Clinical Skills · Supplementary · from Clinical Skills
Case 2: Acute Abdomen Physical Examination
Patient Presentation
Demographics: 28-year-old female graduate student
Chief Complaint: "I have terrible pain in my lower right belly that started last night."
History of Present Illness: A 28-year-old female graduate student presents to the emergency department with a 14-hour history of abdominal pain. The pain began periumbilically last evening as a dull, vague discomfort that she initially attributed to something she ate. She took antacids without relief. Over the next 6-8 hours, the pain migrated to the right lower quadrant and became sharp, constant, and progressively severe (8/10). She vomited twice this morning, after the onset of pain. She reports anorexia since the pain began and has had no bowel movement today. She denies diarrhea, urinary symptoms, vaginal discharge, or missed menstrual period. Her last menstrual period was 12 days ago and was normal.
She was previously healthy and has never had abdominal surgery. She denies recent travel, sick contacts, or antibiotic use.
Past Medical History:
- No significant medical history
- No prior surgeries
- Regular menstrual cycles (28-day cycle, LMP 12 days ago)
Medications:
- Combined oral contraceptive pill
- Ibuprofen as needed for headaches
Social History:
- Graduate student in chemistry
- Non-smoker, occasional alcohol
- Sexually active with one male partner, uses OCP for contraception
- No illicit drug use
Family History:
- Mother: cholecystectomy at age 42
- No family history of inflammatory bowel disease or colon cancer
Physical Examination
- Vital Signs: BP 118/74 mmHg, HR 96 bpm, RR 18/min, Temp 38.2°C (100.8°F), SpO2 99% on room air
- General: Young woman lying still on stretcher with knees flexed, reluctant to move, appears uncomfortable
- Abdominal Inspection: Flat abdomen, no distension, no visible scars, no discoloration
- Auscultation: Hypoactive bowel sounds in all quadrants
- Percussion:
- Tympanitic throughout
- Localized tenderness to percussion in RLQ
- No shifting dullness
- Palpation (systematic, beginning away from site of pain):
- LUQ: Soft, non-tender
- LLQ: Soft, non-tender
- RUQ: Soft, mild tenderness
- RLQ: Marked tenderness with involuntary guarding at McBurney's point (one-third the distance from ASIS to umbilicus)
- No palpable masses
- No hepatosplenomegaly
- Special Abdominal Signs:
- Rovsing's sign: POSITIVE (palpation of LLQ produces referred pain in RLQ)
- Psoas sign: POSITIVE (pain with passive extension of right hip -- suggests retrocecal inflammation)
- Obturator sign: NEGATIVE (no pain with internal rotation of flexed right hip)
- Rebound tenderness: POSITIVE in RLQ (localized peritoneal irritation)
- Dunphy's sign: POSITIVE (pain worsens with coughing)
- Rectal examination: Tenderness on right side of rectum
- Pelvic examination: Cervical os closed, no cervical motion tenderness, no adnexal masses, minimal right adnexal tenderness
Workup and Results
Laboratory Studies:
| Test | Result | Reference Range |
|---|---|---|
| WBC | 14,200/µL | 4,500-11,000/µL |
| Neutrophils | 82% | 40-70% |
| Hemoglobin | 13.4 g/dL | 12.0-16.0 g/dL |
| Platelets | 268,000/µL | 150,000-400,000/µL |
| CRP | 4.8 mg/dL | <0.5 mg/dL |
| Urinalysis | 3-5 WBC/hpf, no bacteria, no nitrites | Normal |
| Urine hCG | Negative | Negative |
| Lipase | 32 U/L | 10-140 U/L |
| Lactate | 1.2 mmol/L | 0.5-2.0 mmol/L |
Imaging/Additional Studies:
- CT abdomen/pelvis with IV contrast:
- Dilated appendix (11 mm diameter, normal <6 mm)
- Appendiceal wall enhancement and thickening
- Periappendiceal fat stranding
- No appendicolith identified
- Small amount of free fluid in pelvis
- No free air
- No evidence of abscess formation
Clinical Image
Diagram of the abdomen divided into four quadrants with labeled surface anatomy landmarks, McBurney's point location, and illustrations of special examination signs for appendicitis (Rovsing's sign, psoas sign, obturator sign). Source: Educational illustration.
Diagnosis
Acute Appendicitis (Uncomplicated)
Key Diagnostic Criteria:
- Classic pain migration from periumbilical to RLQ (visceral to somatic pain transition)
- Anorexia followed by vomiting (sequence is important: pain precedes vomiting in appendicitis)
- Low-grade fever with leukocytosis and left shift
- McBurney's point tenderness with involuntary guarding
- Positive Rovsing's, psoas, and Dunphy's signs
- CT confirming dilated, inflamed appendix with periappendiceal fat stranding
- Alvarado Score: 9/10 (high probability)
Treatment Plan
- NPO status, IV fluid resuscitation with lactated Ringer's
- IV antibiotics: cefoxitin 2g IV (or piperacillin-tazobactam if penicillin-allergic)
- Pain management: IV morphine 4 mg (analgesics do NOT mask peritoneal signs -- this is a debunked myth)
- Urgent surgical consultation for laparoscopic appendectomy
- Laparoscopic appendectomy performed within 12 hours of presentation
- Post-operative: advance diet as tolerated, early ambulation, discharge when tolerating PO and afebrile
- Pathology review of appendix specimen
Key Learning Points
- The classic presentation of appendicitis follows a predictable pain migration pattern: vague periumbilical visceral pain (appendiceal distension stimulating T10 visceral afferents) localizing to RLQ somatic pain (parietal peritoneal inflammation)
- Systematic abdominal examination should begin palpation AWAY from the area of maximal pain to avoid causing guarding that obscures findings
- Rovsing's sign (referred RLQ pain with LLQ palpation) indicates peritoneal irritation and has a sensitivity of 22-68% but specificity of 58-96% for appendicitis
- The psoas sign suggests retrocecal appendicitis (the appendix lies against the psoas muscle); the obturator sign suggests pelvic appendicitis
- Withholding analgesia to "preserve examination findings" is no longer supported by evidence and constitutes inadequate pain management