Appendicitis physical examination should be correct to get right diagnosis of appendicitis. First thing that you need to do before assessing the appendix, you have to understand and remember the appendix position in the abdomen.
Appendix position is variable. In 3-dimensional (3D) multidetector computed tomography (MDCT) scanning, the base of the appendix is located at the McBurney point. Sometimes patients have variable appendix position, about 3-5 cm from McBurney point.
During appendicitis physical examination, the most specific physical findings are:
- Rebound tenderness
- Pain on percussion
Although right lower quadrant (RLQ) abdomen tenderness is present in almost patients, but this is not a specific finding. Rarely, left lower quadrant (LLQ) of the abdomen tenderness has been the major manifestation in patient with situs inversus. It can be found in patients with a lengthy appendix that extends into LLQ. If you palpate the McBurney point in RLQ, you may found tenderness; this is the most important sign.
The focus of appendicitis physical examination is not limited to the abdomen. The assessment must be performed in other body systems such as gastrointestinal (GI), genitourinary, and pulmonary systems.
Male infants and children sometime present with an inflamed hemiscrotum. This is because of the migration of inflamed appendix or pus. This circumstance is often misdiagnosed as acute testicular torsion.
It is recommended to perform rectal examination in any patient with an clear clinical image, and perform a pelvic examination in all women with abdominal pain. According to ACEP (American College of Emergency Physicians) in 2010 clinical policy update, clinical signs and symptoms should be used to stratify patient risk and to choose next steps for testing and management.
In rare case of patients with acute appendicitis, some other signs of appendicitis may be noted. However, the absence never should be used to rule out appendiceal inflammation.
Rovsing sign is right lower quadrant abdomen pain during the palpation of left lower quadrant of the abdomen. It suggests peritoneal irritation in RLQ precipitated by palpation at remote location.
Obsturator sign is right lower quadrant abdomen pain with internal and external rotation of the flexed right hip. This sign suggests that the inflamed appendix is located deep in the right hemipelvis.
Psoas sign is right lower quadrant abdomen pain with extension of the right hip or with flexion of the right hip against resistance. It suggests that an inflamed appendix is located along the course of the right psoas muscle.
Dunphy sign is a sharp pain in the right lower quadrant of the abdomen elicited by voluntary cough. It may be helpful in making the right diagnosis of localized peritonitis. Similarly, right lower quadrant abdomen pain in response to percussion of a remote quadrant of the abdomen, or it can be firm percussion of the patient’s heel. This sign is peritoneal inflammation.
This is a pain elicited in a certain location of the abdomen when the standing patient drop from standing on toes to the heels with a jarring landing. The accuracy of this appendicitis physical examination is about 75 percent from 190 patient undergoing appendectomies.
Currently there are no evidences in the medical literature that the digital rectal examination (DRE) provide useful information in the evaluation of patients with suspected appendicitis. However, this physical examination is frequently cited in successful malpractice claims. This examination was performed and studied by Sedlak and colleges. They studied 577 patients who underwent DRE as a part of evaluation for suspected appendicitis patient. They found no value as a means of distinguishing patients with and without appendicitis.