Physical examination

A useful checklist for conducting the examination is:

• general appearance

• vital parameters: temperature, pulse, BP, respiratory rate

• chest: check heart and lungs for upper abdominal pain (especially if absent abdominal signs)

• abdomen: inspection, palpation, percussion and auscultation.

The abdominal examination should be performed with the patient lying flat and the abdomen uncovered from xiphisternum to groin. Ask the patient to breathe through the mouth during the examination. Consider the following:

• inguinal region (including hernial orifices) and femoral arteries

• rectal examination: mandatory

• vaginal examination (females): for suspected problems of the fallopian tubes, uterus or ovaries

• thoracolumbar spine (if referred spinal pain suspected)

• urine analysis: white cells, red cells, glucose and ketones, porphyrins

• special clinical tests o Murphy's sign (a sign of peritoneal tenderness with acute cholecystitis) o iliopsoas and obturator signs

Guidelines

Palpation: palpate with gentleness—note any guarding or rebound tenderness

• guarding indicates peritonitis

• rebound tenderness indicates peritoneal irritation (bacterial peritonitis, blood). Feel for maximum site that corresponds to focus of the problem.

Patient pain indicator: the finger pointing sign indicates focal peritoneal irritation; the spread palm sign indicates visceral pain.

Atrial fibrillation: consider mesenteric artery obstruction. Tachycardia: sepsis and volume depletion. Tachypnoea: sepsis, pneumonia, acidosis. Pallor and 'shock': acute blood loss.

Physical signs may be reduced in the elderly, grossly obese, severely ill and patients on corticosteroid therapy.

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