Medications. Physical examination

Nonsteroidal anti-inflammatory drugs predispose to peptic ulcer disease.

Antibiotic therapy may obscure the signs of peritonitis. Patients with abdominal pain and diarrhea who have received antibiotics may have pseudomembranous colitis.

Anticoagulants. Warfarin therapy predisposes to retroperitoneal or intramural intestinal hemorrhage and can cause bowel obstruction.

Thiazide diuretics may rarely cause of pancreatitis.

Surgical history. Small bowel obstruction is often caused by postoperative adhesions.

General appearance. Peritonitis is suggested by shallow, rapid breathing and the patient often will lie still with knees flexed to minimize peritoneal stimulation. Patients may be pale or diaphoretic. Cachexia may indicate malignancy or chronic illness.

Fever suggests an inflammatory or infectious etiology. Tachycardia and tachypnea may be caused by pain, hypovolemia, or sepsis. Hypothermia and hypotension often suggest a serious infectious process. Pneumonia and myocardial infarction may occasionally cause pain that is felt in the abdomen.

Abdominal examination

  • Inspection. Surgical scars should be sought. Distention suggests obstruction, ileus, or ascites. Venous engorgement of the abdominal wall suggests portal hypertension. Masses or peristaltic waves may be visible. Hemoperitoneum may cause bluish discoloration of the umbilicus (Cullen’s sign). Retroperitoneal bleeding (eg, from hemorrhagic pancreatitis) can cause flank ecchymoses (Turner’s sign).
  • Auscultation. Borborygmi may be heard with obstruction. A quiet, tender abdomen may occur with generalized peritonitis. Bruits suggests an aortic aneurysm.


With the patient supine and knees flexed, palpation should be gently started at a point remote from the pain. Muscle spasm, tympany or dullness, masses and hernias should be sought.

Peritoneal signs. Rigidity is caused by reflex spasm of the abdominal wall musculature from underlying inflamed parietal peritoneum. Stretch and release of inflamed parietal peritoneum causes rebound tenderness.

Common signs

  • Murphy’s sign. Inspiratory arrest from palpation in the right upper quadrant occurs when an inflamed gallbladder descends to meet the examiner’s fingers.
  • Obturator sign. Suprapubic tenderness on internal rotation of the hip joint with the knee and hip flexed results from inflammation adjacent to the obturator internus muscle.
  • Iliopsoas sign. Extension of the hip elicits tenderness if the iliopsoas muscle is involved by inflammatory disorders in the retroperitoneum.
  • Rovsing’s sign. Deep palpation in the left lower quadrant causing pain on the right is indicative of appendicitis.

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