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Difficulty: MediumPhysical Examination Findings

An evaluation is requested in the emergency department for a 4848-year-old female patient complaining of acute-onset abdominal discomfort. The pain localized to the right upper quadrant approximately 1212 hours prior, shortly after she consumed a heavy meal. Associated symptoms include intermittent nausea and a feeling of warmth. Vital signs demonstrate a temperature of 38.2∘C38.2^\circ\text{C} (100.8∘F100.8^\circ\text{F}), a heart rate of 96/min96\text{/min}, a respiratory rate of 18/min18\text{/min}, and a blood pressure of 132/84 mmHg132/84\text{ mmHg}. Upon physical assessment of the abdomen, the examiner places their hand firmly below the right costal margin and instructs the patient to breathe in deeply. Midway through inspiration, she suddenly gasps and stops breathing in due to a sharp spike in pain. Serum analysis shows a white blood cell count of 12,500/mm312,500\text{/mm}^3 with an unremarkable basic metabolic panel and normal lipase. Based on this characteristic examination finding, which of the following represents the optimal next diagnostic intervention?

  1. Perform a transabdominal ultrasonography of the right upper quadrantAnswer
  2. B
    Obtain a contrast-enhanced computed tomography scan of the abdomen
  3. C
    Schedule a hepatobiliary iminodiacetic acid scan
  4. D
    Initiate inpatient intravenous antibiotic therapy without further diagnostic imaging
  5. E
    Provide reassurance and discharge with oral acid-suppressing therapy

Answer

Perform a transabdominal ultrasonography of the right upper quadrant
The patient's presentation of fever, right upper quadrant pain, and leukocytosis is highly suspicious for acute cholecystitis. The physical examination finding described—inspiratory arrest upon deep right subcostal palpation—is known as Murphy sign, which has a high sensitivity and specificity for gallbladder inflammation. According to current medical guidelines, the most appropriate next step in establishing this diagnosis is a transabdominal ultrasonography of the right upper quadrant. Ultrasound is preferred because it is non-invasive, avoids radiation, and is highly sensitive for detecting gallstones, gallbladder wall thickening, and pericholecystic fluid.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and vital signs.
The patient has postprandial right upper quadrant pain, fever, and leukocytosis, suggesting an acute inflammatory or infectious process in the hepatobiliary system.
Establishing the syndromic presentation helps narrow the differential diagnosis from general abdominal pain to specific regional etiologies.
2
Interpret the described physical examination maneuver.
The patient experiences inspiratory arrest upon deep right subcostal palpation. This is a positive Murphy sign.
Murphy sign is a highly sensitive and specific clinical finding for acute cholecystitis, as the inflamed gallbladder moves downward with the diaphragm during inspiration and contacts the examiner's hand.
3
Determine the most appropriate initial diagnostic step based on the clinical findings.
Transabdominal ultrasonography is the required next step.
Ultrasound is the most sensitive, specific, and cost-effective initial imaging modality for identifying gallstones, gallbladder wall thickening, and pericholecystic fluid without ionizing radiation.

Key Concept

A positive Murphy sign (inspiratory arrest during deep right upper quadrant palpation) is a hallmark physical examination finding of acute cholecystitis, for which right upper quadrant transabdominal ultrasound is the standard initial diagnostic step.
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Physical Examination Findings

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