Murphy's Sign: Physical Exam
- A patient presenting with upper right quadrant pain/tenderness
- Concern for cholecystitis
- Have the patient lie supine on the exam table
- Place your left hand, fingers pointing toward the midline, on the patient's lowermost right anterior rib cage so that your index finger is resting on the most inferior rib
- Extend your left thumb and push it into the patient's belly and hold. Note: Do not lean on the patient's rib cage
- Ask the patient to take a deep breath. Note: You should feel the rib cage move toward you during inspiration
- Note the patient's breathing and the degree of tenderness
- Repeat the test with a placebo maneuver by putting your hand in the same position but do not push in with your thumb. Note if the patient can complete a full inspiration
- The patient experiences pain/tenderness sufficient to cause an abrupt halt in inspiration (normally occurs toward the end of inspiration) and acute cholecystitis is suspected.
- The patient is able to complete a full inspiration without significant pain/tenderness.
- Sensitivity: 44% - 97%
- Specificity: 48% - 96%
- Likelihood ratios:
- Positive test: 2.0
- Negative test: nonsignificant
- In older patients
- Sensitivity: 48%
- Specificity: 79%
- Positive predictive value: 0.58
- The signs and symptoms of an acute abdomen in older patients are not as classic or specific (which may explain the differences in sensitivity and specificity).
- In elderly patients, a positive Murphy's sign is useful, but a negative sign is not exclusive and other diagnostic tests should be performed promptly.
- Adedeji OA, McAdam WA. Murphy's sign, acute cholecystitis and elderly people. J R Coll Surg Edinb. 1996;41(2):88-89.
- Bickley LS et al. Bates' Guide to Physical Examination and History Taking. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2013;468.
- Eskelinen M et al. Diagnostic approaches in acute cholecystitis. Theor Surg. 1993;8:15-20.
- McGee S. Evidence-based Physical Diagnosis. Philadelphia, PA: W.B. Saunders; 2001.
- Orient, JM. Sapira's Art and Science of Bedside Diagnosis. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2010;434.
- Popescu I et al. The value of echography for the diagnosis of acute cholecystitis (a Bayesian approach). Theor Surg. 1992;7:10-13.
- Singer AJ et al. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med. 1996;28(3):267-272.
- Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? JAMA. 2003;289(1):80-86.