Medically Fit For Exams
Medically Fit For Exams

Gastrointestinal examination

Introduce yourself, wash hands and check patient’s details


Explain the procedure and gain consent

  • Explain that the patient will have to expose their abdomen and maybe loosen their belt, and that you will be pressing their abdomen, and feeling for some of their organs


General inspection

  • Comfort – is the patient lying overly still, or with their knees up (appendicitis)
  • Jaundice
  • Medication including oxygen and IV medication
  • Obvious abdominal distension, gynecomastia and BMI
  • Scratch marks



  • Feel both hands for temperature
  • Capillary refill (press for 5 seconds, should refill within 3)
  • Dupytron’s contracture – alcoholic liver disease
  • Palmar erythema – liver disease/pregnancy
  • Clubbing – IBD, Coeliac’s disease, cirrhosis
  • Leukonychia (whitening of nail bed) – hypoalbuminaemia – liver failure/enteropathy
  • Koilonychia – chronic iron deficiency
  • Hepatic flap – ask patient to hold arms out with hands dorsiflexed, verbalise that would observe for 30 seconds


Pulse and BP

  • Take pulse and comment on its character, may be raised if:
    • Bleeding
    • Anaemia
    • Infection
  • Verbalise that you would take the blood pressure



  • Check facial colouring:
    • Jaundice
    • Malar flush
  • Check eyes for:
    • Conjunctival pallor
    • Jaundice
    • Kayser-Fleischer rings (dark rings around the iris) – copper deposition (Wilson’s disease)
    • Xanthalasma
  • Check mouth for:
    • Glossitis – iron deficiency
    • Angular stomatitis – iron deficiency
    • Mouth ulcers – Crohn’s disease, coeliac disease
    • Oral candidiasis – iron deficiency/immunodeficiency



  • Cervical lymph nodes – infection, metastatic malignancy
  • Virchow’s node (left supraclavicular fossa) – gastric malignancy


General abdomen inspection

  • Ask the patient to expose their chest and abdomen, may need to loosen their belt and pull down waistband
  • Look for scars and stomas, ask the patient if they have had any surgery
  • Spider naevii
  • Caput medusa
  • Bruising
  • Ascites



  • Ask the patient if they have any tenderness, if so, do this part last, and ask if it is okay to palpate there
  • Lower yourself to the patient’s eye level
  • Palpate the four quadrants lightly, assessing the patients eyes for discomfort, and feeling for masses
  • Palpate nine quadrants more deeply for masses, still assessing the patient’s eyes
  • Palpate for the liver, starting in the right iliac fossa. Ask the patient to take a deep breath in, and push up as they breathe in. Progress up towards the liver. You may or may not be able to feel a normal liver under the inferior costal margin
  • Percuss the liver margins, starting below
  • Palpate for the spleen, starting in the right iliac fossa again. Ask the patient to breathe in, and push up and to the left on inspiration. A normal spleen will not be palpable
  • Ballotte for the kidneys by placing one hand underneath the patient’s back, and the other on their abdomen directly above. Do this for both kidneys. Normal kidneys will not be palpable.
  • Feel for the aorta above the umbilicus, it should be pulsatile, but not expansile (?)
  • If the patient has abdominal distension, check for shifting dullness:
    • Start at the midline, and percuss towards the flank, until the percussion note becomes dull (fluid level)
    • Keep your hand at this point, and ask the patient to roll away from you
    • Wait for about 30 seconds for the fluid to shift
    • Percuss again, this area should now be resonant
    • Percuss back towards the midline, the umbilicus should now have become dull (hence shifting dullness)



  • Place the stethoscope on the abdomen over the ilio-caecal valve and listen for up to 30 seconds or until bowel sounds are heard
    • Gurgling sounds are normal
    • Absent sounds suggest peritonitis
  • Auscultate for aortic bruits just above the umbilicus and slightly to the left


Check for hernias

  • Verbalise that there are no obvious hernias
  • Verbalise that you would check for inguinal hernias



Check for sacral and peripheral oedema

  • Ask the patient to sit forwards to check for sacral oedema
  • Remove the patient’s socks and shoes to assess for peripheral pitting oedema


Further investigations

  • PR if indication – eg anaemia, blood in the stools, tenesmus, pain
  • Endoscopy (gastroscopy/colonoscopy) – anaemia, blood in the stools, malaena, dyspepsia, pain, abdominal mass
  • CT/MRI scan – eg abdominal mass
  • LFT – eg hepatomegaly, jaundice, other evidence of liver disease
  • FBC – eg anaemia, infection

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