Physical Examination Approach for Abdominal Pain with Fever
A thorough, systematic physical examination focusing on vital signs, general appearance, and a complete abdominal examination is essential for patients presenting with abdominal pain and fever to identify potential life-threatening conditions requiring immediate intervention. 1, 2
Initial Assessment
Vital signs: Document temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation
- Tachycardia and hypotension may indicate sepsis or hemorrhage
- Fever pattern and severity should be noted (high fever suggests infection)
General appearance: Assess for:
- Distress level
- Positioning (patients with peritonitis often lie still)
- Skin color (pallor, jaundice)
- Mental status
Abdominal Examination Sequence
1. Inspection
- Observe for:
- Abdominal distension (suggests obstruction or ascites)
- Visible peristalsis (suggests obstruction)
- Surgical scars (important for history of previous surgeries)
- Skin changes (jaundice, ecchymosis, rashes)
- Asymmetry or masses
2. Auscultation
- Listen for bowel sounds in all four quadrants:
- Hyperactive sounds (early obstruction)
- Hypoactive or absent sounds (ileus, peritonitis)
- High-pitched tinkling (obstruction)
- Bruits (vascular disease)
3. Percussion
- Assess for:
- Tympany (gas-filled structures)
- Dullness (fluid or solid masses)
- Liver span
- Splenic dullness
- Shifting dullness (ascites)
4. Palpation
- Begin with light palpation away from the area of pain
- Progress to deep palpation
- Note:
- Areas of tenderness and their location
- Guarding (voluntary or involuntary)
- Rebound tenderness (peritoneal irritation)
- Rigidity (peritonitis)
- Masses or organomegaly
- Murphy's sign (RUQ pain with inspiration during palpation - cholecystitis)
- McBurney's point tenderness (appendicitis)
- Rovsing's sign (RLQ pain with LLQ palpation - appendicitis)
- Psoas sign (appendicitis or retroperitoneal inflammation)
- Obturator sign (pelvic inflammation)
Special Examination Techniques
- Carnett's test: Differentiate abdominal wall from intra-abdominal pain
- Cough test: Pain with coughing suggests peritoneal irritation
- Percussion tenderness: Suggests peritoneal inflammation
- Cutaneous hyperesthesia: May indicate visceral disease
Additional Examination Areas
Rectal examination: Essential for:
- Assessing tenderness (especially in appendicitis)
- Detecting masses
- Checking for occult blood
- Evaluating prostate in men
Pelvic examination in women:
- Assess for cervical motion tenderness
- Evaluate for adnexal masses or tenderness
- Rule out gynecological causes
Extraabdominal examination:
- Chest (lower lobe pneumonia can present as abdominal pain)
- Flank (for costovertebral angle tenderness in pyelonephritis)
- Groin (for hernias)
- Skin (for rashes suggesting systemic disease)
Pitfalls and Special Considerations
Elderly patients may present with atypical symptoms:
- Minimal or absent fever despite serious infection 1
- Reduced pain sensation
- Vague complaints rather than specific pain
Immunocompromised patients:
- Signs of abdominal sepsis may be masked 1
- Lower threshold for imaging studies
Pregnancy:
- Anatomical displacement of organs
- Consider obstetric emergencies
Clinical Pearls
- The absence of fever does not rule out serious pathology
- Repeated examinations over time are often more valuable than a single assessment
- Document the progression of physical findings
- Correlate physical findings with laboratory results and imaging studies
- In patients with fever and diffuse abdominal pain, consider intra-abdominal abscess, peritonitis, or bowel perforation 1
The American College of Radiology recommends CT abdomen and pelvis with IV contrast as the most appropriate initial diagnostic test for patients with nonlocalized abdominal pain and fever when the physical examination cannot pinpoint a specific diagnosis 1, 2.