From the Guidelines
A comprehensive physical examination for a patient with acute abdomen should include vital signs assessment, general appearance evaluation, and a systematic abdominal examination, as this approach helps identify the location, severity, and potential cause of abdominal pain, guiding further diagnostic workup and management decisions. The abdominal exam should start with inspection for distention, visible peristalsis, or surgical scars, followed by auscultation for bowel sounds before palpation disturbs them 1. Gentle palpation should be performed first, progressing to deep palpation to identify areas of tenderness, guarding, rigidity, or rebound tenderness. Special maneuvers like Murphy's sign for cholecystitis, psoas sign for appendicitis or retroperitoneal inflammation, and obturator sign for pelvic inflammation should be included 1.
Some key points to consider in the physical examination of a patient with acute abdomen include:
- Vital signs assessment, including temperature, heart rate, blood pressure, and respiratory rate
- General appearance evaluation, including assessment of the patient's overall condition and any signs of distress
- Systematic abdominal examination, including inspection, auscultation, palpation, and percussion
- Special maneuvers, such as Murphy's sign, psoas sign, and obturator sign, to help identify specific causes of abdominal pain
- Rectal examination to check for tenderness, masses, or blood
- Pelvic examination in female patients to rule out gynecological causes
According to the most recent and highest quality study, a step-up approach for diagnosis should be used and tailored to the clinical setting, resources, patient’s age beginning with clinical and laboratory examination and progressing to imaging examinations 1. This approach is supported by the 2020 update of the WSES Jerusalem guidelines, which emphasizes the importance of a comprehensive physical examination in the diagnosis and treatment of acute appendicitis 1.
In terms of specific physical examination techniques, the presence of a positive psoas sign, fever, or migratory pain to the right lower quadrant suggests an increased likelihood of appendicitis 1. Additionally, the presence of vomiting before pain makes appendicitis unlikely 1.
Overall, a comprehensive physical examination is a crucial component of the diagnostic workup for patients with acute abdomen, and should be used in conjunction with laboratory and imaging studies to guide further management decisions.
From the Research
Physical Exam for Acute Abdomen
The physical examination is a crucial diagnostic tool for patients with acute abdomen, as it can help minimize further testing or radiation and reveal the overall health of the patient as well as acute pathology 2. A thorough abdominal examination should be performed, including:
- Inspection: visual examination of the abdomen for any signs of distension, scars, or other abnormalities
- Auscultation: listening to the sounds of the abdomen with a stethoscope to check for bowel sounds, bruits, or other abnormal sounds
- Percussion: tapping on the abdomen to check for tenderness or abnormalities in the underlying organs
- Palpation: feeling the abdomen with the hands to check for tenderness, masses, or other abnormalities
Key Findings and Indicators
The physical examination should focus on key findings and indicators that suggest the need for immediate surgical intervention, such as:
- Tenderness or guarding in the abdomen
- Rebound tenderness or the psoas sign
- Fever or other signs of infection
- Abdominal distension or masses
- Bowel sounds or other abnormal sounds 3, 4
Special Considerations
Special consideration should be given to certain patient populations, such as:
- Pediatric patients, who may present with atypical symptoms of a disease
- Female patients, who may have gynecologic causes of acute abdomen
- Elderly patients, who may present with atypical symptoms of a disease
- Oncologic patients, who may have unique diagnostic challenges 5
Imaging and Diagnostic Tests
Imaging and diagnostic tests, such as ultrasound or computed tomography (CT) scans, may be used to supplement the physical examination and provide further diagnostic information 5, 4. However, the physical examination remains a critical component of the diagnostic process, and should not be replaced by imaging or other tests alone.