D. Physical examination of Acute Abdominal Pain
Overall appearance should be assessed.
Patients with diffuse peritonitis appear acutely ill and tend to lie quietly on their side with their knees drawn toward their chest.
Patients with colic tend to be restless and unable to find a comfortable position. Patients with ureteral colic may writhe in pain or walk around the examination room.
Patients who are jaundiced may have biliary obstruction.
Patients who appear weak and lethargic may be septic.
Vital signs are important indicators of a patient’s overall condition.
Fever suggests the presence of inflammation or infection. Marked fever (>39°C) suggests an abscess, cholangitis, or pneumonia.
Hypotension or tachycardia, or both, may indicate hypovolemia or sepsis.
The abdominal examination should be carried out thoroughly and systematically. Although opioid analgesia administered prior to physical examination may alter physical exam findings, this is not associated with a decrease in diagnostic accuracy (Ann Emerg Med 2006;48:150) or an increase in management errors (JAMA 2006;296:1764).
The patient’s abdomen should be inspected for distention, surgical scars, bulging masses, and areas of erythema.
Auscultation may reveal the high-pitched, tinkling bowel sounds of obstruction or the absence of sounds due to ileus from diffuse peritonitis.
Percussion may reveal the tympanitic sounds of distended bowel in intestinal obstruction or the fluid wave that is characteristic of ascites. Percussion is also useful in localizing tenderness and peritoneal irritation (deep palpation or rebound is usually unnecessary to determine peritoneal irritation).
Palpation of the patient’s abdomen should be performed with the patient in a supine position and with his or her knees flexed, if necessary, to relieve pain.
Begin the examination at a point remote from the reported site of pain.
Areas of tenderness and guarding should be noted. Rebound tenderness is not a very reliable sign of peritonitis. The presence of involuntary guarding (localized or diffuse) due to muscular rigidity from underlying peritoneal irritation is often a better sign of peritonitis. Peritonitis may also be elicited by rocking the patient’s pelvis or shaking the bed to create friction between the abdominal wall and peritoneal viscera.
Pain out of proportion to physical examination findings suggests mesenteric ischemia.
Thoroughly search for hernias (incisional, ventral, umbilical, inguinal, femoral).
Any palpable masses should be noted.
Rectal examination should be performed routinely in all patients with abdominal pain.
Tenderness or a mass on the right pelvic side wall is sometimes seen in appendicitis.
A mass in the rectum may indicate obstructing cancer. Important details are the fraction of circumference involved, tumor mobility, and distance from the anal verge.
The presence of occult blood in the stool specimen may indicate GI bleeding from peptic ulcer disease.
Pelvic examination must be performed in all women of child-bearing age who present with lower abdominal pain.
Cervical discharge and overall appearance of the cervix should be noted.
Bimanual examination should be performed to assess cervical motion tenderness, adnexal tenderness, and the presence of adnexal masses.
Testicular and scrotal examination is essential in all males who complain of abdominal pain.
Testicular torsion produces a painful, swollen, and tender testicle that is retracted upward in the scrotum.
Epididymitis may coexist with urinary tract infection. The epididymis is swollen and tender, and the vas deferens may also be inflamed.
Specific physical examination findings should be sought in the appropriate clinical setting.
Murphy’s sign is inspiratory arrest while continuous pressure is maintained in the RUQ. Seen in acute cholecystitis, Murphy’s sign reflects the descent of an inflamed gallbladder with inspiration. When the inflamed gallbladder makes contact with the examiner’s hand, the patient experiences pain, causing the inspiratory arrest. A sonographic Murphy’s sign may be elicited during ultrasonographic examination of the gallbladder.
The obturator sign reflects inflammation adjacent to the internal obturator muscle (as is sometimes seen in appendicitis). It may also be present with an obturator hernia. While the patient is supine with the knee and hip flexed, the hip is internally and externally rotated. The test is positive if the patient experiences hypogastric pain during this maneuver.
The iliopsoas sign is seen when an adjacent inflammatory process irritates the iliopsoas muscle. It is classically observed in retrocecal appendicitis. The patient’s thigh is usually already drawn into a flexed position for relief. The test is best performed with the patient lying on the left side. With the knee flexed, the thigh is hyperextended. The test is positive if the patient experiences pain on the right side with this maneuver.
Rovsing’s sign may also be seen in acute appendicitis. Indicative of an inflammatory process in the right lower quadrant (RLQ), Rovsing’s sign is RLQ pain resulting from percussion in the left lower quadrant (LLQ).