Acute cholecystitis physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dildar Hussain, MBBS [2]
Overview
Patients with acute cholecystitis usually appear ill.Physical examination of patients with acute cholecystitis is usually remarkable for right upper quadrant abdominal tenderness, positive murphy's sign, and fever.
The presence of murphy's sign on physical examination is highly suggestive of acute cholecystitis.
Physical Examination
- The presence of positive murphy's sign on physical examination is highly suggestive of acute cholecysitis.[1][2]
Appearance of the Patient
- Ill appearing
- In severe distress
Vital Signs
- High-grade fever [3][4]
- Tachycardia with regular pulse.
- Tachypnea
Skin
-
Description (Adapted from Dermatology Atlas)
-
Description (Adapted from Dermatology Atlas)
HEENT
- Abnormalities of the head/hair may include ___
- Evidence of trauma
- Icteric sclera
- Nystagmus
- Extra-ocular movements may be abnormal
- Pupils non-reactive to light / non-reactive to accomodation / non-reactive to neither light nor accomodation
- Ophthalmoscopic exam may be abnormal with findings of ___
- Hearing acuity may be reduced
- Weber test may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
- Rinne test may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
- Exudate from the ear canal
- Tenderness upon palpation of the ear pinnae / tragus (anterior to ear canal)
- Inflamed nares / congested nares
- Purulent exudate from the nares
- Facial tenderness
- Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae
Neck
- Jugular venous distension
- Carotid bruits may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
- Lymphadenopathy (describe location, size, tenderness, mobility, and symmetry)
- Thyromegaly / thyroid nodules
- Hepatojugular reflux
Lungs
- Asymmetric chest expansion / Decreased chest expansion
- Lungs are hypo/hyperresonant
- Fine/coarse crackles upon auscultation of the lung bases/apices unilaterally/bilaterally
- Rhonchi
- Vesicular breath sounds / Distant breath sounds
- Expiratory/inspiratory wheezing with normal / delayed expiratory phase
- Wheezing may be present
- Egophony present/absent
- Bronchophony present/absent
- Normal/reduced tactile fremitus
Heart
- Chest tenderness upon palpation
- PMI within 2 cm of the sternum (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
- Heave / thrill
- Friction rub
- S1
- S2
- S3
- S4
- Gallops
- A high/low grade early/late systolic murmur / diastolic murmur best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope
Abdomen
- Abdominal tenderness in the right upper abdominal quadrant.
- Rebound tenderness[5]
- A palpable gall bladder,positive Courvoisier's sign.[6]
- Voluntary and involuntary guarding may be present.[7]
- Murphy test positive.[8]
Back
- Point tenderness over __ vertebrae (e.g. L3-L4)
- Sacral edema
- Costovertebral angle tenderness bilaterally/unilaterally
- Buffalo hump
Genitourinary
- A pelvic/adnexal mass may be palpated
- Inflamed mucosa
- Clear/(color), foul-smelling/odorless penile/vaginal discharge
Neuromuscular
- Patient is usually oriented to persons, place, and time
- Altered mental status can be observed in some patients.
Extremities
- Clubbing
- Cyanosis
- Pitting/non-pitting edema of the upper/lower extremities
- Muscle atrophy
- Fasciculations in the upper/lower extremity
References
- ↑ Adedeji OA, McAdam WA (1996). "Murphy's sign, acute cholecystitis and elderly people". J R Coll Surg Edinb. 41 (2): 88–9. PMID 8632396.
- ↑ Diehl AK (1992). "Symptoms of gallstone disease". Baillieres Clin. Gastroenterol. 6 (4): 635–57. PMID 1486206.
- ↑ Singer AJ, McCracken G, Henry MC, Thode HC, Cabahug CJ (1996). "Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis". Ann Emerg Med. 28 (3): 267–72. PMID 8780468.
- ↑ Cooper C (1997). "Acute cholecystitis". Ann Emerg Med. 29 (4): 554–5. PMID 9095024.
- ↑ Strasberg SM (2008). "Clinical practice. Acute calculous cholecystitis". N. Engl. J. Med. 358 (26): 2804–11. doi:10.1056/NEJMcp0800929. PMID 18579815.
- ↑ Fitzgerald JE, White MJ, Lobo DN (2009). "Courvoisier's gallbladder: law or sign?". World J Surg. 33 (4): 886–91. doi:10.1007/s00268-008-9908-y. PMID 19190960.
- ↑ Katabathina VS, Zafar AM, Suri R (2015). "Clinical Presentation, Imaging, and Management of Acute Cholecystitis". Tech Vasc Interv Radiol. 18 (4): 256–65. doi:10.1053/j.tvir.2015.07.009. PMID 26615166.
- ↑ Jain A, Mehta N, Secko M, Schechter J, Papanagnou D, Pandya S, Sinert R (2017). "History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis". Acad Emerg Med. 24 (3): 281–297. doi:10.1111/acem.13132. PMID 27862628.