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Year 2 MBChB

Clinical Skills Session

Abdominal examination

Written by: The Clinical Skills Lecturer Team

Reviewed by:

Mr C Halloran – Gastroenterology System lead

Dr P Collins – Consultant Gastroenterologist

Miss R Hamm – Urinary and Renal System Lead (Consultant Urologist)

August 2019

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Learning objectives.

To revise anatomy and physiology of the Abdomen

To link the anatomy and physiology to the examination

To be able to perform an abdominal examination including an understanding of the common abnormalities and

examination of appropriate lymph nodes

Theory and background.

There are numerous reasons for performing an abdominal examination, the majority of which are related to the

GI tract. For that reason we are going to look at examining the GI tract and then the rest of the abdomen (where

needed)

The gastrointestinal tract

The gastrointestinal system is composed of two groups of organs: the gastrointestinal tract (GI) and the

accessory digestive organs.

The GI tract or alimentary canal is a continuum that extends from the mouth to the anus through the ventral

body cavity (comprised of thoracic and abdominopelvic cavities). Organs of the gastrointestinal tract include the

mouth, most of the pharynx, oesophagus, stomach, small and large intestine. The accessory digestive organs are

the teeth, tongue, salivary glands, liver, gallbladder and pancreas.

The function of the gastrointestinal tract is to take a bolus of food; masticate it, swallow it, digest it, absorb it

and to expel the unwanted products.

The abdominal cavity

The abdominal cavity is bordered by the pelvis (inferiorly,) the diaphragm (superiorly) and laterally by the walls

of the torso. For the purpose of identifying abnormalities the abdomen is divided into either 4 quadrants or 9

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regions (see illustrations below).

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Indications for an abdominal examination.

The decision as to which examinations will be performed is always based upon the patient’s history. There are

many indications for performing the abdominal examination some examples are:

o Chronic / acute vomiting

o Changes in bowel habits including constipation or diarrhoea

o Blood or mucus evident in faeces

o Unexplained weight loss which may be due to malabsorption or malignancy

o Chronic / acute abdominal or rectal pain

o Abdominal distension

o Jaundice

o Abnormal blood

o Trauma

Pain associated with abdominal disorders

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Acute appendicitis

Nausea, vomiting, central abdominal pain that later shifts to right iliac fossa

Fever, tenderness, guarding or palpable mass in right iliac fossa, pelvic peritonitis on rectal examination

Perforated peptic ulcer with acute peritonitis

Vomiting at onset associated with severe acute-onset abdominal pain, previous history of dyspepsia, ulcer disease, non-steroidal anti-inflammatory drugs or glucocorticoid therapy

Shallow breathing with minimal abdominal wall movement, abdominal tenderness and guarding, board-like rigidity, abdominal distension and absent bowel sounds

Acute pancreatitis

Anorexia, nausea, vomiting, constant severe epigastric pain, previous alcohol abuse/cholelithiasis

Fever, periumbilical or loin bruising, epigastric tenderness, variable guarding, reduced or absent bowel sounds

Ruptured aortic aneurysm

Sudden onset of severe, tearing back/loin/abdominal pain, hypotension and past history of vascular disease and/or high blood pressure

Shock and hypotension, pulsatile, tender, abdominal mass, asymmetrical femoral pulses

Acute mesenteric ischaemia

Anorexia, nausea, vomiting, bloody diarrhoea, constant abdominal pain, previous history of vascular disease and/or high blood pressure

Atrial fibrillation, heart failure, asymmetrical peripheral pulses, absent bowel sounds, variable tenderness and guarding

Intestinal obstruction

Colicky central abdominal pain, nausea, vomiting and constipation

Surgical scars, hernias, mass, distension, visible peristalsis, increased bowel sounds

Ruptured ectopic pregnancy

Premenopausal female, delayed or missed menstrual period, hypotension, unilateral iliac fossa pain, pleuritic shoulder-tip pain, ‘prune juice’-like vaginal discharge

Suprapubic tenderness, periumbilical bruising, pain and tenderness on vaginal examination (cervical excitation), swelling/fullness in fornix on vaginal examination

Pelvic inflammatory disease

Sexually active young female, previous history of sexually transmitted infection, recent gynaecological procedure, pregnancy or use of intrauterine contraceptive device, irregular menstruation, dyspareunia, lower or central abdominal pain, backache, pleuritic right upper quadrant pain (Fitz-Hugh–Curtis syndrome)

Fever, vaginal discharge, pelvic peritonitis causing tenderness on rectal examination, right upper quadrant tenderness (perihepatitis), pain/tenderness on vaginal examination (cervical excitation), swelling/fullness in fornix on vaginal examination

Considerations in History

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During the first 1–2 hours after perforation, a ‘silent interval’ may occur when abdominal pain resolves

transiently. The initial chemical peritonitis may subside before bacterial peritonitis becomes established. For

example, in acute appendicitis, pain is initially periumbilical (visceral pain) and moves to the right iliac fossa

(somatic pain) when localised inflammation of the parietal peritoneum becomes established.

If the appendix ruptures, generalised peritonitis may develop. Occasionally, a localised appendix abscess

develops, with a palpable mass and localised pain in the right iliac fossa.

Change in the pattern of symptoms suggests either that the initial diagnosis was wrong or that complications

have developed. In acute small bowel obstruction, a change from typical intestinal colic to persistent pain with

abdominal tenderness suggests intestinal ischaemia, as in a strangulated hernia, and is an indication for urgent

surgical intervention.

Abdominal pain persisting for hours or days suggests an inflammatory disorder, such as acute appendicitis,

cholecystitis or diverticulitis.

Exacerbating and relieving factors

Pain exacerbated by movement or coughing suggests inflammation. Patients tend to lie still to avoid

exacerbating the pain. People with colic typically move around or draw their knees up towards the chest during

spasms.

Severity

Excruciating pain, poorly relieved by opioid analgesia, suggests an ischaemic vascular event, such as bowel

infarction or ruptured abdominal aortic aneurysm. Severe pain rapidly eased by potent analgesia is more typical

of acute pancreatitis or peritonitis secondary to a ruptured viscus.

Equipment required to perform the examination

Hand wash

Stethoscope

Alcohol swabs to clean stethoscope

Patient safety.

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WHO (2009) http://www.who.int/infection-prevention/tools/hand-hygiene/en/

On first meeting a patient introduce yourself, confirm that you have the correct patient with the name and date

of birth, if available please check this with the name band and written documentation and the NHS/ hospital

number/ first line of address.

Check the patient’s allergy status, being aware of the equipment you will be using in your examination. Ensure

the procedure is explained to the patient in terms that they understand, gain informed consent and ensure that

you are supervised, with a chaperone available as appropriate. Don personal protective equipment as required,

especially if you are likely to come into contact with bodily fluids, you may need to carry out a rectal exam at the

end of the examination.

Be aware of hand hygiene and preventing the spread of disease, WHO (2009) http://www.who.int/infection-

prevention/tools/hand-hygiene/en/

This procedure may require the presence of a chaperone, and certainly will if a rectal examination takes place. A

chaperone is someone who is familiar with the examination and can ensure that nothing inappropriate occurs

by either party. The chaperone can be a useful resource, not just being present to ensure the patient is treated

appropriately, but to help and support the patient.

The patient should ideally be laid flat and you should be on the same level as the patient to reduce the risk of

causing any pain.

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Prior to any clinical examination a detailed history should be taken from the patient, this will enable you to tailor

the examination to the patient’s presenting complaint and additional symptoms the patient may elude to when

you elicit a full history. For guidance on history taking please click MBCHB students – Year 2 – History taking.

General Inspection

Look at the patient and their environment at the beginning of the examination.

In the environment there may be many indicators of possible abdominal conditions including:

o Vomit bowls

o Medications related to GI system

o Supplemental nutrition including tube feeding paraphernalia

o Uneaten meals

o Odours such as vomit, faeces, hepatic fetor and pear drops (associated with diabetes)

o Commode

o Alcohol containers

o What position are they in? Are they curled up in a ball? Have they got their arms clutching their abdomen?

These are some signs the patient may be in pain.

The patient may show some signs of possible abdominal conditions such as:

o Cachexia: wasting of the body due to severe chronic illness.

o Vomit or faecal soiling of bed linen or clothing.

o Signs of pain including facial expression and patient positioning

o A change in colour such as yellow (jaundice) associated with hepatobiliary conditions, pallor due to anaemia

which may be secondary to bleeding into the bowel or a flushed appearance secondary to inflammation /

infection and scars.

Specific Inspection

Moving on we will now look closely at the patient for signs of abdominal conditions. Adopting a systematic

approach we look at the:

Hands (see hand and nail study guide)

Look for nail signs which may develop over a period of time and indicate a chronic disease process. These signs

may include:

o Clubbing – Not specific for abdominal conditions but occurs with chronic disease. The tips of the fingers

take on a bulbous (swollen) appearance.

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o Koilonychia – another sign of chronic disease. Koilonychia is commonly termed as spooning. It occurs

secondary to a chronic iron deficiency anaemia which may be secondary to dietary influences or chronic

bowel problems such as ulcerative colitis.

o Leukonychia – white nails due to problems associated with protein metabolism

o Nicotine tar staining – indicating chronic / heavy smoking

o Pale nail beds which may indicate acute / chronic anaemia

We will also assess for asterixis, also known as metabolic or liver flap: ask the patient to stretch out their arms,

abduct their fingers and cock their wrists back and to hold this position for at least 15 seconds; if the patient is

unable to maintain this position and the hands “flap” this is known as asterixis. This flapping (tremor) may be

due to liver or respiratory conditions so again is not specific to abdominal conditions. However, all examination

findings are considered together when looking to make your diagnosis.

You should also take this opportunity to check all the patient’s vital signs including ACVPU or Glasgow coma

scale (should hepatic encephalopathy be suspected) and capillary refill time in the case of sepsis or shock.

Face, mouth and neck

Look at the face:

o Are the scleras of the eyes jaundiced? - jaundice will be evident in the sclera much earlier than the skin in

hepatobiliary conditions

o Are the tarsal conjunctiva (lining of the eye lids) pink or are they pale which may indicate chronic or acute

anaemia?

o Is there inflammation evident at the corners of the mouth (angular cheilitis / angular stomatitis) which can

be associated with some of the inflammatory bowel diseases, diabetes, cancer, oral thrush and certain

medications?

Look in the mouth (the start of the GI system) ensuring you look under the tongue:

o Is the mouth well hydrated? Dehydration may be a sign of poor oral intake, acute kidney injury or

chronic vomiting / diarrhoea.

(NICE guidance https://www.evidence.nhs.uk/search?q=diarrhoea+and+vomiting+in+adults)

o Ulceration of the oral mucosa may be associated with chronic inflammatory bowel conditions.

o Whilst examining the face and oral cavity any odours on the breath such as a faecal odour may indicate

a bowel obstruction, hepatic fetor (sweet musty smell) indicating liver disease not to be confused with

pear drops which are associated with diabetes may be easier to identify.

o Look for signs of oral thrush – there are a number of reasons patients may have this, including poor oral

hygiene, dry mouth, dentures – especially if they are poorly fitting.

Lymph nodes in the head and neck

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As part of an abdominal examination you should palpate for possible enlarged lymph nodes. As the GI system

starts at the mouth it may include, submental, submandibular, tonsillar, the deep and superficial cervical chain,

supra and infra clavicular, axillary and inguinal lymph nodes. An enlarged left supra clavicular lymph node

(Virchow’s node / Troiser’s sign) may be associated with metastatic spread of an abdominal malignancy. See

lymph examination study guide for further information (Lymph examination will be taught later in the year).

Inspection of the torso

The majority of inspection of the torso may be done with the patient lying supine with hands by their sides and

a single pillow under their head. It is important that the abdominal muscles are relaxed, even raising the head

slightly can increase abdominal tone, to relax a taught abdomen you can get the patient to flex their hips and

knees (“can you bend your knees and bring your feet towards their bottom”).

The patient’s torso should be exposed to the suprapubic region - inguinal and genital areas should remain

covered until they are to be examined.

If the patient is sat up at this point you may wish to inspect the patient’s back before laying them flat.

o Scars must be identified and the reason for the scar. If the patient has had previous abdominal surgery this

may help to rule out or indicate some possible causes of abdominal symptoms such as “adhesions”.

o Spider naevi / telangiectasia (swollen blood vessels which appear as a red central spot with reddish blood

vessels which spread out from this central spot) may be associated with liver disease and an increase in

oestrogen levels in the blood stream. The presence of more than 5 on the torso is abnormal.

o Gynecomastia (breast tissue in male patients) may also develop as it is associated with liver disease and an

increase in oestrogen levels.

o Abdominal distension (gross swelling) which can be remembered as the 6 F’s.

o Flatus (gas) – taut abdomen which is compressible

o Faeces – firm to hard mass take note of position as may be normal finding

o Fluid (ascites) – taut abdomen which may be non-compressible dependant on volume

o Fat – soft and compressible

o Foetus – obstetric palpation will be taught in later year

o Fairly big tumours - firm to hard mass

o Rashes - shingles may be a cause of pain and psoriasis may be associated with chronic inflammatory bowel

disorders.

o Mottled abdomen, can be associated with several disorders including pancreatitis, ruptured aortic

aneurysm, antiphospholipid syndrome or shock.

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o Dilated veins on the torso or around the umbilicus may be associated with increased pressure in the vena

cava due to restricted flow through the liver in liver disease.

o Abnormal abdominal movement i.e. visible peristalsis in bowel obstruction or pulsation which may indicate

an abdominal aortic aneurysm (AAA).

Percussion of liver

Usually palpation would follow on from inspection, however with an abdominal examination it is advised before

palpating the abdomen you should percuss for the size and position of the liver. You can either percuss down

from the right clavicle until you find the superior border when dullness is noted, then up from the right inguinal

region until the lower border is found. Alternately you may percuss up from the right inguinal region identify the

lower border of the liver and continue upwards until the note changes indicating the superior border. After

percussing for the liver you should palpate, before return to percuss the rest of the abdomen.

Palpation of the abdominal wall

As the examiner you should position yourself to be on level with the abdominal surface, either use a chair, raise

the bed or stoop to achieve this. The reason you should be level with the abdomen is to ensure you DO NOT

apply too much pressure when palpating what may already be a painful / tender abdomen. Secondary to this

you will be able to look across the abdomen for swellings and it will be less intimidating for the patient as you

will not be standing over them.

If the patient has complained of abdominal pain or tenderness you should start your palpation away from the

affected area and move towards it palpating the tender area last.

Throughout abdominal palpation you should observe the patient’s face for visual signs of pain; as on occasion

patients will not verbally complain of pain but visually you can see the pain on their face as you palpate. This

observation could give you key clinical signs that may be missed had you not observed the patients face.

There are 3 elements of abdominal palpation:

o Superficial palpation is performed to determine the tone of the abdominal wall muscles which can become

tense (contract) due to pain, infection or inflammation in order to protect the underlying structures within

the abdomen.

o Deep palpation is performed to identify possible abnormal masses within the abdominal / peritoneal cavity.

o Specific organ palpation is used to identify potential enlargement of the liver and spleen.

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o Pain elicited during palpation is an important finding as other signs may not be evident in the early stages of

a condition.

o Guarding is the contraction of the abdominal muscles in response to pressure being applied over an area of

infection / inflammation. The muscles tense in response to the pressure applied by the examiner’s hand to

protect the underlying structures from further insult.

o Rigidity is the contraction of the abdominal muscles in response to infection / inflammatory changes within

the abdominal / peritoneal cavity. This contraction is evident prior to any palpation and the abdomen will be

“rock” hard. Normal abdominal movement with respiration will be absent. Rigidity is a concerning sign and

should be reported to a senior upon immediately

If an abnormal finding is evident relate it to the region of the abdomen being palpated and document its

position.

Deep palpation

Deep palpation is performed using a similar technique as that for superficial palpation but pressing deeply

through the abdominal (muscle) wall to palpate for any abnormal masses or swelling of the abdominal organs. If

a mass is palpated describe it by the region of the abdomen being palpated, the underlying structures / organs

and document it’s size (in cm), shape, depth (superficial or deep), surface (smooth or irregular), consistency

(hard, firm, soft or fluid), edge (defined or diffuse) or if it is pulsating (if a pulsating mass is found ensure you

inform a senior member of staff and do not continue with the examination until the patient has been seen).

To determine if the mass is in the abdominal wall or in the abdomen itself you can ask the patient to raise their

head, this will cause the muscles to contract and allow you to differentiate whether the mass is on the wall or

within the abdomen itself.

Specific Organ Palpation

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Specific organ palpation technique is used to identify any enlargement of the liver, spleen or kidneys

(organomegaly). The patient is asked to relax and take deep breaths at a steady rate which may be determined

by the examiner. However, care must be taken to ensure the patient is not stressed by the rate of respiration

required as this may lead to light-headedness.

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Percussion

If a mass is palpated percussion allows us to determine the boundaries of a mass and also to determine the

consistency i.e. gas, fluid or solid tissue. The overall percussion note found over the abdomen is resonance as in

the supine position any fluid in the bowel settles to the patients back and gases rise to the anterior surfaces of

the bowel.

Routine percussion is performed for the purposes of identifying the superior border of the liver and the inferior

border. Starting in the midclavicular line percuss down from the right clavicle until the note becomes dull (this

should identify the superior border of the liver). Once the superior border is identified percuss up from the right

iliac fossa until the lower border is identified (the normal abdomen is resonant when the patient is lying supine).

If a mass or organomegaly was detected during the examination of the abdomen, then percussion is performed

to determine the borders.

There may be an area of dullness evident on the left side where the descending colon lies due to the presence of

faecal matter.

Percussion Tenderness (when pain is elicited during percussion) indicates an inflammatory process within the

abdominal / peritoneal cavity i.e. peritonitis or appendicitis.

Palpation of the kidneys

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If on palpation of the abdomen you notice abnormalities you may want to carry out further system

examinations. E.g. genitourinary examination with palpation of kidneys or bladder, CVS for palpation of the

aorta, gynaecological examination with uterus and ovaries (this will be shown in third year).

The kidneys are situated in the renal angle which extends from the twelfth thoracic vertebrae to the third

lumbar vertebrae. The right kidney is slightly lower than the left due to the position of the liver. The kidneys

descend inferiorly on inspiration and we feel for the kidneys as they descend. The kidneys are retroperitoneal

organs and a deep bimanual technique of palpation is required. Not normally palpable unless the patient is thin.

How to palpate for enlarged kidneys

Place one hand in the small of the back feel the vertebral column and the body of muscle to the side you should

end up in a softer area known as the renal angle this is marked by the ribs at the top and the hip bone at the

base. So with this hand the fingers need to push upwards whilst the abdominal hand pushes towards mirroring

the hand position behind the patients back. As the patient breathes in the kidneys move downwards and may

be felt ‘skidding’ between the opposing hands. Some clinicians keep the front hand still and use the back hand

to push the kidney forward - ballot the kidney - allowing it to be palpated between the hands so that its size,

shape, and mobility may be determined.

Palpation of the aorta

Palpating for the aorta may be carried out as part of an abdominal examination. Please see CVS examination for

information about this.

Percuss the bladder from umbilicus going down to pubis

Shifting dullness is a sign elicited when the patient has ascites (fluid in the peritoneal cavity). With the patient

supine percuss the whole abdomen. Note the distribution of dullness and resonance. Then place the patient on

their side and wait for 30-60 seconds. Percuss the abdomen again this time systematically starting from the

lower side (in contact with the couch) and move towards the upper side. If 500ml or more of ascitic fluid is

present in the peritoneal cavity you should pick up consistently dull sounds from the lower side and resonance

from the upper side. The level of dull sounds represents the amount of ascetic fluid present.

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In a positive shifting dullness test there will be consistently dull percussion sounds from the lower side and

resonant sounds from the top side. The level of dullness represents the level of ascetic fluid present. In a

negative shifting dullness tests there would be little difference noted in the percussion sounds compared with

the supine position.

Auscultation

Auscultation for bowel sounds may be considered if organomegaly is present or signs / symptoms suggest

disruption of normal bowel activity has occurred. Not all clinicians will routinely auscultate the abdomen.

To auscultate for bowel sounds; place the head of the stethoscope onto the abdominal wall in the right lower

quadrant and listen. The right lower quadrant is where sounds are more frequently and therefore more likely to

be heard. Do not move the position of the stethoscope for 2 minutes or until bowel sounds are heard. After this

time if NO bowel sounds are heard the stethoscope may be moved to another position and listen again for a

further 2 minutes.

o Normal bowel sounds are termed as borborygmi, these are low to medium pitched grumbles associated

with the passage of fluid and gases through the bowel as peristalsis occurs. Sounds should occur at least

every 2 – 4 minutes in health, but the frequency will increase after a meal or in the case of an acute bowel

obstruction as the peristaltic action of the bowel tries to clear the obstruction.

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o Increased bowel sounds may be an indication of inflammation, infection, recent intake of food, partial

obstruction or the initial stages of acute obstruction –the sounds increase in frequency and become higher

in pitch as the peristaltic action of the bowel increases to try to move the obstruction along.

o Tinkling bowel sounds may be an indication of acute obstruction. They are increased in frequency and

higher in pitch due to the increased peristaltic action of the bowel trying to move the obstruction along.

o “Absent” bowel sounds occur if an obstruction is complete. Complete obstruction may lead to necrosis and

as a result peristaltic action may cease (ileus). If after 4 minutes of listening in a variety of places on the

abdomen you have not heard bowel sounds contact a senior member of the health care team. You may hear

referred heart and breath sounds if bowel sounds are absent.

o Whilst auscultating the abdomen you should take the opportunity to listen for abdominal bruits as detailed

within your cardiovascular examination study guide.

Examination of hernias

Hernias are common and typically occur at openings of the abdominal wall, such as the inguinal, femoral and

obturator canals, the umbilicus and the oesophageal hiatus. They may also occur at sites of weakness of the

abdominal wall, as in previous surgical incisions. An external abdominal hernia is an abnormal protrusion of

bowel and/or omentum from the abdominal cavity. External hernias are more obvious when the pressure within

the abdomen rises, such as when the patient is standing, coughing or straining at stool. Internal hernias occur

through defects of the mesentery or into the retroperitoneal space and are not visible. An impulse can often be

felt in a hernia during coughing (cough impulse). Identify a hernia from its anatomical site and characteristics,

and attempt to differentiate between direct and indirect inguinal hernias.

Examine the groin with the patient standing upright. Inspect the inguinal and femoral canals and the scrotum for

any lumps or bulges. Ask the patient to cough; look for an impulse over the femoral or inguinal canal and

scrotum. Identify the anatomical relationships between the bulge, the pubic tubercle and the inguinal ligament

to distinguish a femoral from an inguinal hernia. Palpate the external inguinal ring and along the inguinal canal

for possible muscle defects. Ask the patient to cough and feel for a cough impulse. Now ask the patient to lie

down and establish whether the hernia reduces spontaneously. If so, press two fingers over the internal inguinal

ring at the mid-inguinal point and ask the patient to cough or stand up while you maintain pressure over the

internal inguinal ring. If the hernia reappears, it is a direct hernia. If it can be prevented from reappearing, it is

an indirect inguinal hernia. Examine the opposite side to exclude the possibility of asymptomatic hernias.

An indirect inguinal hernia bulges through the internal ring and follows the course of the inguinal canal. It may

extend beyond the external ring and enter the scrotum. Indirect hernias comprise 85% of all hernias and are

more common in younger men.

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A direct inguinal hernia forms at a site of

muscle weakness in the posterior wall of the

inguinal canal and rarely extends into the

scrotum. It is more common in older men

and women

A femoral hernia projects through the

femoral ring and into the femoral canal.

Inguinal hernias are palpable above and

medial to the pubic tubercle. Femoral

hernias are palpable below the inguinal

ligament and lateral to the pubic tubercle.

In a reducible hernia the contents can be

returned to the abdominal cavity, spontaneously or by manipulation; if they cannot, the hernia is irreducible

(incarcerated). An abdominal hernia has a covering sac of peritoneum and the neck of the hernia is a common

site of compression of the contents. If the hernia contains bowel, obstruction may occur. If the blood supply to

the contents of the hernia (bowel or omentum) is restricted, the hernia is strangulated. It is tense, tender and

has no cough impulse, there may be bowel obstruction and, later, signs of sepsis and shock. A strangulated

hernia is a surgical emergency and, if left untreated, will lead to bowel infarction and peritonitis.

Recording your findings

Don’t forget when recording your findings to include the patient identifiers, date (and time), your signature and

print your name and designation at the end.

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When documenting or describing your findings remember to comment on inspection describing the position of

any abnormalities seen, the tone of the abdominal wall and any sign such as guarding or rigidity, any masses

found, findings of percussion and auscultation.

Remember to describe your findings as fully as possible: e.g. size, position (relative to the regions or quadrants

as previously described) and the shape of a swelling etc.

A diagram may often be useful in written notes (see below)

What next?

Blood tests may be taken to assist diagnosis and treatment.

Review the pain, does the patient require analgesia for pain, an antiemetic for nausea / vomiting or fluids for

dehydration?

Special examination techniques for self-directed study

McBurney's sign

Deep tenderness at a point approx’ 2 inches from the anterior superior iliac spine on a line between the

umbilicus and the anterior superior iliac spine (McBurney’s point, see image page 13.) is indicative of late stage

acute appendicitis with an increase in the risk of rupture.

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Aaron's sign

Referred pain felt in the epigastrium upon continuous firm pressure over McBurney's point. It is indicative of

appendicitis.

Obturator sign

Flexing the right hip and knee, then internally rotation the right hip will cause an increase in abdominal pain in

appendicitis.

Murphy’s sign

Placing fingers or thumb under right costal cartilage and asking the patient to breathe in. If there is an increase

in pain +/- catching breath then this is indicative of cholecystitis.

Rosving’s Sign

Pressure over the patient's left lower quadrant causes pain in the right lower quadrant in appendicitis. However

this test is unreliable with a sensitivity of 30.1%.

https://www.bmj.com/rapid-response/2011/11/03/rovsings-sign-0

Further Reading

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Innes, J Alastair, BSc PhD FRCP(Ed); Dover, Anna R, PhD FRCP(Ed); Fairhurst, Karen, PhD FRCGP. Macleod's

Clinical Examination, Fourteenth Edition

Petroianu, A. (2012). Diagnosis of acute appendicitis. International Journal of Surgery, 10(3), 115-119.

Thomas, M., & Hollins, M. (1974). Epidemic of postoperative wound infection associated with ungloved abdominal palpation doi:

https://doi.org/10.1016/S0140-6736(74)91019-8

WHO (2009) http://www.who.int/infection-prevention/tools/hand-hygiene/en/ [accessed 08/07/19]