GI 6 - Examine for appendicitis Flashcards
Explains procedure to patient, positions and drapes (re-drapes as needed).
“Today I am going to be examining you for appendicitis. This will involve me looking, touching, and listening to your tummy area. Please let me know if at any point you feel uncomfortable or I cause you any pain.”
Inspects for and comments on findings: scars, asymmetry, visible peristalsis etc.
“I’m going to begin by observing the general appearance of my patient lying quietly. (Standing on the right of the patient; you should be bending down so that you can view the abdomen tangentially) I will be inspecting the surface contours, and movements of my patient’s abdomen, looking for bulges or peristalsis. My patient’s abdomen appears (say what you see- symmetric, flat, rounded, protuberant, or scaphoid-markedly concave or hollow). There is no visible peristalsis (normally peristalsis is visible in very thin people). Visible peristalsis could suggest intestinal obstruction. (Color) I’m noting no bruises, erythema, or jaundice.
No scarsare visible which could be due to any trauma or past surgeries. I’m noting no striae (stretch marks). Abnormally colored striae (pink-purple) are a hallmark of Cushing syndrome. I’m also noting no signs of engorged veins (a few small veins may be visible normally). Visibly engorged veins could suggest portal hypertension from cirrhosis (caput medusa) or inferior vena cava obstruction. Also, the umbilicus doesn’t appear everted. An everted umbilicus suggests a ventral hernia. There appears to be no bulging of the flanks* (full flanks are present)*. If bulging of the flanks were present this could suggest ascites.”
Auscultates for bowel sounds and comments on their significance
“Next, using the diaphragm of the stethoscope, I will be placing it on the right umbilicus (RLQ), listening for bowel sounds. Normal bowel sounds consist of clicks and gurgles, occurring at an estimated frequency of 5 to 34 per minute. Altered bowel sounds are common in diarrhea, peritoneal inflammation (peritonitis), and obstruction.”
(Because bowel sounds are widely transmitted through the abdomen, listening in one spot, such as the RLQ, is usually sufficient).
[Only conclude they are absent after listening for 2 minutes. Absence of bowel sounds indicates peristalsis has ceased due to paralytic ileus or peritonitis. Changed sounds are common in diarrhea, peritoneal inflammation (peritonitis), and obstruction. Mechanical intestinal obstruction increases the volume and frequency of bowel sounds (high-pitched tinkling quality.]
Performs light palpation and comments on findings i.e. guarding, rigidity, etc.
“Now I’m going to gently place my hands (palpate) in different areas* (4 quadrants of abdomen)* of your abdomen, feeling for any abdominal tenderness, muscular resistance, or superficial organs or masses. Are you in any pain? I do not feel any superficial masses or organs, any are of tenderness and the patient isn’t displaying increased resistance to palpation. Guarding or involuntary rigidity could suggest peritonitis.”
Parietal pain originates from inflammation of the parietal peritoneum (peritonitis) it is a steady, arching pain that is more severe than visceral pain and localized over structures. It is aggravated by movement or coughing. They prefer to lie still.
Assess for rebound tenderness at McBurney’s point, clearly informs patient of procedure and comments on findings
“Next, I’m going to assess for rebound tenderness at McBurney’s point which is 2/3 from the anterior superior iliac spine to the umbilicus. Let me know if you feel any pain when I’m pressing down or when I let go. Any pain? Ok. That is a negative sign for McBurney’s sign. A positive sign would be indicative of appendicitis. If tender, that would be significant for peritoneal inflammation.”
McBurney’s Point:
locate the McBurney’s point 2/3 away from umbilicus to anterior superior iliac spine. While watching the patient face, press down with fingers firmly and slowly, and then withdraw quickly. Watch for rebound tenderness: patient feels more uncomfortable after you release than while your press it down.
Demonstrates Rovsing’s, Psoas and Obturator sign, listing each by name and explaining procedure to patient. Comment on findings.
Next, I’m going to be doing the same thing on the left side* (again 2/3 from the anterior superior iliac spine to the umbilicus).* Please let me know if you feel pain anywhere especially if your feel it on your right side.” “I’m now going to access for Rovsing’s, Psoas and Obturator signs.”
Rovsing:
“Starting with the Rovsing, I’m going to press down deeply on your LLQ, and quickly release. Did you feel any pain? Where did you feel the pain? That is a negative test for Rovising’s sign. A positive sign would due to the peritoneum rubbing on an inflamed appendix causing the patient feel pain in the RLQ. Pain in the RLQ could be indicative of appendicitis.”
Psoas:
“Now I’m going to be checking for Psoas. I’m going to place my hand just above your right knee, and I’m going to push down. Can your life your thigh against my resistance (hand)? Did that cause any pain for you? Where? Pain in the RLQ could be due to contraction of the psoas major and fascia rubbing against an inflamed appendix.”
Obturator:
“I’m going to check for the obturator. Can you please relax your leg for me? Now I’m going to bend your knee, and internally rotate it, pulling your foot laterally.* (flex the patient’s right thigh at the hip with the knee bent and rotate the leg internally at the hip).”*
“Did you experience any pain from that? If my patient were to feel any pain, that would be due to manipulation of the fascia from contraction of the obturator muscles. If my patient were to feel pain in the RLQ, that would be due to appendicitis.”
