• The examination may begin with the abdomen but should then include the other systems since the disorder may be non-alimentary in origin,
• The hernial orificcs, scrotal contents and rectum are important components of the examination.
• Rectal examination is uncomfortable. Repeated examination should be avoided. The examination is best performed by the clinician making the management decisions.
• Tenderness elicited by rectal and vaginal examination may be the sole sign of inflammation of the pelvic peritoneum in acute appendicitis and salpingitis respectively.
• Bimanual rectal and vaginal examination can be useful in assessing pelvic masses.
• Palpation of the abdominal wall overlying an inllamed organ may produce localised pain. In acute cholecystitis. Murphy's sign (p. 1641 will be present.
• Localised peritonitis may be revealed by eliciting rebound tenderness on palpation.
• Attempts to elicit rebound tenderness are often both painful and unnecessary, and should not be made when evidence of peritonitis has already been established, inflammation of the parietal peritoneum causes reflex contraction of the overlying abdominal muscles to produce guarding. Generalised peritonitis may produce 'boardlike' rigidily when even light percussion may elicit pain.
Symptom patterns. In many abdominal disorders, there is .1 recognised typical pattern of specific features, although in many patients these arc not all present. Such clusters of specific symptoms and signs can prove particularly useful diagnostic aids in patients with an 'acute abdomen". These principles can be applied to a number of specific conditions (see Table .5.33 and Figs 5.24, 5.25 and 5.26).
TABLE 5.33 Some typical clinical features of the important causes of an 'acute abdomen'
Perforated peptic ulcer with acute peritonitis
Ruptured aortic aneurysm
Acute mesenteric ischaemia
Intestinal obstruction Ruptured ectopic pregnancy
Pelvic inflammatory disease (PID)
Nausea, vomlling, central abdominal pain which later shifts lothe right iliac fossa (RIF)
Vomiting at onset associated with acute-onset severe abdominal pain , previous history of dyspepsia, ulcer disease, NSAID or corticosteroid therapy
Sudden onset of tearing, severe back/loin/abdominal pain, circulatory collapse, history of peripheral vascular disease and/or hypertension
Anorexia, nausea, vomiting, bloody diarrhoea, constant, severe, sustained abdominal pain, previous history ot cardiovascular disease
Sexually active female; previous history of STD/PID: recenl gynaecological procedure, pregnancy or use of Intrauterine contraceptive device. Irregular menstruation, dysurla, dyspareunia, lower or central abdominal pain, backache, pleuritic right upper quadrant abdominal pain (Filz-Hugh-Curtis syndrome)
Fever, tenderness and guarding in the RIF, palpable mass in the RIF, pelvic peritonitis on examination
Shallow breathing with minimal abdominal wall movement, abdominal tenderness and guarding, board-like rigidity, abdominal distension and absent bowel sounds
Fever, periumbilical bruising (Cullen's sign), bruising In the loin (Grey Turner's sign), epigastric tenderness, variable guarding, reduced or absent bowel sounds
Shock and hypotension, pulsatile, lender, central abdominal mass with an overlying bruit, asymmetrical femoral pulses Sometimes hypertension (renal artery Involvement)
Atrial fibrillation, cardiac failure, asymmetrical peripheral pulses, absent bowel sounds, variable tenderness and guarding
Surgical scars, hernias, abdominal mass, distension, visible peristalsis, increased tinkling bowel sounds
Suprapubic tenderness, periumbilical bruising (Cullen's sign), pain/tenderness on vaginal examination (cervical excitation), swelling/lullness In the fornix on vaginal examination
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 the fornix on vaginal examination
Delayed or absent femoral pulses
Fig. 5.26 Ruptured aortic aneurysm.
Delayed or absent femoral pulses
A palpable spleen is always pathological.
Pelvic peritonitis is often best elicited by rectal examination.
A succussion splash is suggestive of gastric outlet obstruction only if it is elicited at least 2 hours after food or drink,
Pancreatic carcinoma is the likely diagnosis in a jaundiced patient with a palpable gall bladder.
Absence of one or both testes from the scrotum should promote a search for an incompletely descended or ectopic testis Non-thrombosed haemorrhoids are not palpable on rectal examination.
A hard craggy gland and loss of the median sulcus are features of carcinoma of the prostate.
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