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Part VI ♦ Special Subjects D. Peritoneal signs 1. Include rebound pain, involuntary guarding, and pain with slight motion of the bed. 2. Patients will be lying still, usually flat. 3. Indicate visceral irritation. III. Rectal exam 1. Essential part of the exam. 2. Helps to localize tenderness. 3. Presence of blood: Raises concern for ischemia, malignancy, or hemorrhoids. IV. Genital exam A. Females: Pelvic exam can suggest intrauterine or ectopic pregnancy, pelvic inflammatory disease (PID), or an ovarian mass. B. Males: Testicular torsion presents with sudden pain and requires emergent intervention. V. Specific signs A. Murphy sign 1. Right upper quadrant (RUQ) pain with inspiration during palpation under the costal margin. 2. Patient ceases inspiratory effort. 3. Seen in acute cholecystitis. B. McBurney sign: Pain at McBurney point (one third the distance from the anterior superior iliac spine to the umbilicus); typically seen in appendicitis (Fig. 18-2). C. Rovsing sign: Pain (or rebound pain) in the right lower quadrant (RLQ) with palpation of the left lower quadrant (LLQ); seen in appendicitis. D. Obturator sign: Pain with internal rotation of a flexed leg; associated with appendicitis. E. Psoas sign: Pain with hip extension or flexion against pressure; seen with retrocecal appendicitis. F. Markle sign: Pain with shaking the bed or patient’s foot; suggests generalized peritonitis. G. Charcot triad: Fever, jaundice, and RUQ pain; occurs in cholangitis. H. Reynold pentad: Fever, jaundice, RUQ pain, mental status change, and shock/sepsis; indicates a severe form of cholangitis. I. Chandelier sign: Pain with manual palpation of the cervix on bimanual exam; due to pelvic peritonitis (PID or abscess). J. Cullen sign: Bluish ecchymosis in the periumbilical region caused by retroperitoneal hemorrhage. K. Kehr sign: Referred left shoulder pain from peritoneal irritation in the left upper quadrant (LUQ), suggesting splenic rupture or subdiaphragmatic abscess.