a. Inspection. Distention may be associated with intestinal obstruction or peritonitis. Note scars from previous surgery.

b. Auscultation. Hyperactive bowel sounds accompany many nonsurgical causes of abdominal pain (eg, gastroenteritis). High-pitched sounds are associated with early obstruction. Diminished or absent sounds are indicative of peritonitis.

c. Percussion. If abdomen is distended, tympany signifies gas; dullness occurs with fluid or solid organs. Loss of liver dullness may indicate pneumoperitoneum.

d. Palpation. The most important part of the exam. As a rule, involuntary guarding signifies peritonitis and warrants surgical intervention. Beginning in the area most remote from the pain, palpate, first gently and then deeply. Watch for wincing (implies significant tenderness). Ask if patient feels pain in the area being palpated or somewhere else. Instead of testing for rebound, ask patient to puff out the abdomen and then suck it in; pain during this maneuver implies peritoneal irritation.

5. Rectal exam. Unnecessary to perform in all cases, because yield is low and exam is traumatic. Useful for feeling a mass, diagnosing fecal retention, and as an alternative to pelvic exam in young girls.

6. Pelvic exam. Often deferred, even in adolescent girls, because similar information may be obtained from rectal exam with patient supine or from ultrasound. Cervical motion tenderness and cervical cultures are positive in PID.

7. Skin. Jaundice is a manifestation of hepatobiliary disease. Some causes of abdominal pain are associated with characteristic rashes (eg, Henoch-Schonlein purpura).

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