Important components of the physical examination for the patient with acute abdo
General status
Is the patient hemodynamically unstable? Does he or she need immediate hemodynamic resuscitation and emergent laparotomy, e.g., ruptured spleen, hepatic tumor, aneurysm, ectopic pregnancy, or mesenteric apoplexy.
Inspection/Auscultation
Visually evaluate for distention, hernias, scars, and hyperperistalsis. Hyperperistalsis suggests obstruction; absence of peristalsis for more than three minutes suggests peritonitis (silent abdomen); bruits suggest presence of an aneurysm.
Percussion/Palpation
Tympany suggests either intraluminal or free abdominal air. Start the examination away from the area of tenderness and be gentle. Abdominal pain with voluntary coughing suggests peritoneal signs. Deeply palpating the abdomen in this case will only diminish patient trust and cooperation. The enlarged gallbladder will be missed on 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).
The abdominal examination of visceral ischemia/infarction is characteristically disproportionate to the degree of abdominal pain.
Pelvic and rectal exam
These exams should be done in any patient with abdominal pain. A painful rectal examination may be the only sign of pelvic appendicitis, diverticulitis, or tuboovarian pathology. Bimanual examination is critical in order to exclude obstetric or gynecologic cause.
Iliopsoas test
With the patient supine and the legs fully extended, the patient is requested to raise the legs. Pain occurs when the psoas muscle is inflamed (e.g., appendicitis).
Obturator test
This test is performed by flexing the patients’s thigh at right angles to the trunk and then rotating the leg externally. Inflammation of the obturator internus muscle will cause pain to be elicited with this test, e.g., tuboovarian abscess or pelvic appendicitis.What are the important components of the physical examination for the patient with acute abdominal pain?
Reprinted with permission: McNally PR, Cremins JE. GI and Liver Secrets: Questions You Will Be Asked on Rounds in the Clinic on Oral Exams Philadelphia: Handley & Belfast, Inc.; 1997:374.
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