5 Appendicitis Signs You Don't Want to Miss

William Kelly, MSN, FNP-C

Updated June 2026 · Medically reviewed for nurses

8 min read

Knowing your appendicitis signs is essential at the bedside. Appendicitis is the number one cause of abdominal pain needing emergent surgery — and missing it can lead to sepsis, perforation, longer hospital stays, and even death.

Abdominal pain is common and its causes are endless, and the pain doesn't always present where you'd expect. That's why these five physical-exam maneuvers matter: they raise your suspicion for appendicitis and guide the need for imaging.

The Appendix & Appendicitis

The appendix is a small appendage at the beginning of the large intestine, stemming off the cecum. Its actual function is unknown, though theories suggest it helps maintain healthy gut bacteria and supports the immune system.

The appendix can become blocked and inflamed, which leads to appendicitis. This is usually caused by a small piece of feces — a fecalith — that occludes the lumen. It can also be blocked by stones, lymphoid tissue, infections, and even cancer.

A blocked appendix eventually develops bacterial overgrowth, ischemia, and possibly perforation of the bowel, which can cause sepsis and severe infection.

Common Symptoms

A patient with appendicitis will often complain of the following — though, as you'll see, these are not very specific aside from the location of the pain, which can be a late sign.

General Malaise

Indigestion, fatigue, or a change in bowel habits — vague and easy to dismiss early on.

Migrating Pain

Vague pain near the umbilicus that eventually migrates to the right lower quadrant (RLQ).

Nausea & Vomiting

Often follows the onset of pain rather than preceding it.

Fever

Low-grade fever is common; a higher fever raises concern for perforation.

The physical exam is critical when evaluating abdominal pain. There are multiple physical-exam maneuvers you can do as the nurse or APP to detect appendicitis signs and guide imaging. See also the 5 advanced physical exam maneuvers.

1. McBurney's Sign

The first sign to know is McBurney's sign — the bread and butter of recognizing appendicitis. Also called McBurney's point tenderness, it's when the patient's most tender area is 1.5–2 inches from the anterior superior iliac spine in the direction of the umbilicus.

To find it, draw an imaginary line from the anterior superior iliac spine to the navel; roughly 1/3 down that line, closer to the iliac spine, is McBurney's point. If you press generally in the RLQ and the patient is tender, appendicitis should be high on your differential.

2. Guarding & Rebound Tenderness

Guarding is when a patient involuntarily tenses their abdominal muscles as you palpate. Rebound tenderness is when the pain temporarily worsens as you suddenly release pressure.

While these aren't specific to appendicitis, they indicate potential peritonitis — inflammation of the inner lining of the abdominal cavity. Causes of peritonitis include ruptured appendicitis, a perforated bowel elsewhere (such as perforated diverticulitis), or direct infection from trauma or peritoneal dialysis.

For what comes next if infection spreads, see 6 steps for sepsis management.

3. Rovsing's Sign

Rovsing's sign is when you palpate the left lower quadrant and the patient feels tenderness in the right lower quadrant. This indicates local peritoneal irritation and is also called indirect tenderness.

4. Psoas Sign

The psoas sign checks for irritation of the iliopsoas muscle, which lies in close proximity to the appendix. There are two ways to test it:

The psoas sign tends to correlate more with retrocecal appendicitis — when the appendix sits behind the cecum, which occurs in up to 33% of cases.

5. Obturator Sign

The obturator sign is tested with the patient supine: passively flex the hip and knee, then internally rotate the hip. Pain in the RLQ is a positive obturator sign.

The appendix sometimes lies near the right obturator internus muscle, so this sign is associated with a pelvic appendix — when the tip migrates toward the pelvis.

Appendicitis Management

After folding these signs into your physical exam, you should have a good sense of your suspicion. The next steps usually involve abdominal imaging.

Imagingconfirm the diagnosis

In children and sometimes pregnant patients, a RLQ ultrasound is used first. In most adults, the preferred and most sensitive test is a CT abdomen/pelvis with IV contrast (with or without PO contrast). PO contrast can help if BMI <25; its use is often facility-dependent. CT also reveals possible alternative causes of pain — the downside being radiation exposure.

Antibioticsstart once diagnosed

Once appendicitis is confirmed, start antibiotics and consult surgery emergently. Common regimens include:

• Zosyn (piperacillin-tazobactam)
• Flagyl (metronidazole) + Ceftriaxone or Cefepime
• Ertapenem

Always confirm regimen and dosing per your facility protocol or a current antibiotic reference.

Surgerydefinitive treatment

Ultimately, the patient will likely need emergent appendectomy to remove the appendix, though rarely it can be managed medically with antibiotics alone.

Related Guides

Assessment

5 Advanced Physical Exam Maneuvers

Emergency

6 Steps for Sepsis Management

Procedures

10 IV Insertion Tips for Nurses

New Nurse

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