What is the appropriate history and physical (H and P) for a patient presenting with right upper quadrant pain?

Comprehensive Approach to Right Upper Quadrant Pain History and Physical Examination

Ultrasonography is the initial imaging test of choice for patients presenting with right upper quadrant pain, as it is highly accurate for diagnosing gallbladder disease and can identify other potential causes of pain without exposing patients to ionizing radiation. 1

History Components for RUQ Pain

• Pain characteristics: Assess onset, duration, quality, severity, radiation, and exacerbating/alleviating factors. For example, biliary colic typically presents as episodic, severe pain that may radiate to the right shoulder or back 1
• Associated symptoms: Document presence of fever, nausea, vomiting, anorexia, jaundice, changes in bowel habits, or weight loss 1
• Medication history: Record all medications taken within 6 weeks of presentation, including prescription drugs, over-the-counter medications, herbal medicines, and supplements 1
• Prior medical history: Note any history of biliary disease, prior biliary surgery, liver disease, or other relevant conditions 1
• Family history: Inquire about family history of cholestatic liver disease or other hereditary disorders that may cause RUQ pain 1
• Social history: Document alcohol intake, as alcoholic liver disease can present with RUQ pain 1

Physical Examination Components

• Vital signs: Check for fever, tachycardia, or hypotension which may indicate infection or sepsis 1
• Abdominal examination: Assess for:
  • Right upper quadrant tenderness 1
  • Murphy's sign (pain with inspiration during palpation of the right upper quadrant) - highly suggestive of acute cholecystitis 1
  • Hepatomegaly or splenomegaly 1
  • Abdominal distension, masses, or peritoneal signs 1
• Skin and sclera: Examine for jaundice, spider angiomata, or other signs of chronic liver disease 1
• Cardiopulmonary examination: Evaluate for right-sided pneumonia or heart failure that may present with RUQ pain 2

Laboratory Testing

• Complete blood count: To assess for leukocytosis, which may indicate infection or inflammation 1
• Liver function tests: Including ALT, AST, alkaline phosphatase, GGT, and bilirubin to evaluate for hepatobiliary disease 1
• Pancreatic enzymes: Amylase and lipase to rule out pancreatitis 1
• Pregnancy test: For all women of reproductive age to rule out ectopic pregnancy or other pregnancy-related conditions 1

Diagnostic Imaging Algorithm

1. Initial imaging: Ultrasonography of the abdomen is the first-line imaging modality for RUQ pain 1

   • Highly accurate for diagnosing gallstones (96% accuracy) 1
   • Can identify gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy sign 1
   • No radiation exposure 1

2. If ultrasonography is inconclusive or additional imaging is needed:

   • Cholescintigraphy: Consider if ultrasonography suggests biliary disease but is not definitive 1
   • CT with contrast: May be appropriate when complications of cholecystitis are suspected or for surgical planning 1
   • MRI/MRCP: Consider for patients with suspected hepatic or biliary abnormalities that cannot be characterized on ultrasound 1

Common Pitfalls to Avoid

• Overlooking non-biliary causes: Remember that more than one-third of patients with acute RUQ pain do not have acute cholecystitis 3, 2
• Relying solely on Murphy's sign: While suggestive of cholecystitis, its absence is unreliable if the patient has received pain medication prior to examination 1
• Neglecting thoracic causes: Conditions such as right-sided pneumonia or pulmonary embolism can present with RUQ pain 2
• Dismissing normal ultrasound findings: Patients with acalculous cholecystitis may have normal initial imaging 1
• Failing to consider pregnancy: Always perform pregnancy testing in women of reproductive age before diagnostic imaging 1

By following this structured approach to history and physical examination for right upper quadrant pain, clinicians can efficiently narrow the differential diagnosis and select appropriate diagnostic testing to guide management decisions.