What could be causing dull pain under my right rib, painful on deep palpation, especially in the frontal area, in an otherwise healthy adult with no significant medical history?

Differential Diagnosis of Right Upper Quadrant Pain with Deep Palpation Tenderness

The most likely diagnoses for dull right upper quadrant pain with frontal deep palpation tenderness in a healthy adult are gallbladder disease (cholecystitis or biliary colic), hepatic pathology, or musculoskeletal costochondritis—with gallbladder disease being the most common visceral cause requiring urgent evaluation. 1

Immediate Life-Threatening Causes to Exclude

Before considering benign etiologies, you must systematically rule out serious conditions:

• Acute coronary syndrome can present with epigastric or right upper quadrant discomfort, particularly in atypical presentations. The pain may be accompanied by diaphoresis, dyspnea, or nausea. 1 Obtain an ECG within 10 minutes and measure cardiac troponin as soon as possible. 1

• Pulmonary embolism presents with dyspnea, pleuritic chest pain (which can be perceived in the right upper quadrant), tachycardia, and tachypnea in >90% of cases. 2 This must be excluded before considering benign causes. 2

• Pneumonia in the right lower lobe can cause referred pain to the right upper quadrant, accompanied by fever, productive cough, regional dullness to percussion, and egophony. 1, 2

• Pneumothorax presents with dyspnea, pain on inspiration, and unilateral absence of breath sounds with hyperresonant percussion. 2, 3

Most Likely Gastrointestinal Causes

Gallbladder disease is the primary visceral cause of right upper quadrant pain with deep palpation tenderness:

• Murphy's sign (right upper quadrant tenderness with inspiratory arrest during deep palpation) is highly suggestive of acute cholecystitis. 1

• Pain typically occurs after fatty meals and may radiate to the right shoulder or back. 1

• Associated symptoms include nausea, vomiting, and fever if cholecystitis is present. 1

Peptic ulcer disease or gastritis can cause epigastric tenderness that extends to the right upper quadrant:

• History of NSAID use, potassium supplements, iron, or bisphosphonates should be sought. 1

• Pain may be relieved or worsened by eating, depending on whether it's gastric or duodenal. 1

Hepatic pathology (hepatitis, hepatic congestion) can cause right upper quadrant fullness and tenderness, though this is less common in otherwise healthy adults without risk factors. 1

Musculoskeletal Causes

Costochondritis is the most common musculoskeletal cause of chest wall pain:

• Characterized by reproducible tenderness of costochondral joints on palpation, particularly along the right costal margin. 1, 4

• However, 7% of patients with reproducible chest wall tenderness may still have acute coronary syndrome, so this finding does not exclude cardiac pathology. 2

• Recent or occult chest trauma, including rib fractures, may present as costochondritis even without clear injury history. 4

• Axial spondyloarthritis can present with anterior chest wall pain as the first manifestation, though this typically affects younger patients. 4

Diagnostic Algorithm

Step 1: Immediate Assessment

• Obtain vital signs looking for tachycardia, tachypnea, fever, or hypotension. 1
• Perform focused cardiovascular examination to identify signs of acute coronary syndrome or heart failure. 1
• Obtain ECG within 10 minutes if any concern for cardiac etiology. 1

Step 2: Targeted Physical Examination

• Palpate for Murphy's sign: Place hand below right costal margin and ask patient to take deep breath—positive if pain causes inspiratory arrest. 1
• Systematically palpate costochondral joints for reproducible tenderness. 2, 3
• Auscultate lungs for unilateral decreased breath sounds, crackles, or egophony. 1, 2
• Check for peritoneal signs (guarding, rebound) suggesting acute abdomen. 1

Step 3: Initial Diagnostic Testing

• Chest X-ray to evaluate for pneumonia, pneumothorax, or pleural effusion. 2
• Cardiac troponin if any suspicion of acute coronary syndrome. 1
• Right upper quadrant ultrasound if gallbladder disease suspected—this is the first-line imaging for biliary pathology. 1
• Liver function tests and complete blood count if hepatobiliary cause suspected. 1

Step 4: Risk Stratification

• If cardiac testing, chest X-ray, and abdominal examination are normal, musculoskeletal costochondritis becomes most likely. 1, 2
• If Murphy's sign positive or ultrasound shows gallstones/gallbladder wall thickening, pursue surgical consultation. 1

Critical Pitfalls to Avoid

• Do not assume reproducible chest wall tenderness excludes serious pathology—7% of patients with palpable tenderness have acute coronary syndrome. 2

• Do not use nitroglycerin response as a diagnostic criterion—relief with nitroglycerin does not confirm or exclude myocardial ischemia. 2

• Do not delay transfer for troponin testing in office settings—patients with suspected acute coronary syndrome should be transported urgently to the ED by EMS. 2

• Do not dismiss atypical presentations in older patients, women, or diabetics—these groups have increased frequency of atypical symptoms including isolated epigastric or right upper quadrant pain. 1

Management Based on Diagnosis

If cardiac and pulmonary causes excluded and examination suggests costochondritis:

• Treat with anti-inflammatory medications (NSAIDs if no contraindications). 2
• Provide reassurance about benign nature. 2

If gallbladder disease confirmed:

• Surgical consultation for cholecystectomy, particularly if acute cholecystitis. 1
• NPO status and IV fluids if acute presentation. 1

If gastrointestinal cause suspected but imaging normal:

• Consider trial of empiric acid suppression therapy for 2-4 weeks. 1
• If symptoms persist, consider upper endoscopy or additional gastrointestinal evaluation. 1