Key Components of Physical Examination for Suspected Appendicitis
The key components of a physical examination for suspected appendicitis include assessment for right lower quadrant tenderness, rebound tenderness, guarding, and peritoneal signs, which are the most reliable physical examination findings for diagnosing appendicitis. 1
Essential Physical Examination Components
Right Lower Quadrant (RLQ) Tenderness: Focal tenderness at McBurney's point (located approximately two-thirds of the way from the umbilicus to the anterior superior iliac spine) is a classic finding 2, 1
Rebound Tenderness: Pain that worsens when pressure is suddenly released, indicating peritoneal irritation, is a significant finding associated with acute appendicitis 2, 1
Guarding: Involuntary muscle rigidity of the abdominal wall, particularly in the RLQ, suggests peritoneal inflammation 2, 1
Rovsing's Sign: Pain in the RLQ when palpating the left lower quadrant, suggesting peritoneal irritation 1
Psoas Sign: Pain with passive extension of the right hip, suggesting irritation of the psoas muscle by an inflamed appendix 1
Obturator Sign: Pain with internal rotation of the flexed right hip, suggesting irritation of the obturator muscle by an inflamed appendix 1
Clinical Assessment Considerations
Temperature Assessment: Fever (>38°C) is an important finding, though not always present in early appendicitis 2
Migration of Pain: Document if pain began periumbilically and migrated to the RLQ, which is a classic symptom pattern 3
Atypical Presentations: Physical findings may vary based on appendix location (retrocecal or pelvic) and patient demographics (elderly, pregnant women, children) 1, 4
Pain as Sole Indicator: Some patients (up to 15.6%) may present with isolated RLQ pain without fever or elevated inflammatory markers, yet still have appendicitis 5
Validated Clinical Scoring Systems
AIR Score (Appendicitis Inflammatory Response): Combines physical examination findings with laboratory values for better diagnostic accuracy 1
Alvarado Score: Includes RLQ tenderness, rebound pain, elevated temperature, migration of pain, anorexia, nausea/vomiting, leukocytosis, and left shift 2
Adult Appendicitis Score (AAS): Has high discriminating power in adults with suspected appendicitis 1
Special Population Considerations
Pregnant Patients: Physical examination may be less reliable due to anatomical changes; right-sided abdominal pain remains the most consistent finding 2
Elderly Patients: May present with less pronounced physical examination findings despite having more advanced disease 1
Obese Patients: Physical examination findings may be less reliable, with higher false-negative and false-positive rates 2
Common Pitfalls in Physical Examination
Relying on a single physical finding: No single physical examination finding is sufficiently sensitive or specific to rule in or rule out appendicitis 1
Overlooking atypical presentations: Patients with retrocecal or pelvic appendix may have minimal or atypical RLQ findings 1
Premature exclusion: Absence of fever or normal white blood cell count does not exclude appendicitis; 15.6% of patients with appendicitis may present with isolated RLQ pain without inflammatory signs 5
Confusing with other conditions: Physical findings may mimic other conditions such as cecal diverticulitis, epiploic appendagitis, or gynecological conditions 4, 6
Integrated Diagnostic Approach
Combine physical examination with laboratory tests: WBC count with differential and CRP can increase diagnostic accuracy 1
Consider imaging when physical examination is equivocal: Ultrasound as first-line imaging, especially in children and pregnant women; CT with IV contrast when ultrasound is inconclusive 2
Reassessment: Serial physical examinations may be necessary as appendicitis findings can evolve over time 3