Macleod's Clinical Examination · 4th Year Study Guide by NOVA

GI System
NOVA's Examination

Systematic approach — General → Hands → Face → Neck → Abdomen → Auscultation

InspectLook
PalpateFeel
PercussPercuss
AuscultateListen
InterpretThink
👁️
General Appearance
First Impression
What to Assess
  • Note the patient's demeanour and overall appearance
  • Look for pain, cachexia, thinness, good nourishment, or obesity
  • Assess height, weight, BMI, and waist circumference
  • If obese, note whether it is truncal or generalized
  • Look for abdominal striae and loose skin folds
General appearance / body habitus
🤲
Hands
Peripheral Signs
Look for
Clubbing
Painless enlargement of terminal phalanges; Schamroth's window lost
Cirrhosis, IBD, malabsorption syndromes
Koilonychia
Spoon-shaped, concave nails
Iron deficiency anaemia
Leuconychia
White discoloration of nails due to hypoalbuminaemia
Hypoalbuminaemia, nephrotic syndrome, protein malnutrition
Palmar Erythema
Redness of palms — thenar & hypothenar areas — from ↑ oestrogen
Chronic liver disease, pregnancy
Dupuytren's Contracture
Thickening and shortening of palmar fascia → flexion deformity
Alcohol-related chronic liver disease
Clubbing Koilonychia Leuconychia / palmar erythema
👅
Mouth, Throat & Tongue
Oral Signs
Angular Cheilitis
Painful cracks at corners of mouth → iron deficiency
Atrophic Glossitis
Smooth, pale, sore tongue — loss of papillae → iron deficiency
Beefy / Smooth Tongue
Large, beefy red tongue → folate / B12 deficiency
Aphthous Ulcers
May occur in coeliac disease and IBD
Angular cheilitis Atrophic glossitis Aphthous ulcers / tongue
👁️
Eyes
Jaundice / Anaemia
Technique
  1. 1
    Ask the patient to look down and gently retract the upper eyelid
  2. 2
    Inspect the sclera in natural light for jaundice
  3. 3
    Pull down the lower eyelid and check the conjunctiva for pallor (anaemia)
Jaundice vs Pingueculae

Do NOT confuse jaundice with pingueculae — small, localized yellowish fat deposits at the periphery of the sclera. True jaundice causes diffuse yellow discoloration.

Scleral jaundice Jaundice / scleral inspection
🔵
Lymph Nodes
Troisier's Sign
Examination Points
  • Examine the cervical, axillary, and inguinal lymph nodes
  • Left supraclavicular lymphadenopathy (Troisier's sign) → may indicate GI malignancy, particularly gastric or pancreatic cancer
  • Generalized lymphadenopathy + hepatosplenomegaly → consider lymphoma
Troisier's Sign

Virchow's Node = Left supraclavicular lymphadenopathy

Represents metastatic malignancy classically from the GI tract, especially gastric cancer. The enlarged node is called the Virchow–Troisier node.

Troisier's sign / Virchow's node
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Iron Deficiency Anaemia — Stigmata
IDA Signs
FindingDescription
PallorEspecially conjunctival and palmar pallor
KoilonychiaSpoon-shaped, concave nails
Angular CheilitisPainful cracks at the corners of the mouth
Atrophic GlossitisSmooth, pale, sore tongue due to loss of papillae
Brittle NailsNails become thin and fragile
PicaCraving for non-food substances, e.g. ice (pagophagia)
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Stigmata of Chronic Liver Disease
CLD Signs
Liver Functions — Why Signs Occur

Synthetic: produces albumin, coagulation factors → low albumin → oedema, ascites; low clotting factors → bruising

Metabolism: detoxifies hormones, drugs → excess oestrogen → spider naevi, palmar erythema, gynaecomastia

Bilirubin metabolism: heme breakdown → failure → jaundice

Ammonia metabolism: NH₃ → urea → failure → hepatic encephalopathy (asterixis)

FunctionMain Roles
SyntheticProduces albumin and coagulation factors; synthesizes glycogen and amino acids
Metabolism & DetoxificationMetabolizes carbohydrates, proteins, lipids; detoxifies hormones and drugs
Bilirubin MetabolismBreaks down heme and processes bilirubin for excretion into bile
Ammonia MetabolismConverts toxic NH₃ → urea via the urea cycle
StorageStores fat-soluble vitamins (A, D, E, K), vitamin B12, glycogen and minerals
Liver function diagram
A — Oestrogen Metabolism Signs
Sign 01
Spider Naevi
Central arteriole with radiating small vessels. Found in SVC distribution: face, arms, upper trunk. Caused by ↑ oestrogen.
Multiple in men → suggest CLD. Few may be normal in women / pregnancy.
Sign 02
Palmar Erythema
Redness of the palms — thenar & hypothenar areas — due to ↑ circulating oestrogen.
In men, persistent → suggest CLD
Sign 03
Gynaecomastia
Breast enlargement in males. Reduced hepatic breakdown of oestrogens.
Associated with loss of body hair and testicular atrophy
Spider naevi / gynaecomastia Gynaecomastia / testicular atrophy
B — Bilirubin Signs
Sign 04
Jaundice
Diffuse yellow discoloration of the sclera. Check in natural light. Do NOT confuse with pingueculae.
Significant hepatic dysfunction
Jaundice classification / types Scleral jaundice close-up Jaundice body
C — Albumin (Synthetic Function) Signs
↓ Albumin
→
↓ Oncotic Pressure
→
Fluid shifts to tissues
Peripheral Oedema
Ascites
Pleural Effusion
Leuconychia (white nails)
May be associated with Clubbing
D — Other CLD Signs
Sign 05
Leuconychia
White discoloration of nails. From hypoalbuminaemia. Not specific to liver disease.
Also: malnutrition, coeliac, nephrotic syndrome
Sign 06
Finger Clubbing
May occur in liver cirrhosis, IBD, malabsorption syndromes
Sign 07
Dupuytren's Contracture
Thickening and shortening of palmar fascia → flexion deformity of fingers
Alcohol-related CLD
Sign 08
Bilateral Parotid Enlargement
Usually due to sialadenosis. May be associated with chronic alcohol abuse.
Parotid enlargement Parotid / alcohol stigmata
Signs of Liver Failure
Liver Failure Findings
Asterixis
Coarse flapping tremor with arms outstretched and wrists dorsiflexed → hepatic encephalopathy
Fetor Hepaticus
Characteristic mousy/musty breath odour due to portosystemic shunting
Altered Mental State
Drowsiness → sleep reversal → confusion/disorientation → coma
Jaundice
May indicate significant hepatic dysfunction
Ascites
Accumulation of fluid in the peritoneal cavity
Late Neurological Signs
Spasticity, extensor posturing and extensor plantar responses
Asterixis / hepatic encephalopathy Liver failure signs
⚡
Portal Hypertension
Portal HTN
Mechanism

Cirrhosis → fibrosis + regenerative nodules → ↑ resistance to portal blood flow → ↑ portal pressure → development of portosystemic collaterals

A — Congestion of Portosystemic Anastomoses

Oesophageal Varices

Dilated veins in the lower oesophagus. Major complication: rupture → massive upper GI bleeding

Haemorrhoids

May be associated with venous congestion in rectal system. Not specific for portal hypertension

Caput Medusae

Dilated, tortuous periumbilical veins. Caused by reopening of portosystemic collateral veins

Ascites

Accumulation of fluid in the peritoneal cavity. Common complication of advanced cirrhosis

B — Congestion of Organs

Splenomegaly

Splenic venous congestion → hypersplenism → thrombocytopenia, leukopenia, and anaemia

Portal hypertension sign 1 Caput medusae Portal hypertension diagram
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Abdominal Examination — Inspection
Look
Patient Position & Exposure
  • Good lighting, warm environment, patient comfortably supine
  • Head on one or two pillows to relax abdominal muscles
  • Expose from xiphisternum → symphysis pubis; keep chest and legs covered
Normal Abdominal Findings
  • Flat or slightly scaphoid and symmetrical
  • Diaphragmatic respiration — abdominal wall moves outward during inspiration
  • Liver, spleen & kidneys move downward with inspiration
  • Umbilicus: normally central and inverted
Normal abdomen / inspection diagram
1 — From the Foot of the Bed
  • Assess overall shape and symmetry
  • Abdomen should move with respiration
  • Look for obvious masses or distension
  • Umbilicus: normally central and inverted
  • Check for flank fullness
2 — From the Right Side
Abnormal Movements
  • Visible masses
  • Abnormal pulsations
  • Visible peristalsis
  • Dilated abdominal veins
Skin Abnormalities
  • Scars
  • Stomas
  • Discoloration / Striae
  • Bruising / Scratch marks
3 — Abdominal Wall
  • Ask the patient to raise their head off the bed
  • Look for divarication (diastasis) of the recti muscles
Diastasis recti Abdominal wall inspection Abdominal wall
Visible Abdominal Veins

↑ Blood flow UPWARD

IVC obstruction — blood diverted from lower body through collateral veins toward the SVC

↓ Blood flow DOWNWARD

SVC obstruction — blood from upper body diverted through abdominal collaterals toward the IVC

Caput Medusae vs IVC/SVC obstruction

Prominent periumbilical veins radiating away → Portal HTN (caput medusae)

To distinguish from IVC/SVC obstruction: empty a segment of vein between two fingers, release one end and observe the direction of refilling.

Abdominal veins / caput medusae
Abdominal Swelling
Ascites
Diffuse distension
Intestinal Obstruction
Diffuse distension
Urinary Retention
Localized — suprapubic
Abdominal Mass
Localized — variable
Organomegaly
Localized — hepatomegaly
Umbilicus Signs

Obesity: umbilicus sunken/inverted. Ascites: umbilicus flat or everted (↑ intra-abdominal pressure). Umbilical hernia: everted + cough impulse.

Abdominal Scars & Stomas
Abdominal scars diagram Stoma types Abdominal scars / stoma identification
✋
Abdominal Palpation
Feel
Before Palpation — Always

Ask the patient if they have any pain and identify the painful area. Maintain eye contact. Ensure your hands are warm and clean. Ask the patient to relax and breathe normally.

Palpation technique / hand position
1. Light Palpation
  • Start away from the site of pain
  • Palpate each region systematically
  • Assess: tenderness, guarding, abdominal wall abnormalities
2. Deep Palpation
  • Repeat with deeper pressure
  • Assess for deep tenderness and masses
If a Mass is Found — Describe it as:

SS SS CM M

Site · Size · Surface · Shape · Consistency · Movement with respiration · Mobility/Fixity

Abdominal Wall vs Intra-abdominal Mass
Abdominal Wall Mass
  • Ask patient to raise head off the bed to tense muscles
  • Mass remains palpable or becomes more prominent
Intra-abdominal Mass
  • Same manoeuvre — tense the muscles
  • Mass becomes difficult to palpate or disappears
Peritonism
Types of Guarding
  1. 1
    Voluntary guarding — voluntary contraction due to pain/anxiety; usually decreases when patient relaxes
  2. 2
    Involuntary guarding — reflex contraction due to inflammation of parietal peritoneum → suggests peritonism
  3. 3
    Generalized peritonitis — perforated viscus → board-like rigidity → abdominal movement with respiration reduced/absent → predominantly thoracic breathing
  4. 4
    Cough / percussion tenderness — reproduction of pain on coughing or gentle percussion → intra-abdominal inflammation
  5. 5
    Rebound tenderness — pain increases when hand rapidly released after deep palpation → intra-abdominal pathology
Guarding / peritonism summary Abdominal peritonism signs
⚠️ Signs May Be Masked In

Patients taking glucocorticoids, immunosuppressants, anti-inflammatory drugs, or with alcohol intoxication / altered consciousness

Important Palpation Findings
Pulsatile Upper Abdominal Mass
May be: normal aortic pulsation (thin patients), gastric/pancreatic tumour transmitting aortic pulsation, or AAA
Pulsatile ≠ automatically aneurysm — assess carefully
Sister Mary Joseph's Nodule
Hard subcutaneous nodule at the umbilicus — represents metastatic intra-abdominal or pelvic malignancy
Sister Mary Joseph's nodule
Normal Structures — Do NOT Misinterpret as Masses

Liver edge (below right costal margin) · Aorta (pulsatile, above umbilicus) · Right kidney lower pole (right flank) · Faecal scybala (left iliac fossa — sigmoid colon) · Full bladder (suprapubic)

Normal palpable structures diagram
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Palpation of Enlarged Organs
Hepato / Spleno
General Technique

Start well below the costal margin and move upward. Keep examining hand still and ask the patient to take a deep breath in — the enlarged organ descends with inspiration onto your hand.

Hepatomegaly — Palpation Technique

  1. 1
    Place hand flat in the right iliac fossa, fingers pointing upward, lateral to rectus muscle
  2. 2
    Keep hand stationary; ask patient to take a deep breath in through the mouth
  3. 3
    Feel for the liver edge descending onto your fingertips
  4. 4
    Move hand 1 cm upward after each breath until you reach the costal margin or feel the liver
If Liver Edge is Palpable — Describe

Size (cm below costal margin) · Surface (smooth/irregular) · Edge · Consistency (soft/hard) · Tenderness · Pulsatility

Liver Percussion

  1. 1
    Start percussion from the 2nd intercostal space on the right
  2. 2
    Ask patient to hold breath at end of expiration
  3. 3
    Percuss downward in right mid-clavicular line
  4. 4
    Identify resonance → dullness transition = upper border of liver
  5. 5
    Continue downward to find lower border. Measure liver span. Normal: 8–12 cm
Liver percussion technique Liver span measurement
Causes of Hepatomegaly
  • Chronic liver disease — enlarged early in cirrhosis; small/shrunken in advanced cirrhosis
  • Fatty liver (hepatic steatosis) — may cause marked hepatomegaly
  • Metastatic liver disease — typically hard, irregular ± nodular
  • Right heart failure / tricuspid regurgitation — enlarged, tender and soft
⭐ Resonance in 5th ICS where dullness expected → consider: Hyperinflated lungs (liver pushed down) or Chilaiditi's sign (transverse colon between liver and diaphragm)
Chilaiditi's sign / liver percussion

Gallbladder

  • Palpate the right upper quadrant in the mid-clavicular line during deep inspiration
  • Murphy's sign: pain with inspiration during palpation → acute cholecystitis
  • Palpable gallbladder is rare; typically smooth and globular
⭐ Courvoisier's sign: Painless palpable gallbladder + obstructive jaundice → think malignancy (pancreatic head cancer)

Splenomegaly — Palpation

  • Spleen must enlarge to ~3× normal size before it becomes palpable
  • A palpable spleen = splenomegaly
  • Enlargement occurs downwards and medially from left costal margin toward umbilicus
  • The splenic notch may be palpable along its medial border — helps distinguish from enlarged left kidney
Splenomegaly palpation Splenomegaly technique Splenomegaly vs kidney differentiation
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Ascites — Percussion
Percuss
What is Ascites?

Accumulation of free fluid within the peritoneal cavity.

Shifting Dullness
  • Percuss from umbilicus outward to the flank
  • Note where dullness begins
  • Ask patient to roll toward you
  • If dullness shifts → free fluid present
Fluid Thrill / Fluid Wave
  • Used when ascites is large or tense
  • Ask patient or assistant to place edge of hand in midline
  • Flick one flank — feel the thrill on the other side
Shifting dullness technique Ascites percussion Fluid thrill / wave
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Abdominal Auscultation
Listen
Bowel Sounds — Technique
  1. 1
    Place the diaphragm just to the right of the umbilicus and keep it stationary
  2. 2
    Listen for up to 2 minutes before concluding bowel sounds are absent
Normal Bowel Sounds
Intermittent gurgling — normal peristalsis, every ~5–10 seconds
Absent Bowel Sounds
No sounds for >2 minutes
Paralytic ileus or peritonitis
High-pitched / Tinkling
Increased, loud, frequent high-pitched sounds
Intestinal obstruction
Bruits
Vascular sounds over aorta, renal arteries, liver
Atherosclerosis, aneurysm, renal artery stenosis
Friction Rub
Grating sound like rubbing dry fingers — over liver or spleen
Perihepatitis (liver) or Perisplenitis (spleen)
Succussion Splash
Like shaking a half-filled bottle — rocking pelvis/abdomen. Positive >4h after food
Delayed gastric emptying — pyloric stenosis
Abdominal auscultation sites Auscultation findings summary

Normal: intermittent gurgling bowel sounds, no bruits, no friction rub

Obstruction: high-pitched, tinkling, increased bowel sounds

Ileus/Peritonitis: absent bowel sounds

Vascular: bruit over aorta or renal arteries

Succussion splash >4h: delayed gastric emptying / pyloric stenosis

— Auscultation OSCE Quick Summary
To Complete the Examination

Always state these at the end of your OSCE

• Examine the hernial orifices
• Perform a DRE (digital rectal examination)