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Difficulty: EasyPhysical Examination Findings

An overweight 45-year-old female is evaluated in an urgent care clinic for severe, right-sided upper abdominal pain that started after eating a large, fatty meal last night. The pain occasionally radiates to her right shoulder. She also complains of nausea. Her current temperature is 38.1°C (100.6°F) and heart rate is 98/min. During the abdominal assessment, the clinician applies deep, firm palpation just below the right rib cage and instructs the patient to take a slow, deep breath. The patient abruptly catches her breath and stops inhaling midway due to a sudden spike in focal pain. Which of the following conditions is most strongly supported by this specific examination maneuver?

  1. A
    Acute pancreatitis
  2. Acute cholecystitisAnswer
  3. C
    Choledocholithiasis
  4. D
    Acute cholangitis
  5. E
    Right lower lobe pneumonia

Answer

Acute cholecystitis is the most likely diagnosis due to the presence of a classic Murphy's sign.
The correct answer is acute cholecystitis because the patient exhibits a classic positive Murphy's sign. During deep inspiration, the diaphragm descends, pushing the liver and an inflamed gallbladder down toward the examiner's palpating fingers. When the inflamed gallbladder makes contact, the patient experiences a sudden, sharp pain that causes an abrupt arrest in inspiration. This physical examination finding is highly indicative of acute cholecystitis and helps distinguish it from other hepatobiliary or pulmonary pathologies.

Step-by-Step Solution

1
Analyze the patient's demographic profile and history of present illness.
The patient is a 45-year-old female with postprandial right upper quadrant pain radiating to the shoulder, nausea, and low-grade fever.
This establishes a classic clinical picture of biliary tract disease, narrowing the differential diagnosis.
2
Evaluate the specific physical examination maneuver performed.
The clinician applied deep subcostal palpation during patient inhalation, which resulted in a sudden halt in inspiration due to pain.
Identifying the eponymous sign (Murphy's sign) is crucial for linking the physical finding to the underlying pathophysiology.
3
Correlate the physical examination finding with the correct medical condition.
The positive Murphy's sign occurs when the inflamed gallbladder descends and contacts the examiner's fingers, which is specific to acute cholecystitis.
This definitively differentiates acute cholecystitis from other causes of right upper quadrant pain.

Key Concept

Murphy's sign is a highly sensitive and specific physical examination finding for acute cholecystitis.
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Topics

Physical Examination Findings

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