When right upper quadrant pain and tenderness suggest acute cholecystitis, look for Murphy's sign. Hook your left thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Alternatively, if the liver is enlarged, hook your thumb or fingers under the liver edge at a comparable point below. Ask the patient to take a deep breath. Watch the patient's breathing and note the degree of tenderness.
A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy's sign of acute cholecystitis. Hepatic tenderness may also increase with this maneuver, but is usually less well localized.
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