NRP/531 Week 5: Abdominal Examination Note, sample paper

Pain Under the Right Ribs After Her Daughter's Birthday Dinner: A Focused Abdominal Examination Note for Suspected Acute Cholecystitis in a 44-Year-Old Woman, and What a Positive Murphy Sign Can and Cannot Prove

[Student Name]

University of Phoenix

NRP/531: Advanced Health Assessment I

Week 5 Assignment

[Instructor Name]

[Date]

The patient is a composite written for a model paper.

Subjective

Ms. V., a 44-year-old office manager, presents with six hours of steady pain in the right upper abdomen that began about an hour after a large, fatty dinner at her daughter's birthday party. The pain has not eased, spreads to the right shoulder blade and is 7 out of 10. She vomited twice. She has had three shorter episodes of similar pain after meals over the past year, each resolving within two hours. She reports feeling feverish. No jaundice, dark urine or pale stools. Last menstrual period two weeks ago. History: obesity, two pregnancies. Medications: an oral contraceptive. No allergies.

Objective

Vital signs: temperature 38.3 °C, pulse 104, blood pressure 128/78 mm Hg, respiratory rate 18.

General: uncomfortable, lying still, guarding when moving.

Skin and sclerae: no jaundice.

Abdomen, inspection: obese, no distension, scars or visible peristalsis.

Auscultation: bowel sounds present but reduced in all quadrants; no bruits.

Percussion: tympanic except over the liver; liver span 11 cm at the right midclavicular line; percussion tenderness in the right upper quadrant.

Palpation: light palpation shows guarding in the right upper quadrant. Deep palpation causes marked tenderness below the right costal margin. Murphy's sign positive: inspiratory arrest with pressure under the right costal margin. No rebound tenderness elsewhere. No palpable mass. No costovertebral angle tenderness. McBurney's point nontender.

Pelvic examination: deferred given history and location of pain; urine pregnancy test negative.

Assessment

Suspected acute calculous cholecystitis, with prior episodes consistent with biliary colic. Differential: biliary colic, choledocholithiasis, peptic ulcer disease, hepatitis, right lower lobe pneumonia and pyelonephritis.

Plan

Transfer to the emergency department for right upper quadrant ultrasound, complete blood count, C-reactive protein, liver function tests, lipase and blood cultures if fever persists. Nothing by mouth. Surgical evaluation expected.

Murphy's sign raised my suspicion; it did not make the diagnosis, and the note should not pretend it did.

Why Auscultation Comes Before Palpation

Unlike the chest or joints, the belly is heard before it is handled: once the examiner has pressed and tapped, the bowel may speed up or slow down, and the sounds heard afterward no longer reflect the resting state. Reduced bowel sounds in Ms. V. may reflect local inflammation slowing the adjacent bowel.

What Each Finding Is Worth

Trowbridge et al. (2003) reviewed the diagnostic accuracy of clinical and laboratory findings for acute cholecystitis and found that no single finding had a positive likelihood ratio high enough or a negative likelihood ratio low enough to rule the diagnosis in or out. The Murphy sign had a positive likelihood ratio of 2.8, and right upper quadrant tenderness a negative likelihood ratio of 0.4, but the confidence intervals for both included 1.0. The authors concluded that combinations of findings and imaging are needed.

For Ms. V., the Murphy sign modestly raises the probability, fever and a raised pulse suggest systemic inflammation, the history of prior postprandial episodes suggests gallstones and her pain has lasted longer than typical biliary colic. Together these findings create a high clinical suspicion, but not a diagnosis.

The Tokyo Guidelines Criteria

The Tokyo Guidelines 2018 diagnose acute cholecystitis using three groups of findings: local signs of inflammation, such as Murphy's sign or right upper quadrant pain, mass or tenderness; systemic signs, such as fever, raised C-reactive protein or raised white cell count; and imaging findings characteristic of acute cholecystitis (Yokoe et al., 2018). A suspected diagnosis requires one local and one systemic sign; a definite diagnosis also requires imaging. Ms. V. meets criteria for suspected acute cholecystitis now, and ultrasound will determine whether it is definite.

Why Ultrasound First

Ultrasound is the usual starting point for imaging in this setting because it is widely available, avoids radiation and can show gallstones, gallbladder wall thickening, pericholecystic fluid and a sonographic Murphy sign (Gallaher & Charles, 2022). If ultrasound is equivocal, cholescintigraphy can assess cystic duct patency.

Why the Differential Matters

Right lower lobe pneumonia can cause upper abdominal pain; her lungs are clear. Pyelonephritis would usually cause costovertebral angle tenderness and urinary symptoms; she has neither. Peptic ulcer disease usually causes epigastric pain; hers is lateral. Choledocholithiasis would often raise bilirubin and liver enzymes and may cause jaundice, so laboratory tests are essential. Hepatitis would raise transaminases more markedly.

How the Examination Was Performed

I examined Ms. V. supine with knees slightly bent to relax the abdominal wall, warming my hands and asking her to point to the area of greatest pain, which I examined last. Light palpation of all four quadrants came before deep palpation, so that guarding could be judged before causing pain. Murphy's sign was elicited by placing my fingers below the right costal margin at the midclavicular line and asking her to breathe in deeply; she stopped abruptly at the peak of inspiration. The same maneuver on the left produced no pain, a useful comparison.

What Laboratory Tests Will Add

A raised white blood cell count and C-reactive protein would satisfy the systemic criterion of the Tokyo Guidelines on their own, even without fever (Yokoe et al., 2018). Liver enzymes and bilirubin help detect a stone in the common bile duct, which changes management, and lipase helps rule out pancreatitis, which gallstones can also cause. A normal white count would not exclude cholecystitis, since, as Trowbridge et al. (2003) found, no laboratory value alone is decisive.

Risk Factors in the History

Ms. V. has several risk factors for gallstones: female sex, age in her forties, obesity, two pregnancies and estrogen exposure from her contraceptive. Her three prior episodes of postprandial pain were likely biliary colic, a warning that preceded today's inflammation.

Management Expectations

Acute calculous cholecystitis is usually treated with antibiotics, supportive care and cholecystectomy, often early in the same admission for patients fit for surgery (Gallaher & Charles, 2022). The Tokyo Guidelines grade severity to guide timing and approach (Yokoe et al., 2018). Her fever and tachycardia require assessment for complications, such as gangrene or perforation, if she worsens.

Why Not Send Her Home With Pain Medicine

Biliary colic without inflammation can often be managed as an outpatient with pain control and elective surgical referral. Ms. V.'s fever, tachycardia, pain lasting more than six hours and positive Murphy sign all suggest inflammation beyond simple colic. Sending her home would risk progression to gangrene, perforation or sepsis. The decision to transfer her follows directly from the findings documented above.

Documentation Notes

The note records each examination step with its finding, including important negatives, such as absent jaundice, costovertebral angle tenderness and McBurney's point tenderness, which show the differential was considered.

Conclusion

Ms. V.'s right upper quadrant pain after a fatty meal, fever, tachycardia and positive Murphy sign meet the Tokyo Guidelines criteria for suspected acute cholecystitis. Because no single sign is accurate enough to confirm or exclude the diagnosis, the note records the combination of findings and sends her for ultrasound and laboratory testing, which will decide whether the diagnosis is definite.

References

Gallaher, J. R., & Charles, A. (2022). Acute cholecystitis: A review. JAMA, 327(10), 965-975. https://doi.org/10.1001/jama.2022.2350

Trowbridge, R. L., Rutkowski, N. K., & Shojania, K. G. (2003). Does this patient have acute cholecystitis? JAMA, 289(1), 80-86. https://doi.org/10.1001/jama.289.1.80

Yokoe, M., Hata, J., Takada, T., Strasberg, S. M., Asbun, H. J., Wakabayashi, G., Kozaka, K., Endo, I., Deziel, D. J., Miura, F., Okamoto, K., Hwang, T.-L., Huang, W. S.-W., Ker, C.-G., Chen, M.-F., Han, H.-S., Yoon, Y.-S., Choi, I.-S., Yoon, D.-S., . . . Yamamoto, M. (2018). Tokyo Guidelines 2018: Diagnostic criteria and severity grading of acute cholecystitis. Journal of Hepato-Biliary-Pancreatic Sciences, 25(1), 41-54. https://doi.org/10.1002/jhbp.515