For education and revision only. Not individual medical advice; check current NICE/BNF and local guidance before clinical use. Clinical safety and terms.
🩺 Clinical examination II: abdomen, hernias, breast, thyroid, lymph nodes and vascular. These examinations are high-yield for surgical and medical OSCE stations and are performed daily on wards and in clinics. Several are intimate examinations that need careful consent and a chaperone. This chapter sets out a routine for each, the signs you should be able to elicit and interpret, and how to describe a lump - a skill that underpins breast, thyroid, hernia, lymph node and skin examinations. Your four questions: Where exactly is the abnormality and which organ does it arise from? What are its characteristics (size, shape, consistency, tenderness, mobility, pulsatility)? Are there features suggesting malignancy, infection or vascular compromise? What would be the next investigation or referral pathway?
Describing a Lump
Site (anatomical position, relation to landmarks), size (measure in two dimensions), shape, surface (smooth, irregular), edge (well or poorly defined), colour and overlying skin (erythema, tethering, peau d'orange, punctum - epidermoid cyst), temperature, tenderness.
Consistency - soft, rubbery, firm, hard (malignancy, calcification), fluctuant (fluid).
Mobility and fixity - mobile, tethered to skin, fixed to deep structures (contract the underlying muscle to test).
Special features:fluctuation (fluid-filled), transillumination (clear fluid - hydrocele, epididymal cyst, cystic hygroma), pulsatility - expansile (aneurysm - fingers pushed apart) versus transmitted (mass over an artery), compressibility/reducibility (hernia, varix, vascular malformation), cough impulse (hernia, saphena varix), bruit.
Regional lymph nodes and the surrounding tissues (nerve function, vascular supply).
Malignant features - hard, irregular, fixed, growing, painless, ulcerated, with lymphadenopathy. Soft tissue lumps >5 cm, deep, growing or painful → urgent ultrasound (sarcoma, NICE NG12).
Position flat with one pillow, arms by the sides; expose from xiphisternum to symphysis pubis (ideally nipples to knees for groins, preserving dignity).
General inspection - jaundice, pallor, cachexia, distension, scars and stomas, visible peristalsis or pulsation, nasogastric tube, drains, catheters, PEG.
Neck and chest - Virchow's node (left supraclavicular - Troisier's sign), gynaecomastia and spider naevi (chronic liver disease), loss of body hair.
Abdomen:
Inspection - distension (the five Fs: fat, fluid, flatus, faeces, fetus - and organomegaly/masses), caput medusae (portal hypertension), striae, scars, stomas (ileostomy - spouted, right iliac fossa; colostomy - flush, left iliac fossa; urostomy - spouted, right, urine), hernias (ask the patient to cough), visible pulsation.
Palpation - kneel at the bedside; ask about pain and start away from it; light palpation of all nine regions (tenderness, guarding, rigidity, rebound), then deep palpation (masses).
Organs - liver (start in the right iliac fossa, move up with each breath; note edge in cm below the costal margin, surface, tenderness, pulsatility - TR), spleen (start in the right iliac fossa, move diagonally towards the left costal margin; roll the patient to the right if needed; spleen has a notch, moves with respiration, cannot get above it, dull to percussion), kidneys (bimanual ballotment in each flank - you can get above them, resonant over them), aorta (expansile pulsation above the umbilicus - AAA), bladder.
Percussion - liver span (upper border normally 5th intercostal space in the mid-clavicular line), spleen, bladder; shifting dullness (ascites - percuss from midline laterally to dullness, hold, roll the patient towards you, wait 30 seconds, re-percuss - dullness shifts) or fluid thrill (tense ascites).
Completion: "I would examine the hernial orifices and external genitalia, perform a digital rectal examination (with consent and a chaperone), dip the urine, check observations and review relevant bloods and imaging."
Gastric carcinoma, pancreatic pseudocyst or cancer, AAA, left lobe of liver
Signs of chronic liver disease: clubbing, leuconychia, palmar erythema, Dupuytren's, asterixis, spider naevi, gynaecomastia, testicular atrophy, loss of body hair, jaundice, bruising, ascites, caput medusae, splenomegaly.
Peritonitis - lying still, shallow breathing, guarding, rigidity (board-like in perforation), rebound and percussion tenderness, absent bowel sounds.
Special signs:Murphy's sign (inspiratory arrest on palpation of the right upper quadrant - acute cholecystitis; negative on the left), Rovsing's sign (pain in the right iliac fossa on pressing the left - appendicitis), psoas sign, Cullen's (periumbilical) and Grey Turner's (flank) bruising (haemorrhagic pancreatitis, ruptured ectopic), Courvoisier's law (painless palpable gallbladder with jaundice - unlikely to be stones; consider pancreatic head cancer).
Consent (explain why, what it involves, that it may be uncomfortable but should not be painful, that they can ask you to stop), chaperone (record name), privacy.
Position - left lateral with knees drawn up to the chest and buttocks at the edge of the couch.
Inspect the perianal area - skin tags, fissures (posterior midline commonest - do not perform DRE if very painful; examine under anaesthesia), fistulae (Crohn's), haemorrhoids (prolapsed), warts, rashes, ulcers, blood, mucus, pilonidal sinus.
Palpate - lubricated gloved index finger; assess anal tone (and squeeze - ask the patient to squeeze your finger - cauda equina, neurological disorders), sweep the rectal wall circumferentially (masses - distance from the anal verge, consistency, fixity; faecal loading), prostate in men (anteriorly - size, normally walnut-sized, smooth with a palpable median sulcus; hard, craggy, nodular or loss of the sulcus suggests carcinoma; tender and boggy in prostatitis), cervix and pouch of Douglas in women.
Inspect the glove - stool colour (melaena, pale), blood, mucus.
Clean the patient, offer tissues, ensure privacy to dress; document findings, chaperone and consent.
Indications - rectal bleeding, change in bowel habit, suspected prostate disease, constipation or faecal impaction, suspected cauda equina, GI bleed (melaena), urinary retention.
Chronic liver disease - describe stigmata, signs of decompensation (jaundice, ascites, encephalopathy - asterixis, confusion; GI bleeding history) and portal hypertension (splenomegaly, caput medusae, ascites); suggest causes (alcohol, MASLD, viral hepatitis, autoimmune, haemochromatosis, PBC/PSC, Wilson's) and complications (varices, SBP, HCC, hepatorenal syndrome).
Renal patient - AV fistula (thrill and bruit; signs of use), tunnelled line scars, peritoneal dialysis catheter or scars, transplanted kidney (iliac fossa scar and mass), polycystic kidneys, nephrectomy scar; signs of immunosuppression (Cushingoid, skin cancers, gum hypertrophy - ciclosporin, tremor - tacrolimus).
Stomas - identify the type (site, spout, contents), check health (colour, retraction, prolapse, parastomal hernia - cough impulse, skin irritation), suggest the reason (e.g. ileostomy for UC or Crohn's; end colostomy after Hartmann's or APR - check for a perineal scar).
Abdominal aortic aneurysm - expansile pulsatile mass above the umbilicus; check femoral and popliteal pulses (popliteal aneurysms are associated); ultrasound; urgent vascular referral if symptomatic or ≥5.5 cm.
Examine standing first, then lying. Expose from umbilicus to knees with a chaperone for genital examination.
Inspect both groins and scrotum for lumps; ask the patient to cough and look for an impulse.
Palpate - determine whether the lump is above and medial to the pubic tubercle (inguinal) or below and lateral (femoral); assess cough impulse, tenderness, reducibility (ask the patient to reduce it), scrotal extension (can you get above the swelling? - if not, it is a hernia descending into the scrotum).
Deep ring occlusion test - reduce the hernia, press over the deep inguinal ring (midpoint of the inguinal ligament, about 1–2 cm above the femoral pulse), ask the patient to cough: controlled = indirect inguinal hernia; reappears medially = direct. Clinically unreliable - the distinction is made at surgery.
Examine the other side, the scrotum (testes present, hydrocele, varicocele), and abdomen (causes of raised intra-abdominal pressure - ascites, chronic cough, constipation, prostatism).
Feature
Indirect inguinal
Direct inguinal
Femoral
Relation to pubic tubercle
Above and medial
Above and medial
Below and lateral
Passage
Through deep ring along the canal (lateral to inferior epigastric vessels)
Through posterior wall - Hesselbach's triangle (medial to inferior epigastric vessels)
Through the femoral canal
Who
Commonest in all ages; young men; children (patent processus vaginalis)
Other hernias - umbilical (infants - usually close by 4 years), paraumbilical (adults - obesity), incisional, epigastric, Spigelian, obturator (thin older women - pain down the medial thigh - Howship–Romberg sign).
Consent, chaperone, examine standing then lying; warm hands.
Inspect - asymmetry, swelling, skin changes, scars; the left testis normally hangs lower.
Palpate each testis between thumb and two fingers - size (and compare), consistency, tenderness, masses; epididymis (posterolateral - cysts, tenderness), spermatic cord (vas deferens; varicocele - "bag of worms", disappears when lying, worse with Valsalva; a new left varicocele or one that does not empty lying down may indicate a renal tumour obstructing the left testicular vein).
Key questions for a scrotal swelling: can you get above it (if not - inguinoscrotal hernia)? Is it separate from the testis (epididymal cyst - separate, transilluminates) or within/surrounding it (hydrocele - testis impalpable within it, transilluminates; tumour - hard, painless, part of the testis - urgent ultrasound and 2-week-wait referral)? Does it transilluminate?
Testicular torsion - acute severe pain, high-riding horizontal testis, absent cremasteric reflex - emergency surgical exploration (within 6 hours); do not delay for imaging. Epididymo-orchitis - gradual onset, tender epididymis, Prehn's sign (pain relief on elevation - unreliable).
Examine the abdomen for para-aortic lymph nodes (testicular lymph drains to para-aortic nodes, scrotal skin to inguinal nodes).
Consent and chaperone (record), privacy, offer to examine in a private room; expose to the waist.
Inspection - sitting with arms by the sides, then hands pressed on the hips (contracts pectoralis - reveals tethering), then arms raised above the head: asymmetry, masses, scars, skin changes (peau d'orange, erythema, ulceration, dimpling/tethering), nipple changes (inversion - new or unilateral is concerning; discharge - bloody; eczema-like changes - Paget's disease of the nipple).
Palpation - patient lying at 45° with the hand behind the head on the side being examined; examine the normal side first; use the flat of the fingers systematically (concentric circles, radial spokes or vertical strip) covering all quadrants, the axillary tail and under the nipple; describe any lump fully.
Nipple - ask the patient to express any discharge (note colour, single or multiple ducts).
Lymph nodes - axillary (support the patient's arm, examine the apical, anterior, posterior, central and medial groups), supraclavicular and infraclavicular.
Completion - "I would offer triple assessment: clinical examination, imaging (mammography over 35-40; ultrasound in younger women) and tissue sampling (core biopsy)."
Urgent referral (NICE NG12) - aged 30 and over with an unexplained breast lump; aged 50 and over with unilateral nipple discharge, retraction or other concerning changes; consider for skin changes suggestive of cancer or an unexplained axillary lump in those aged 30 and over.
Lump
Typical features
Fibroadenoma
Young women; smooth, rubbery, very mobile ("breast mouse"), painless
Cyst
30s–50s; smooth, may be tender, fluctuant
Carcinoma
Older; hard, irregular, fixed or tethered, skin or nipple changes, axillary nodes
Fat necrosis
History of trauma; firm, irregular - mimics carcinoma
Abscess
Lactating women (S. aureus); hot, tender, fluctuant; non-lactational in smokers (periductal mastitis)
Position sitting on a chair with space behind; expose the neck down to the clavicles; have a glass of water ready.
Inspection from the front - midline swelling, scars (thyroidectomy - collar incision), skin changes, prominent veins (retrosternal goitre); ask the patient to swallow water (thyroid and thyroglossal cysts move up) and to protrude the tongue (thyroglossal cyst moves up; thyroid does not).
Palpation from behind - with the neck slightly flexed, palpate both lobes and the isthmus: size, shape (diffuse, multinodular, solitary nodule), consistency, tenderness, mobility; repeat during swallowing; check the lower border (retrosternal extension); lymph nodes; trachea (deviation).
Percussion over the manubrium (dullness - retrosternal extension); auscultation for a thyroid bruit (Graves' - increased vascularity).
Pemberton's sign - raising both arms causes facial plethora and distress (retrosternal goitre compressing the thoracic inlet).
Thyroid status:
Area
Hyperthyroid
Hypothyroid
Hands
Fine tremor, sweaty, palmar erythema, onycholysis, thyroid acropachy (Graves')
Dry, cold, carpal tunnel
Pulse
Tachycardia, AF
Bradycardia
Eyes
Lid retraction, lid lag; Graves' ophthalmopathy - exophthalmos, chemosis, ophthalmoplegia, proptosis (check visual acuity and colour vision - optic nerve compression is an emergency)
Periorbital puffiness, loss of outer third of eyebrows
Weight gain, dry hair, hoarse voice, myxoedematous facies, cold intolerance
Solitary thyroid nodule - ultrasound (U-classification) ± FNA cytology (Thy categories); TFTs; urgent referral if rapidly enlarging, hard, with stridor, nodes or voice change (2-week wait).
Other neck lumps - midline (thyroglossal cyst, thyroid isthmus, dermoid), anterior triangle (lymph nodes, branchial cyst - young adults, anterior border of sternocleidomastoid; carotid body tumour - pulsatile, moves side to side but not up and down; salivary glands), posterior triangle (lymph nodes - infection, lymphoma, metastases; cystic hygroma in children; cervical rib).
Head and neck nodes (examine from behind): submental, submandibular, preauricular, postauricular, occipital, anterior cervical chain, posterior cervical chain, supraclavicular (left - Virchow's - abdominal malignancy; right - thoracic, oesophageal).
Axillary - five groups (anterior/pectoral, posterior/subscapular, lateral/humeral, central, apical); epitrochlear (above the medial epicondyle - lymphoma, sarcoidosis, syphilis, hand infection); inguinal (horizontal and vertical groups - drain lower limb, perineum, anal canal below the pectinate line, scrotum skin, vulva); popliteal.
Describe - site, size, number, consistency (rubbery - lymphoma; hard - metastatic carcinoma; soft and tender - infection), tenderness, mobility, matting; examine the drainage area for the source (scalp, mouth, skin, breast, limbs, genitals) and the liver and spleen.
Concerning features - >2 cm, hard, fixed, supraclavicular, persisting >6 weeks, with B symptoms (fever, drenching night sweats, weight loss >10% in 6 months), hepatosplenomegaly - urgent investigation (FBC and film, urgent node excision biopsy).
Inspect the legs (including between the toes and the heels) - colour (pallor, cyanosis, dependent rubor), hair loss, shiny skin, nail dystrophy, muscle wasting, ulcers (arterial - punched out, painful, on pressure points and toes), gangrene, amputations, scars (bypass grafts, vein harvest).
Palpate - temperature (compare), capillary refill (>2 seconds is abnormal), pulses (radial, brachial, carotid, abdominal aorta, femoral - midinguinal point; popliteal - knee flexed, palpate deep in the fossa (easily felt - suspect popliteal aneurysm); posterior tibial - behind the medial malleolus; dorsalis pedis - lateral to extensor hallucis longus tendon).
Auscultate - aortic, renal, iliac and femoral bruits.
Buerger's test - raise the legs while lying; pallor at <20° (Buerger's angle) indicates severe ischaemia; then hang the legs over the edge - reactive hyperaemia (dependent rubor - "sunset foot") confirms it.
Complete with ankle-brachial pressure index (ABPI), neurological examination of the feet (diabetic neuropathy - monofilament, vibration), and cardiovascular examination.
ABPI
Interpretation
>1.3
Calcified, incompressible vessels (diabetes, CKD) - unreliable; use toe pressures
Inspect standing - varicose veins (great saphenous - medial leg; small saphenous - posterior calf), saphena varix (groin lump with cough impulse and thrill - disappears lying), skin changes of chronic venous insufficiency (haemosiderin pigmentation, venous eczema, lipodermatosclerosis - "inverted champagne bottle", atrophie blanche), oedema, ulcers (venous - shallow, large, sloping edges, gaiter area above the medial malleolus, relatively painless).
Palpate - tenderness (thrombophlebitis), cough impulse at the saphenofemoral junction (2–3 cm below and lateral to the pubic tubercle).
Tests - tap test and tourniquet/Trendelenburg tests are largely replaced by duplex ultrasound (identifies reflux and site of incompetence; NICE CG168 - refer people with symptomatic varicose veins, skin changes, ulceration or superficial thrombophlebitis to a vascular service).
Scenario. Present: 58-year-old man, jaundiced, with clubbing, palmar erythema, spider naevi, gynaecomastia, shifting dullness and splenomegaly.
Answer: "This man has stigmata of chronic liver disease with signs of decompensation (jaundice, ascites) and portal hypertension (splenomegaly). The likely causes include alcohol, MASLD, viral hepatitis and autoimmune or metabolic liver disease. I would check observations and for encephalopathy (asterixis), do a diagnostic ascitic tap to exclude spontaneous bacterial peritonitis (neutrophils >250/mm³), check LFTs, INR, albumin, FBC, U&E, liver screen and ultrasound with Doppler, and refer to hepatology."
Scenario. How do you distinguish an inguinal from a femoral hernia on examination, and why does it matter?
Answer: Inguinal hernias emerge above and medial to the pubic tubercle; femoral hernias emerge below and lateral to it (palpate the pubic tubercle by following the adductor longus tendon). Femoral hernias have a narrow, rigid neck and a high risk of strangulation, so they need prompt surgical referral.
Scenario. A 32-year-old woman finds a smooth, mobile 2 cm breast lump. What should happen?
Answer: Examine both breasts and axillae with a chaperone. As she is 30 or over with an unexplained lump, NICE NG12 recommends a suspected cancer pathway referral for triple assessment (clinical examination, ultrasound, core biopsy). The likely diagnosis is a fibroadenoma or cyst, but assessment is needed to exclude cancer.