See also topic B42 for differential diagnosis.
Physical examination of acute abdomen
|Inspect for any hernias||–|
|Patient lies completely still (any small movement causes pain) with knees bent||Peritonitis|
|Patients is curled up, writhes in agony, wants to keep moving||Biliary or renal colic|
|Abnormally active, high-pitched bowel sounds||Early bowel obstruction|
|Absent bowel sounds||Late bowel obstruction|
|Bruit on auscultation||Abdominal aortic aneurysm|
|Even gentle percussion causes pain||Peritonitis|
|Shifting dullness on percussion||Ascites|
|Palpate the whole abdomen to locate the area of maximal pain, first superficially then deeper||–|
|Palpate for hepatomegaly or splenomegaly||–|
|Palpate for any masses||–|
|Muscular rigidity or “guarding” on palpation||Peritonitis|
|Markle sign/Heel-drop test||Peritonitis|
|Maximal pain at the McBurney’s point||Appendicitis|
|Palpation of contralateral McBurney’s point elicits pain at the McBurney’s point (Rovsing sign)||Appendicitis|
|Psoas sign||Appendicitis, especially retrocaecal appendicitis|
|Obturator sign||Appendicitis, especially pelvic appendicitis|
|Carnett sign||Abdominal wall pathology (rather than visceral pathology)|
|Pain out of proportion to physical findings (severe pain but nontender, soft abdomen)||Mesenteric ischaemia|
Peritonitis may be local or generalised, and the physical findings will follow this. It’s important to know that, because the visceral organs aren’t innervated with somatic pain fibres, appendicitis isn’t painful in itself but causes pain because it causes localised peritonitis in the overlying peritoneum.
Markle sign is tested by asking the patient to stand on their toes and suddenly drop down on the heels with an audible thump, which causes localised pain. An alternative way to elicit this sign is to lift the patient’s legs slightly off the bed and striking the patient’s heels.
Carnett sign refers to increased tenderness when the abdominal wall muscles are voluntarily contracted.
Murphy sign refers to the patient abruptly stopping a deep inspiration during palpation of the upper right quadrant due to sudden pain. This occurs because during inspiration, the tender gallbladder is pushed caudally by the expanding lungs, eventually hitting the palpating hand. Note that Murphy sign is not sensitive in elderly.
Psoas sign is elicited by asking the patient to lie on the left side with the hip flexed, and the examiner passively extending the right hip. This causes pain in the right lower quadrant in the case of appendicitis because the right psoas muscle lies beneath the appendix, and so stretching or contracting it elicits pain.
Obturator sign is elicited by the examiner flexing the patient’s right hip and knee, followed by internal rotation of the right hip. This causes pain in the right lower quadrant in the case of appendicitis because the right obturator internus muscle lies beneath the appendix, and so stretching or contracting it elicits pain.
Digital rectal examination
See topic A26.
A23. Hemoptoe, hematemesis
A26. Differential diagnosis of bloody stool. The significance of rectal digital investigation