How do you elicit the Murphy sign?

How to Elicit Murphy's Sign

To elicit Murphy's sign, the AGACNP should palpate the right upper quadrant (RUQ) deeply and ask the patient to take a deep breath. 1

Proper Technique for Murphy's Sign

• Murphy's sign is performed by placing your hand in the right upper quadrant and asking the patient to take a deep breath while maintaining deep palpation 1
• During inspiration, the diaphragm pushes the inflamed gallbladder downward against the examiner's fingers, causing pain and respiratory arrest 1
• The patient will typically stop breathing mid-inspiration due to the sharp pain if acute cholecystitis is present 1
• This maneuver specifically targets the gallbladder and is distinct from general RUQ tenderness 1, 2

Clinical Significance

• Murphy's sign is an important clinical finding in the evaluation of suspected biliary disease, particularly acute cholecystitis 1
• When positive, Murphy's sign increases the likelihood of acute cholecystitis, though it has relatively low specificity 1
• The absence of Murphy's sign is unreliable as a negative predictor if the patient has received pain medication prior to examination 1
• Murphy's sign is more characteristic of acute rather than chronic cholecystitis 1

Sonographic Murphy's Sign

• The sonographic version is defined as tenderness reproducing the patient's abdominal pain when the ultrasound probe compresses directly on the gallbladder 1, 2
• In a study of 497 patients with suspected acute cholecystitis, the positive predictive value of gallstones plus a positive sonographic Murphy's sign was 92% 3
• The negative predictive value of the absence of stones combined with either a normal gallbladder wall or a negative Murphy's sign was 95% 3

Diagnostic Value in Context

• Murphy's sign alone has limitations in diagnosing acute cholecystitis 4
• When combined with other findings such as elevated neutrophil count and ultrasound showing cholelithiasis, the diagnostic accuracy improves significantly 4
• In gangrenous cholecystitis, Murphy's sign may be absent despite severe disease, as reported in one study where only 33% of patients with pathologically proven gangrenous cholecystitis had a positive sonographic Murphy's sign 5

Common Pitfalls

• False positive Murphy's sign can occur in conditions other than cholecystitis, such as hepatitis, subphrenic abscess, or even cardiac conditions 6
• False negative results may occur in patients who have received analgesics or in cases of gangrenous cholecystitis 1, 5
• Proper positioning of the patient (supine) and correct localization of the gallbladder area are essential for accurate assessment 1