Physical Examination

Like the history, the findings upon physical examination of a patient with acute appendicitis depend on the duration of the illness prior to the examination. Early in the course of acute appendicitis, the patient may not have localized tenderness. As the illness progresses, the patient typically develops tenderness, especially to deep palpation, over McBurney's point. This is a point just below the middle of a line connecting the umbilicus and the anterosuperior iliac spine. Pain in the right lower quadrant with palpation of the left lower quadrant (Rosving sign) may also be elicited. As with the subjective pain, the localization of tenderness varies with the anatomic position of the appendix. If the patient has a pelvic appendix, the patient's tenderness may be most pronounced on rectal examination. With a retrocecal appendix, tenderness to palpation may be attenuated by the overlying cecum or may be most pronounced in the right flank. Additional components of the physical examination that may help in the diagnosis of pain resulting from acute appendicitis include rebound tenderness, voluntary guarding, local muscular rigidity over the inflamed area (involuntary guarding), and tenderness on rectal examination. The sensitivity and specificity of these findings are seen in Tab]e,..Z4z1.

Special maneuvers that can aid in the diagnosis of acute appendicitis include the psoas sign and the obturator sign. The examiner checks for a psoas sign by placing the patient in the left lateral decubitus position and extending the right leg at the hip. If an inflamed appendix is overlying the psoas muscle, this maneuver will cause an increase in the patient's pain, thereby eliciting a positive psoas sign. The obturator sign is evaluated by passively flexing the right hip and knee and internally rotating the hip. This action will stretch the obturator muscle. An inflamed appendix may irritate the obturator muscle, and this maneuver will increase pain, indicating a positive obturator sign.

Fever is another relatively late physical finding in acute appendicitis. At the onset of pain, the patient's temperature will probably be normal. If the temperature is taken frequently during the progression of the illness, it will usually rise 1 to 2°C. Temperatures above 39°C (102.2°F) are uncommon in the first 24 h of the illness but not uncommon after rupture of an appendix.

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