Some additional techniques are sometimes helpful.
■ Check the tender area for rebound tenderness. (If other signs are typically positive, you can save the patient unnecessary pain by omitting this test.)
Rebound tenderness suggests peritoneal inflammation, as from appendicitis.
■ Check for Rovsing'ssign and for referred rebound tenderness. Press deeply and evenly in the left lower quadrant. Then quickly withdraw your fingers.
Pain in the right lower quadrant during left-sided pressure suggests appendicitis (a positive Rovsing's sign). So does right lower quadrant pain on quick withdrawal (referred rebound tenderness).
■ Look for a psoas sign. Place your hand just above the patient's right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then extend the patient's right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it.
Increased abdominal pain on either maneuver constitutes a positive psoas sign, suggesting irritation of the psoas muscle by an inflamed appendix.
■ Look for an obturator sign. Flex the patient's right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. (Internal rotation of the hip is described on p. 510.)
Right hypogastric pain constitutes a positive obturator sign, suggesting irritation of the obturator muscle by an inflamed appendix.
■ Test for cutaneous hyperesthesia. At a series of points down the abdominal wall, gently pick up a fold of skin between your thumb and index finger, without pinching it. This maneuver should not normally be painful.
Localized pain with this maneuver, in all or part of the right lower quadrant, may accompany appendicitis.
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