Which signs should be noted in patients with suspected acute appendicitis?

Updated: Jul 23, 2018
  • Author: Sandy Craig, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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In a minority of patients with acute appendicitis, some other signs may be noted. However, their absence never should be used to rule out appendiceal inflammation. The Rovsing sign (RLQ pain with palpation of the LLQ) suggests peritoneal irritation in the RLQ precipitated by palpation at a remote location. The obturator sign (RLQ pain with internal and external rotation of the flexed right hip) suggests that the inflamed appendix is located deep in the right hemipelvis. The psoas sign (RLQ pain with extension of the right hip or with flexion of the right hip against resistance) suggests that an inflamed appendix is located along the course of the right psoas muscle.

The Dunphy sign (sharp pain in the RLQ elicited by a voluntary cough) may be helpful in making the clinical diagnosis of localized peritonitis. Similarly, RLQ pain in response to percussion of a remote quadrant of the abdomen, or to firm percussion of the patient's heel, suggests peritoneal inflammation.

The Markle sign, pain elicited in a certain area of the abdomen when the standing patient drops from standing on toes to the heels with a jarring landing, was studied in 190 patients undergoing appendectomy and found to have a sensitivity of 74%. [2]

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