General appearance | Assess appearance (eg, jaundice, pallor, cachexia), vital signs, and urine output |
Visual inspection of the abdomen |
Asymmetry, swelling, distention, and visible pulsation from the end of the bed Contour of the abdomen (flat, protuberant, or scaphoid) All surgical scars, sinuses, fistulae, dilated veins, bruises, Cullen sign, Grey Turner sign, striae Check for hernias (inguinal, abdominal, umbilical) Assess patient reaction to coughing, movement Observe patient's behavior in bed; eg, laying still, resistant to movement, restless, writhing |
Abdominal palpation |
Start with the area away from the pain:
Light palpation to elicit superficial tenderness and muscular resistance, and assess superficial organs or masses Deep palpation to assess deep tenderness, deep masses, or pulsatile masses Palpation of liver, spleen, and kidneys Assess for peritoneal inflammation: Ask the patient to cough and determine location of pain produced by cough Test for rebound tenderness Assess rigidity (involuntary guarding) Assess hernial orifices and external genitalia Ascites: Test for fluid wave and shifting dullness |
Special maneuvers | |
Rovsing sign | RLQ pain when pressure is applied to the LLQ. To test, press deeply in the LLQ. Test is positive and suggestive of an inflammed appendix when LLQ pressure elicits RLQ pain. |
Psoas sign | Place your hand just above the patient's right knee, and ask the patient to raise the right thigh against your hand. Pain indicates irritation of the psoas muscle by an inflamed appendix. |
Obturator sign | Flex the patient's right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. Pain indicates irritation of the obturator muscle by an inflamed appendix. |
Murphy sign | Hook your left thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects the costal margin. Ask the patient to take a deep breath. A sharp increase in tenderness with sudden stop of inspiratory effort constitutes a positive Murphy sign and is indicative of acute cholecystitis. |
Dunphy sign | Increased pain with coughing or other movement indicating appendicitis or other inflammation of the peritoneum. |
Percussion | Percuss the whole abdomen to asses for dullness and tympany Determine the liver span (normal range is 6-12 cm in the right midclavicular line) |
Ascultation | Listen for bowel sounds, bruits |
Digital rectal exam | Look for masses and blood |
Bimanual exam | Cervical motion tenderness (PID), adnexal masses |
LLQ=left lower quadrant; LUQ=left upper quadrant; RLQ=right lower quadrant; RUQ=right upper quadrant |