Physical examination for acute abdominal pain

What are the important components of the physical examination for patients with acute abdominal pain?

• General status: Is the patient hemodynamically unstable? Does he or she need immediate hemodynamic resuscitation and emergent laparotomy (e.g., ruptured spleen, ruptured hepatic tumor, aneurysm, ectopic pregnancy, or mesenteric apoplexy)?

• Inspection: Visually evaluate for distention, hernias, scars, and hyperperistalsis.

• Auscultation: Hyperperistalsis suggests obstruction; absence of peristalsis (no bowel sounds heard over 3 minutes) suggests peritonitis (silent abdomen); bruits suggest presence of an aneurysm.

• Percussion: Tympany suggests either intraluminal or free abdominal air.

• Palpation: Start the examination away from the area of tenderness and be gentle. Abdominal pain with voluntary coughing suggests peritoneal signs. Deeply palpating the abdomen only diminishes patient trust and cooperation. The enlarged gallbladder will be missed on aggressive, deep palpation. Inspiratory arrest during light palpation of the right hypochondrium suggests gallbladder pain (Murphy’s sign). Localized pain suggests localized peritonitis (e.g., appendicitis, cholecystitis, diverticulitis).

• Pelvic and rectal examination: These examinations should be done in all patients with abdominal pain. A painful examination may be the only sign of pelvic appendicitis, diverticulitis, or tubo-ovarian pathologic conditions. Bimanual examination is critical to exclude an obstetric or a gynecologic cause.

• Iliopsoas test: With the legs fully extended in a supine position, the patient is requested to raise the legs unilaterally. Pain occurs when the right psoas muscle is inflamed (e.g., appendicitis).

• Obturator test: This test is performed by flexing the patient’s thigh at right angle to the trunk and then rotating the leg externally. Inflammation of the obturator internus muscle causes pain (e.g., tubo-ovarian abscess or pelvic appendicitis).

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