Physical Examination for Abdominal Pain
The physical examination for abdominal pain should follow a systematic four-step approach: inspection, auscultation, percussion, and palpation, with specific attention to identifying peritoneal signs, assessing pain location by anatomic quadrant, and checking for often-missed findings like hernias at surgical scars. 1, 2
Systematic Examination Sequence
Step 1: Vital Signs Assessment
- Tachycardia is the most sensitive early warning sign of surgical complications and should trigger urgent investigation even before other symptoms develop 3
- Assess for hemodynamic instability (tachycardia or hypotension), which suggests bleeding or sepsis 1
- Fever with severe pain suggests infection, abscess, or perforation 1
Step 2: Inspection
- Look for abdominal distension with vomiting, which indicates bowel obstruction 1
- Examine all hernia orifices and surgical scars carefully, as overlooking these can miss incarcerated hernias 1
- Assess for visible peristalsis or asymmetry 2
Step 3: Auscultation (Before Palpation)
- Listen for bowel sounds to assess for obstruction or ileus 2
- Perform this before palpation to avoid altering bowel sounds 2
Step 4: Percussion
- Assess for tympany versus dullness to identify fluid, masses, or distension 2
- Check for loss of liver dullness, which may indicate pneumoperitoneum 2
Step 5: Palpation (Light Then Deep)
- Check for peritoneal signs including rigid abdomen or rebound tenderness, which indicate perforation or ischemia 1
- Assess pain location by quadrant to guide differential diagnosis 1, 3
- Pain out of proportion to physical findings strongly suggests mesenteric ischemia 1
Location-Specific Examination Focus
Right Upper Quadrant Pain
- Palpate for Murphy's sign (inspiratory arrest with deep palpation under right costal margin) to assess for acute cholecystitis 1, 3
- Assess for hepatomegaly or tenderness suggesting hepatobiliary pathology 1
Right Lower Quadrant Pain
- Appendicitis is the critical diagnosis to exclude 1, 3
- Check for McBurney's point tenderness, Rovsing's sign, and psoas/obturator signs 4
- In women of reproductive age, perform pelvic examination to assess for ectopic pregnancy or ovarian pathology 3
Left Lower Quadrant Pain
- Assess for tenderness suggesting diverticulitis, especially in older adults 1
- Palpate for masses or fullness 2
Epigastric/Diffuse Pain
- Assess for tenderness suggesting peptic ulcer disease, gastritis, or pancreatitis 1
- Check for guarding or rigidity indicating peritonitis 1
Critical Examination Pitfalls to Avoid
- Never skip examination of hernia orifices and surgical scars, as this commonly leads to missed incarcerated hernias 1
- In elderly patients, do not dismiss subtle findings, as they frequently present with atypical symptoms despite serious pathology 1, 3
- Always perform pregnancy testing in all women of reproductive age before proceeding, as physical examination alone cannot exclude ectopic pregnancy 1, 3
- Do not over-rely on the absence of peritoneal signs early in disease, as normal examination does not exclude serious pathology 1
Special Population Considerations
Women of Reproductive Age
- Always consider gynecologic causes including ectopic pregnancy, ovarian torsion, and pelvic inflammatory disease 3
- Perform pelvic examination when indicated 3