What are the key components of a physical examination for a patient with suspected cholelithiasis (gallstones)?

Key Components of Physical Examination for Suspected Cholelithiasis

The most critical components of a physical examination for suspected gallstones include assessment for right upper quadrant pain, Murphy's sign, and signs of complications such as fever and jaundice. 1

Primary Physical Examination Findings

• Right upper quadrant (RUQ) abdominal pain/tenderness: This is the cardinal physical finding in patients with suspected gallstones and should be carefully assessed during palpation 1

• Murphy's sign: A positive Murphy's sign occurs when a patient experiences increased pain and stops breathing during deep palpation of the right upper quadrant during inspiration - this has a positive likelihood ratio of 2.8 for acute cholecystitis 2

• Abdominal tenderness: Assess for localized tenderness in the right upper quadrant, which may indicate gallbladder inflammation 1

• Palpable gallbladder: A palpable mass or lump in the right upper quadrant may indicate a distended gallbladder and is a sign of complicated acute cholecystitis 1

• Fever: The presence of fever should be documented as it may indicate cholecystitis (inflammation of the gallbladder) or cholangitis (inflammation of the bile duct) 1

Additional Physical Examination Components

• Referred pain assessment: Evaluate for referred pain to the right supraclavicular region and/or right shoulder, which is commonly reported in cholelithiasis 3

• Collins' sign: Ask the patient to demonstrate where they feel pain - patients with gallstone pain often place their hand behind the back with thumb pointing upwards (Collins' sign), which has been found in 51.5% of gallstone patients versus 7.5% of controls 4

• Jaundice: Inspect for yellowing of the sclera and skin, which may indicate common bile duct obstruction 1

• Vital signs: Document temperature, heart rate, and blood pressure to assess for systemic inflammatory response 1

Special Considerations

• Elderly, diabetic, or immunocompromised patients: Murphy's sign may be absent in these populations despite severe gallbladder disease 2

• Atypical presentations: Be aware that some patients may present with epigastric pain rather than classic RUQ pain, and may have a negative Murphy's sign despite having acute cholecystitis 5

• Asymptomatic patients: Physical examination may be completely normal in patients with asymptomatic cholelithiasis, which represents 50-70% of all gallstone cases 6

Diagnostic Algorithm After Physical Examination

1. Initial imaging: If physical examination suggests cholelithiasis, ultrasound should be the first imaging modality 1, 2

2. Follow-up imaging: If ultrasound is equivocal but clinical suspicion remains high, consider:

   • CT with IV contrast 1
   • MRCP (Magnetic Resonance Cholangiopancreatography) for suspected common bile duct stones 1
   • HIDA scan if cystic duct obstruction is suspected 5

3. Laboratory correlation: Physical examination findings should be correlated with laboratory tests including white blood cell count, liver enzymes, amylase, and lipase 3, 5

Remember that no single physical examination finding has sufficient diagnostic power to establish or exclude acute cholecystitis, and the combination of clinical features, laboratory tests, and imaging findings provides the most accurate diagnosis 2.