What are the key components of a physical exam for suspected appendicitis?

Key Components of Physical Examination for Suspected Appendicitis

A thorough physical examination for suspected appendicitis should include assessment of right lower quadrant pain, abdominal rigidity, and periumbilical pain radiating to the right lower quadrant, which are the most reliable signs for diagnosing acute appendicitis in adults. 1

Essential Physical Examination Elements

Abdominal Examination

• Right Lower Quadrant (RLQ) Assessment:
  • Direct palpation for localized tenderness at McBurney's point (located two-thirds of the way from the umbilicus to the anterior superior iliac spine)
  • Assessment for abdominal rigidity/guarding
  • Evaluation for rebound tenderness

Special Maneuvers

• Rovsing's Sign: Palpation of the left lower quadrant causing pain in the right lower quadrant (indicates peritoneal irritation)
• Psoas Sign: Extension of the right hip causing pain (suggests retrocecal appendicitis irritating the psoas muscle)
• Obturator Sign: Internal rotation of the flexed right hip causing pain (indicates pelvic appendicitis irritating the obturator muscle)
• Cutaneous Hyperesthesia: Increased skin sensitivity in the T10-T12 dermatomes

Additional Examination Components

• Vital Signs: Assessment for fever, tachycardia (signs of systemic inflammatory response)
• Rectal Examination: May reveal tenderness in pelvic appendicitis
• Pelvic Examination: Particularly important in women to rule out gynecological causes of pain

Clinical Findings and Risk Stratification

The physical examination findings should be incorporated into clinical decision-making for risk stratification 2. Clinical scoring systems such as the Alvarado Score and Pediatric Appendicitis Score can help categorize patients into low, moderate, or high risk for appendicitis 2, 1.

Key Physical Examination Findings by Patient Population

Adults

• Most reliable signs: right lower quadrant pain, abdominal rigidity, and periumbilical pain radiating to the right lower quadrant 1
• Absence of these classic findings does not rule out appendicitis

Children

• Most reliable signs: absent or decreased bowel sounds, positive psoas sign, positive obturator sign, and positive Rovsing sign 1
• Children <5 years frequently present with atypical symptoms, making diagnosis more challenging 2

Pregnant Women

• Physical findings may be altered due to displacement of the appendix by the gravid uterus
• Right upper quadrant or right flank pain may be present instead of classic RLQ pain

Common Pitfalls in Physical Examination

1. Premature or excessive analgesia: May mask physical findings, though appropriate pain control should not be withheld as it does not result in delayed or unnecessary intervention 1

2. Relying solely on classic presentation: The classic constellation of symptoms (periumbilical pain migrating to RLQ, anorexia, nausea, vomiting) is only moderately reproducible between clinicians 2

3. Failure to repeat examinations: Serial examinations are valuable for observing the evolution of physical findings

4. Overlooking atypical presentations: Particularly in young children, elderly patients, and pregnant women

Integration with Clinical Decision-Making

Physical examination findings should be integrated with history and laboratory findings to guide further management 2:

• Low clinical suspicion: May be discharged with minimal or no testing
• Intermediate risk: Further evaluation with imaging studies (ultrasound or CT)
• High clinical suspicion: Early surgical consultation with minimal or no additional testing 2

Physical examination remains a cornerstone in the diagnosis of appendicitis, but should be complemented by appropriate laboratory and imaging studies when the diagnosis is uncertain, particularly in high-risk groups (extremes of age, pregnant women, and immunocompromised patients) 3.