
ring. If the hernia reappears, it is a direct hernia. If it can be
prevented from reappearing, it is an indirect inguinal hernia.
• Examine the opposite side to exclude the possibility of
An indirect inguinal hernia bulges through the internal ring and
follows the course of the inguinal canal. It may extend beyond
the external ring and enter the scrotum. Indirect hernias comprise
85% of all hernias and are more common in younger men.
A direct inguinal hernia forms at a site of muscle weakness in
the posterior wall of the inguinal canal and rarely extends into the
scrotum. It is more common in older men and women (Fig. 6.20).
A femoral hernia projects through the femoral ring and into the
femoral canal. Inguinal hernias are palpable above and medial
to the pubic tubercle. Femoral hernias are palpable below the
inguinal ligament and lateral to the pubic tubercle.
In a reducible hernia the contents can be returned to the
abdominal cavity, spontaneously or by manipulation; if they
cannot, the hernia is irreducible. An abdominal hernia has a
covering sac of peritoneum and the neck of the hernia is a
common site of compression of the contents (Fig. 6.21). If the
• Now listen 2–3 cm above and lateral to the umbilicus for
bruits from renal artery stenosis.
• Listen over the liver for bruits.
• Test for a succussion splash; this sounds like a half-filled
water bottle being shaken. Explain the procedure to the
patient, then shake their abdomen by rocking their pelvis
Normal bowel sounds are gurgling noises from the normal
peristaltic activity of the gut. They normally occur every 5–10
seconds but the frequency varies.
Absence of bowel sounds implies paralytic ileus or peritonitis.
In intestinal obstruction, bowel sounds occur with increased
frequency and volume, and have a high-pitched, tinkling quality.
Bruits suggest an atheromatous or aneurysmal aorta or superior
mesenteric artery stenosis. A friction rub, which sounds like
rubbing your dry fingers together, may be heard over the liver
(perihepatitis) or spleen (perisplenitis). An audible splash more than
4 hours after the patient has eaten or drunk anything indicates
delayed gastric emptying, as in pyloric stenosis.
The inguinal canal extends from the pubic tubercle to the
anterior superior iliac spine (Fig. 6.19). It has an internal ring at
the mid-inguinal point (midway between the pubic symphysis
and the anterior superior iliac spine) and an external ring at the
pubic tubercle. The femoral canal lies below the inguinal ligament
and lateral to the pubic tubercle.
Hernias are common and typically occur at openings of the
abdominal wall, such as the inguinal, femoral and obturator
canals, the umbilicus and the oesophageal hiatus. They may
also occur at sites of weakness of the abdominal wall, as in
An external abdominal hernia is an abnormal protrusion of bowel
and/or omentum from the abdominal cavity. External hernias are
more obvious when the pressure within the abdomen rises, such
as when the patient is standing, coughing or straining at stool.
Internal hernias occur through defects of the mesentery or into
the retroperitoneal space and are not visible.
An impulse can often be felt in a hernia during coughing
(cough impulse). Identify a hernia from its anatomical site and
Intra-abdominal malignancy with
Hepatic vein occlusion (Budd–Chiari
Constrictive pericarditis and right
and listen for pericardial rub
Tuberculous peritonitis Low glucose content
Fig. 6.19 Anatomy of the inguinal canal and femoral sheath.
The physical examination • 111
on coughing or on conscious contraction by the patient. Beyond
the anal canal, the rectum passes upwards and backwards along
Spasm of the external anal sphincter is common in anxious
patients. When associated with local pain, it is probably due to
an anal fissure (a mucosal tear). If you suspect an anal fissure,
give the patient a local anaesthetic suppository 10 minutes
before the examination to reduce the pain and spasm, and to
• Explain what you are going to do and why it is necessary,
and ask for permission to proceed. Tell the patient that the
examination may be uncomfortable but should not be
• Offer a chaperone; record a refusal. Make a note of the
• Position the patient in the left lateral position with their
buttocks at the edge of the couch, their knees drawn
up to their chest and their heels clear of the perineum
• Put on gloves and examine the perianal skin, using an
• Look for skin lesions, external haemorrhoids, fissures and
• Lubricate your index finger with water-based gel.
• Place the pulp of your forefinger on the anal margin and
apply steady pressure on the sphincter to push your
finger gently through the anal canal into the rectum
• If anal spasm occurs, ask the patient to breathe in
deeply and relax. If necessary, use a local anaesthetic
suppository or gel before trying again. If pain persists,
examination under general anaesthesia may be
• Ask the patient to squeeze your finger with their
anal muscles and note any weakness of sphincter
Fig. 6.20 Right inguinal hernia.
hernia sac Contents of sac (small bowel in
Fig. 6.21 Hernia: anatomical structure.
hernia contains bowel, obstruction may occur. If the blood supply
to the contents of the hernia (bowel or omentum) is restricted,
the hernia is strangulated. It is tense, tender and has no cough
impulse, there may be bowel obstruction and, later, signs of
sepsis and shock. A strangulated hernia is a surgical emergency
and, if left untreated, will lead to bowel infarction and peritonitis.
Digital examination of the rectum is important (Box 6.15). Do
not avoid it because you or the patient finds it disagreeable. The
patient’s verbal consent is needed, however, and the examination
should be carried out in the presence of a chaperone.
The normal rectum is usually empty and smooth-walled, with
the coccyx and sacrum lying posteriorly. In the male, anterior
to the rectum from below upwards, lie the membranous urethra,
the prostate and the base of the bladder. The normal prostate
is smooth and firm, with lateral lobes and a median groove
between them. In the female, the vagina and cervix lie anteriorly.
The upper end of the anal canal is marked by the puborectalis
muscle, which is readily palpable and contracts as a reflex action
6.15 Indications for rectal examination
• Suspected appendicitis, pelvic abscess, peritonitis, lower
• Diarrhoea, constipation, tenesmus or anorectal pain
• Rectal bleeding or iron deficiency anaemia
• Bimanual examination of lower abdominal mass for diagnosis or
• Malignancies of unknown origin
• Assessment of prostate in prostatism or suspected prostatic cancer
• Dysuria, frequency, haematuria, epididymo-orchitis
• Replacement for vaginal examination when this would be
• Unexplained bone pain, backache or lumbosacral nerve root pain
• Abdominal, pelvic or spinal trauma
112 • The gastrointestinal system
Fig. 6.22 The correct position of the patient before a rectal
Fig. 6.23 Rectal examination. The correct method for inserting your
index finger in rectal examination.
D The most prominent feature in the male is the prostate.
6.16 Causes of abnormal stool appearance
Abnormally pale Biliary obstruction
Black and tarry (melaena) Bleeding from the upper
Grey/black Oral iron or bismuth therapy
Silvery Steatorrhoea plus upper gastrointestinal
bleeding, e.g. pancreatic cancer
Fresh blood in or on stool Large bowel, rectal or anal bleeding
Stool mixed with pus Infective colitis or inflammatory bowel
• Palpate systematically around the entire rectum; note any
abnormality and examine any mass (Fig. 6.24). Record the
percentage of the rectal circumference involved by disease
and its distance from the anus.
• Identify the uterine cervix in women and the prostate in
men; assess the size, shape and consistency of the
prostate and note any tenderness.
• If the rectum contains faeces and you are in doubt about
palpable masses, repeat the examination after the patient
• Slowly withdraw your finger. Examine it for stool colour
and the presence of blood or mucus (Box 6.16).
Haemorrhoids (‘piles’, congested venous plexuses around the
anal canal) are usually palpable if thrombosed. In patients with
chronic constipation the rectum is often loaded with faeces.
Faecal masses are frequently palpable, should be movable and
can be indented. In women a retroverted uterus and the normal
cervix are often palpable through the anterior rectal wall and a
vaginal tampon may be confusing. Cancer of the lower rectum
is palpable as a mucosal irregularity. Obstructing cancer of the
upper rectum may produce ballooning of the empty rectal cavity
below. Metastases or colonic tumours within the pelvis may
be mistaken for faeces and vice versa. Lateralised tenderness
suggests pelvic peritonitis. Gynaecological malignancy may cause
a ‘frozen pelvis’ with a hard, rigid feel to the pelvic organs due
to extensive peritoneal disease, such as post-radiotherapy or
in metastatic cervical or ovarian cancer.
Benign prostatic hyperplasia often produces palpable
symmetrical enlargement, but not if the hyperplasia is confined
• Remove the obturator and carefully examine the anal canal
under good illumination, noting any abnormality. Check for
fissures, particularly if the patient reports pain during the
• Ask the patient to strain down as you slowly withdraw the
instrument to detect any degree of rectal prolapse and the
presence and severity of any haemorrhoids.
Proctoscopic examination of the anus and lower rectum can
confirm or exclude the presence of haemorrhoids, anal fissures
and rectal prolapse. Rectal mucosa looks like buccal mucosa,
apart from the presence of prominent submucosal veins. During
straining, haemorrhoids distend with blood and may prolapse. If
the degree of protrusion is more than 3–4 cm, a rectal prolapse
Selecting the relevant investigation depends on the clinical problem
revealed on history and examination. Investigations are costly
and many carry risks, so choose tests capable of distinguishing
the likely diagnoses and prioritise the most decisive ones (Box
to the median lobe. A hard, irregular or asymmetrical gland with
no palpable median groove suggests prostate cancer. Tenderness
accompanied by a change in the consistency of the gland may
be caused by prostatitis or prostatic abscess. The prostate is
abnormally small in hypogonadism.
Proctoscopy is visual examination of the anal canal; it is an invasive
procedure and should only be practised after appropriate training.
Always undertake digital rectal examination first. If examination
of the rectal mucosa is required, perform flexible sigmoidoscopy
• Place the patient in the left lateral position, as for digital
• With gloved hands, separate the buttocks with the
forefinger and thumb of one hand. With your other hand,
gently insert a lubricated proctoscope with its obturator in
place into the anal canal and rectum in the direction of the
6.17 Investigations in gastrointestinal and hepatobiliary disease
Investigation Indication/comment
Faecal calprotectin Inflammatory bowel disease – raised
Urine: dipstick or biochemistry Jaundice (see Box 6.7)
Ascitic fluid: diagnostic tap Clear/straw-coloured – normal
Uniformly blood-stained – malignancy
Chylous – lymphatic obstruction
High protein (exudate) – inflammation or malignancy
Low protein (transudate) – cirrhosis and portal hypertension
114 • The gastrointestinal system
6.17 Investigations in gastrointestinal and hepatobiliary disease—cont’d
Investigation Indication/comment
Chest X-ray Suspected acute abdomen, suspected perforated viscus or subphrenic abscess
Pneumonia, free air beneath diaphragm, pleural effusion, elevated diaphragm
Abdominal X-ray Intestinal obstruction, perforation, renal colic
Fluid levels, air above liver, urinary tract stones
Barium meal Rarely indicated unless gastroscopy not possible and there is suspicion of pharyngeal or
gastric outlet obstruction on clinical symptoms (dysphagia or vomiting)
Oesophageal obstruction (endoscopy preferable, especially if previous gastric surgery)
Small bowel follow-through Subacute small bowel obstruction, duodenal diverticulosis
Small bowel magnetic resonance imaging or magnetic
resonance enteroclysis (real-time imaging of liquid
moving through the small bowel)
Crohn’s disease, lymphoma, obscure gastrointestinal bleeding
the frail, sick patient, if colonoscopy is unsuccessful or if not acceptable to patient to
diagnose colon cancer, inflammatory bowel disease or diverticular disease; useful in colon
Abdominal ultrasound scan Biliary colic, jaundice, pancreatitis, malignancy
Gallstones, liver metastases, cholestasis, pancreatic calcification, subphrenic abscess
Abdominal CT Acute abdomen, suspected pancreatic or renal mass, tumour staging, abdominal aortic
Confirms or excludes metastatic disease and leaking from aortic aneurysm
MR cholangiopancreatography (MRCP) Obstructive jaundice, acute and chronic pancreatitis
Pelvic structures and abnormalities
Gastric and/or duodenal biopsies are useful
Able to biopsy lesions and remove polyps
bowel disease (vascular malformations, inflammatory bowel disease)
Stenting strictures and removing stones
Endoscopic ultrasound ± fine-needle aspiration (FNA) or
Staging of upper gastrointestinal or pancreatobiliary cancer
Drainage of pancreatic pseudocysts
Laparoscopy Suspected appendicitis or perforated viscus, suspected ectopic pregnancy, chronic pelvic
pain (e.g. due to endometriosis or pelvic inflammatory disease), suspected ovarian disease
(e.g. ruptured ovarian cyst), peritoneal and liver disease
Liver biopsy Parenchymal disease of liver
Tissue biopsy by percutaneous, transjugular or laparoscopic route
Pancreatic function tests Stool elastase, pancreolauryl test
Fig. 6.26 Radiography in gastrointestinal disease. A Air under the
diaphragm on chest X-ray due to a perforated duodenal ulcer. B Dilated
small bowel due to acute intestinal obstruction. C Dilated loop of large
bowel due to sigmoid volvulus.
Fig. 6.27 Ultrasound scan of the gallbladder. A, Thick-walled
gallbladder containing gallstones. B, Posterior acoustic shadowing.
Fig. 6.28 Gastrointestinal endoscopy. A Gastric ulcer. B Gastric
116 • The gastrointestinal system
Fig. 6.29 Colonoscopy. Colon cancer.
Fig. 6.30 Computed tomogram of the pelvis. A, Diverticular abscess.
OSCE example 1: Abdominal pain and diarrhoea
appendicectomy 4 months ago following severe right iliac fossa pain.
Please examine the gastrointestinal system
• Introduce yourself and clean your hands.
• Start with a general inspection: body habitus, signs of dehydration, fever and pallor.
• Inspect the skin: erythema nodosum or pyoderma gangrenosum.
• Inspect the abdomen: laparotomy scars or skin fistulae.
• Palpate for right iliac fossa tenderness or the presence of a firm, non-tender mass.
• Thank the patient and clean your hands.
scar, mild periumbilical and left iliac fossa tenderness, and normal bowel sounds.
Suggest a differential diagnosis
The differential diagnosis is Crohn’s disease and irritable bowel syndrome.
Suggest initial investigations
small bowel magnetic resonance imaging, faecal calprotectin.
although recently he has cut down to a bottle of whisky every 3 days.
Please examine this patient’s abdomen
• Introduce yourself and clean your hands.
• Examine the hands: palmar erythema, finger clubbing, leuconychia, Dupuytren’s contractures.
• Smell for alcohol or fetor hepaticus.
• Inspect the neck and chest for spider naevi, gynaecomastia; look for axillary and chest hair loss.
• Palpate and percuss the abdomen for hepatomegaly and splenomegaly.
• Percuss for shifting dullness.
• Auscultate for hepatic bruits.
• Thank the patient and your clean hands.
liver edge palpable 2 cm below the costal margin.
Suggest a differential diagnosis
The differential diagnosis is alcoholic cirrhosis, chronic hepatitis and hepatoma.
Suggested initial investigations
ultrasound scan and upper digestive endoscopy (to check for oesophagogastric varices).
Integrated examination sequence for the gastrointestinal system
• Describe any mass and decide whether there is an enlarged abdominal organ.
• Percussion to confirm hepatomegaly:
• Ask the patient to hold their breath in full expiration.
• Percuss for liver dullness and measure the distance in centimetres below the costal margin.
• Palpation and percussion for splenomegaly:
• Check for ascites (shifting dullness):
• Percuss from the midline out to the flanks for dullness.
dullness is now resonant, shifting dullness is present.
the abdomen. If you still feel a ripple against your left hand, a fluid thrill is present.
renal artery stenosis, and over the liver for hepatic bruits.
• Check for peripheral oedema.
• Consider a rectal examination (always with a chaperone).
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Common presenting symptoms 122
Assessment of conscious level 124
Optic (II), oculomotor (III), trochlear (IV) and abducens (VI) nerves 128
Vestibulocochlear (VIII) nerve 131
Glossopharyngeal (IX) and vagus (X) nerves 131
Inspection and palpation of the muscles 136
Common presenting symptoms 143
Lateral cutaneous nerve of the thigh 147
Interpretation of the findings 147
OSCE example 1: Headache history 149
Integrated examination sequence for the nervous system 150
For many common neurological symptoms such as headache,
numbness, disturbance/loss of consciousness and memory loss,
the history is the key to diagnosis, as the examination may be
either normal or unhelpful. Some symptoms, including loss of
consciousness or amnesia, require an additional witness history;
make every effort to contact such witnesses.
Remember the two key questions: where (in the nervous
system) is the lesion and what is the lesion?
Neurological symptoms may be difficult for patients to describe,
so clarify exactly what they tell you. Words such as ‘blackout’,
‘dizziness’, ‘weakness’ and ‘numbness’ may have different
meanings for different patients, so ensure you understand what
Ask patients what they think or fear might be wrong with
them, as neurological symptoms cause much anxiety. Patients
commonly research their symptoms on the internet; searches
on common benign neurological symptoms, like numbness or
weakness, usually list the most alarming (and unlikely) diagnoses
such multiple sclerosis, motor neurone disease or brain tumours
first, and almost never mention more common conditions such
as carpal tunnel syndrome or functional disorders.
The onset, duration and pattern of symptoms over time often
provide diagnostic clues: for example, in assessing headache
(Box 7.1) or vertigo (see Box 9.3).
• When did the symptoms start (or when was the patient
• Are they persistent or intermittent?
• If persistent, are they getting better, getting worse or
The nervous system consists of the brain and spinal cord (central
nervous system, CNS) and the peripheral nerves (peripheral
nervous system, PNS). The PNS includes the autonomic nervous
system, responsible for control of involuntary functions.
The neurone is the functional unit of the nervous system. Each
neurone has a cell body and axon terminating at a synapse,
supported by astrocytes and microglial cells. Astrocytes provide
the structural framework for the neurones, control their biochemical
environment and form the blood–brain barrier. Microglial cells
are blood-derived mononuclear macrophages with immune and
scavenging functions. In the CNS, oligodendrocytes produce
and maintain a myelin sheath around the axons. In the PNS,
myelin is produced by Schwann cells.
The brain consists of two cerebral hemispheres, each with
four lobes (frontal, parietal, temporal and occipital), the brainstem
and the cerebellum. The brainstem comprises the midbrain, pons
and medulla. The cerebellum lies in the posterior fossa, with two
hemispheres and a central vermis attached to the brainstem by
three pairs of cerebellar peduncles. Between the brain and the
skull are three membranous layers called the meninges: dura mater
next to the bone, arachnoid and pia mater next to the nervous
tissue. The subarachnoid space between the arachnoid and pia
is filled with cerebrospinal fluid (CSF) produced by the choroid
plexuses. The total volume of CSF is between 140 and 270 mL
and there is a turnover of the entire volume 3–4 times a day;
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