Abdominal examination — right upper quadrant pain
PLAB 2 & PRES 3 · surgery · medium · 10 minutes
Candidate brief
You are an FY2 doctor in the Emergency Department. Mr Tom Ellery, 54, has had pain in the upper right of his abdomen for two days. The nurse has recorded: temperature 37.9 °C, pulse 92 and regular, blood pressure 124/78 mmHg, respiratory rate 16, oxygen saturations 99% on air. Please perform an abdominal examination. Present your findings to the examiner, then discuss the likely diagnosis and your management plan.
What examiners look for
In abdominal examination, palpate the painful area LAST and watch the patient's face, not your hands. Candidates who start in the right upper quadrant get guarding everywhere and learn nothing. Murphy sign is a named mark and a real discriminator: inspiratory arrest as the inflamed gallbladder descends onto the examining fingers. State clearly whether it was positive — "tender in the RUQ" is not the same finding. The yellow eyes change the case. Pain plus fever fits cholecystitis; pain plus fever plus jaundice forces the bile duct into the story — a duct stone or cholangitis — and adds liver function tests, an ultrasound and possibly an MRCP to the plan. The history of brief, fatty-food episodes that settled in one to three hours is biliary colic's signature, and it is the runway to today's presentation: same organ, different chapter. Presenting both halves shows the examiner you understand the disease, not just the signs. Two days of constant pain with fever and guarding is not colic anymore — colic is intermittent, afebrile and short. Duration and systemic upset are what move a patient from "observe" to "admit, fluids, antibiotics, surgeons". Ultrasound is the first-line test for gallstone disease in NICE guidance: it answers stones, gallbladder wall thickening and duct dilatation in one non-invasive step, and it is the investigation to name before CT or MRCP. Finish by closing the loop the patient opened: gallbladder — probably yes; operation — likely, and the surgeons decide timing; yellow eyes — explained by the bile duct backing up, and one of the reasons he is staying in; home tonight — no, and say why kindly.
Guideline references
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