Module 6 Flashcards
has small, rounded elevations formed by sebaceous glands (called Montgomery glands), sweat glands, and accessory areolar glands
The surface of the areola
There are two fascial layers of the breast:
The superficial fascia (lies deep to the dermis), and the deep fascia (lies anterior to the pectoralis major muscle)
suspensory Cooper ligaments
The breast is attached to the skin by suspensory Cooper ligaments, fibrous bands that travel through the breast and insert perpendicular to the dermis
Occasionally, one or more extra nipples are located along the “milk line” (usually, only a small nipple and areola are present, often mistaken for a common mole. They may be familial, and, in the absence of associated glandular tissue, there is little evidence of association with other congenital anomalies. Those containing glandular tissue occasionally show increased pigmentation, swelling, tenderness, or even lactation during puberty, menstruation, or pregnancy and can be associated with other congenital anomalies, mainly renal and thoracic.2 Treatment is recommended if there is diagnostic ambiguity, cosmetic concerns, or possible pathology
supernumerary nipples
To describe clinical findings, the breast is often divided into four quadrants based on horizontal and vertical lines crossing at the nipple (A fifth area, the axillary tail of breast, sometimes termed the…extends laterally across the anterior axillary fold.
The tail of Spence
is of great importance in the spread of carcinoma, and about three-quarters of it is to the axillary nodes.
The lymphatic drainage of the breast
l nodes that are most likely to be palpable during physical examination.
central nodes
a proliferation of palpable glandular tissue generally defined as more than 2 cm in boys or men
gynecomastia,
Causes of gynecomastia include
increased estrogen, decreased testosterone, and medication side effects.
an accumulation of subareolar fat
condition in which the male breast area has excess adipose (fat) tissue behind, around and under the nipples
pseudogynecomastia,
These are the most common breast-related complaints.
lumps, pain, or nipple discharge of her breasts.
15–25 yrs, usually puberty and young adulthood, but up to age 55 yrs
-usually single, maybe multiple
-round, disc-like shape
-maybe soft, usually firm
-well delineated
-very mobile
-usually nontender
-absent retraction signs
A noncancerous breast tumor that most often occurs in young women.
Fibroadenoma
(A benign neoplasm derived from glandular epithelium, in which there is a conspicuous stroma of proliferating fibroblasts and connective tissue elements; commonly occurs in breast tissue.)
-30–50 yrs, regress after menopause except with estrogen therapy
-single or multiple
-round
-soft to firm, usually elastic
-well delineated
-mobile
-often tender
-retraction signs is absent
Cysts
A fluid-filled sac in the breast, which usually isn’t cancerous.
Breast cysts are common in women ages 35 to 50. They usually disappear after menopause, unless a woman is taking hormone therapy.
-30–90 yrs, most common over age 50 yrs
-usually single, although may coexist with other nodules
-Irregular or stellate
-firm or hard
-not clearly delineated from surrounding tissue
-May be fixed to skin or underlying tissues
-usually nontender
retraction signs maybe present
Cancer
visible signs of breast cancer
Retraction signs
-abnormal contours
-skin dimpling
-nipple retraction and deviation
-Paget Disease of the Nipple
-edema of skin
As breast cancer advances, it causes fibrosis (scar tissue). Shortening of this tissue produces dimpling, changes in contour, and retraction or deviation of the nipple. Other causes of retraction include fat necrosis and mammary duct ectasia.
Retraction signs
Look for any variation in the normal convexity of each breast and compare one side with the other. Special positioning may again be useful. Shown here is marked flattening of the lower outer quadrant of the left breast.
Abnormal contours
Look for this sign with the patient’s arm at rest, during special positioning, and on moving or compressing the breast, as illustrated here.
Skin dimpling
A retracted nipple is flattened or pulled inward, as illustrated here. It may also be broadened and feels thickened. When involvement is radially asymmetric, the nipple may deviate or point in a different direction from its normal counterpart, typically toward the underlying cancer.
Nipple Retraction and Deviation
This uncommon form of breast cancer usually starts as a scaly, eczema-like lesion on the nipple that may weep, crust, or erode. A breast mass may be present. Suspect Paget disease in any persisting dermatitis of the nipple and areola. Often (>60%) presents with an underlying in situ or invasive ductal or lobular carcinoma.
Paget Disease of the Nipple
Edema of the skin is produced by lymphatic blockade. It appears as thickened skin with enlarged pores—the so-called peau d’orange (orange peel) sign. It is often seen first in the lower portion of the breast or areol
Edema of the skin
risks of breast cancer in males
Risk factors include increasing age, radiation exposure, BRCA gene mutations, Klinefelter syndrome, testicular disorders, alcohol use, liver disease, diabetes, and obesity.
The strongest risk factors for breast cancer in women are
increasing age, first-degree family members diagnosed with breast cancer (especially two or more diagnosed at an early age), inherited genetic mutations, personal history of breast cancer or ductal or lobular carcinoma in situ, biopsy-confirmed precancerous lesions, relatively denser breasts on mammography, high-dose radiation to the chest at a young age, and high levels of endogenous hormones.24
One of the most commonly used tools is … which incorporates age, race/ethnicity, personal history of breast cancer or ductal or lobular carcinoma in situ, chest radiation, genetic mutations, first-degree relatives with breast cancer, previous breast biopsy results, age at menarche, and age at first delivery.25
the National Cancer Institute’s Breast Cancer Risk Assessment Tool (also known as the Gail model),
Heartburn
a burning sensation in the epigastric
area radiating into the throat; often associated
with regurgitation
needing to belch or pass
gas by the rectum; patients often state they feel bloated
excessive gas or flatus
the reflux of food and stomach acid
back into the mouth; brine-like taste
Regurgitation
Blood or coffee ground emesis is known as
hematemesis
when hollow organs (stomach, colon)
forcefully contract or become distended. Solid organs (liver, spleen) can also generate this type of pain when they swell against their capsules. Visceral pain is usually gnawing, cramping, or aching and is often difficult to localize (hepatitis)
Visceral pain is typically nonspecific and difficult to localize.
As the pain progress, systemic symptoms such as sweating, pallor, nausea, vomiting, and restless May follow.
Visceral pain
when there is inflammation from the hollow or solid organs that affect the parietal peritoneum. Parietal pain
is more severe and is usually easily localized (appendicitis)
- it is a steady, aching pain that is usually more severe than visceral pain and more precisely localized over the involved structure. It is typically aggravated by movement or coughing. Patient with parietal pain prefers to lie still.
Parietal pain or somatic pain
originates at different sites but shares innervation from the same spinal level (gallbladder pain in the
shoulder
Palpating at the site of referred pain often does not result in tenderness
Referred pain
normal abdominal sounds on percussion
-what sound could be a large stool or a mass?
tympany (hollow sounds)
-Dullness
Midclavicular percussion of the liver should be 6–12 cm; longer than this indicates an
enlarged liver
Midsternal line percussion should be 4–8 cm; shorter than this can indicate
a small, hard cirrhotic liver
Liver, gallbladder, pylorus, duodenum, hepatic flexure of colon, and head of pancreas
RUQ
Spleen, splenic flexure of colon, stomach, and body and tail of pancreas
LUQ
Sigmoid colon, descending colon, and left ovary
LLQ
Cecum, appendix, ascending colon, terminal ileum, and right ovary
RLQ
…which rests against the inferior surface of the liver, and the more deeply lying duodenum are generally not palpable unless pathologic
The gallbladder,
rib cage with its xiphoid process, which protects …
the stomach.
… can have visible pulsations and may be palpable in the upper abdomen, or epigastrium in thin patients
The abdominal aorta
In the left upper quadrant (LUQ), the …is lateral to and behind the stomach, just above the left kidney in the left midaxillary line. Its upper margin rests against the dome of the diaphragm. The 9th, 10th, and 11th ribs protect most of the…. its tip may be palpable below the left costal margin in a small percentage of adults (in contrast to readily palpable splenic enlargement, or splenomegaly).
the spleen
the appendix is located in the right lower quadrant (RLQ) at the base of the cecum, the first part of the large intestine where the terminal ileum enters the large intestine at the ileocecal valve. and the pancreas in the LUQ.
In healthy people, these are not palpabl
In the lower midline are the… which can often be palpated when distended and in women, the uterus and ovaries.
urinary bladder
lie posteriorly in the abdominal cavity behind the peritoneum (retroperitoneal). The ribs protect their upper poles (
the kidneys
formed by the lower border of the 12th rib and the transverse processes of the upper lumbar vertebrae, defines where to elicit for kidney tenderness, called
-The costovertebral angle (CVA)
-The costovertebral angle tenderness
Continuous with the abdominal cavity, but angulated posteriorly, lies the funnel-shaped…, which contains the terminal ureters; bladder; pelvic genital organs; and, at times, loops of small and large intestine. These organs are partially protected by the surrounding pelvis.
pelvic cavity
is a hollow reservoir with strong smooth muscle walls composed chiefly of detrusor muscle. It accommodates roughly 400 to 500 mL of urine filtered by the kidneys into the renal pelvis and the ureters.
The urinary bladder
may be palpable above the symphysis pubis.
A distended bladder
painful swallowing
odynophagia
increasing age; personal history of colorectal cancer, adenomatous polyps, or longstanding inflammatory bowel disease (IBD); and family history of colorectal neoplasia—particularly with diagnoses in multiple first-degree relatives, a single first-degree relative diagnosed before age 60, or a hereditary colorectal cancer syndrome.52 While the lifetime risk of colorectal cancer is extremely high in patients with hereditary syndromes, about 75% of colorectal cancers arise in people without any obvious hereditary risk or family history
The strongest risk factors for colorectal cancer
colorectal screening guidelines
-Adults age 50 to 75 yrs—options (grade A recommendation)
Stool-based tests
Fecal immunochemical test (FIT) annually
High-sensitivity guaiac-based fecal occult blood testing annually
FIT-DNA testing every 1 or 3 yrs
Direct visualization tests
Colonoscopy every 10 yrs.
Sigmoidoscopy every 5 yrs
Flexible sigmoidoscopy every 10 yrs with FIT every 3 yrs
CT colonography every 5 yrs
Adults age 76 to 85 yrs—individualized decision making (grade C recommendation), decisions should take into consideration life expectancy and previous screening. Previously unscreened adults might benefit from screening.
Adults older than age 85—do not screen (grade D recommendation), because “competing causes of mortality preclude a mortality benefit that would outweigh the harms”
-Prolonged exposure of esophagus to gastric acid due to impaired esophageal motility or excess relaxations of the lower esophageal sphincter; Helicobacter pylori may be present
-Chest or epigastric
-After meals, especially spicy foods
-ying down, bending over; physical activity; diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal sphincter
-Antacids, proton pump inhibitors; avoiding alcohol, smoking, fatty meals, chocolate, selected drugs such as theophylline, calcium channel blockers
Gastroesophageal Reflux Disease (GERD
-Mucosal ulcer in stomach or duodenum >5 mm, covered with fibrin, extending through the muscularis mucosa; H. pylori infection present in 90% of peptic ulcer
-Epigastric, may radiate straight to the back
-Quality: Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike No symptoms in up to 20%
-timing:Intermittent; duodenal ulcer is more likely than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient at night, and (2) occurs intermittently over a few wks, disappears for months, then recurs
-aggravating factor: variable
-Food and antacids may bring relief (less likely in gastric ulcers)
Peptic Ulcer and Dyspepsia
Visceral periumbilical pain can be suggestive of early acute appendicitis from distention of an inflamed appendix. It gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum.
acute appendicitis
Place the diaphragm over the abdomen to hear bowel sounds called….which are long gurgles. These sounds are transmitted across the abdomen so it is not necessary to listen at multiple places. The normal frequency of sound is 5-34 sounds per minute.
(borborygmi)
(rebound tenderness in the left lower quadrant)
Rovsing’s sign (a.k.a. indirect tenderness) is a right lower quadrant pain elicited by pressure applied on the left lower quadrant. The phenomenon is generally named after the Danish surgeon Niels Thorkild Rovsing
Rovsing’s sign
the patient flexes his thigh against the examiner’s hand; pain indicates a positive sign)
Psoas sign is elicited by having the patient lie on his or her left side while the right thigh is flexed backward. Pain may indicate an inflamed appendix overlying the psoas muscl
psoas sign
flex the patient’s thigh
and rotate the leg internally at the hip; pain indicates
a positive sign)
pain that is elicited in a supine patient by internally and externally rotating the flexed right hip.
obturator’s sign
If patients report heartburn and effortless regurgitation together more than once a week, the accuracy of diagnosing … is over 90%.
GERD
the diagnostic criteria for GERD
hese symptoms or mucosal damage on endoscopy are the diagnostic criteria for GERD. Risk factors include reduced salivary flow, which increases mucosal acid exposure by dampening the actions of the bicarbonate buffer; obesity; delayed gastric emptying; selected medications; hiatal hernia and increased intraabdominal pressure.
GERD atypical sx
Some patients with GERD have atypical respiratory symptoms such as chest pain, cough, wheezing, and aspiration pneumonia. Others complain of pharyngeal symptoms, such as hoarseness chronic sore throat, and laryngitis
endoscopic evaluation
Patients who have uncomplicated GERD who fail empiric therapy, age >55 years, and “alarm symptoms” warrant endoscopy to evaluate possible esophagitis, peptic strictures, Barrett esophagus, or esophageal cancer.
alarm symptoms with GERD
Difficulty swallowing (dysphagia)
Pain with swallowing (odynophagia)
Recurrent vomiting
Evidence of GI bleeding
Early satiety
Weight loss
Anemia
Risk factors for gastric cancer
Palpable mass
Painless jaundice
a metaplastic change in the esophageal lining from normal squamous to columnar epithelium. In those affected, dysplasia on endoscopy increases the risk of esophageal cancer from 0.1% to 0.5% (no dysplasia) to 6% to 19% per patient year (high-grade dysplasia).1
Barrett esophagus,
Approximately 10% of patients with chronic longstanding heartburn have Barrett esophagu
RLQ pain or pain that migrates from the periumbilical region, combined with nausea, vomiting, and loss of appetite is suspicious for
appendicitis.
In women, consider pelvic inflammatory disease (PID), ruptured ovarian follicle, and ectopic pregnancy.
pain in the LLQ accompanied by diarrhea in a patient with a history of constipation is suggestive of
diverticulitis
Nonspecific diffuse abdominal pain with abdominal distention, nausea, emesis, and lack of flatus and/or bowel movements is symptomatic of a
bowel obstruction
marked by severe diffuse abdominal pain with guarding and rigidity on examination. Patients may or may not have accompanying abdominal distention.
peritonitis
Change in bowel habits with a palpable mass warns of late-stage
colon cancer.
a diagnosis of exclusion and requires intermittent pain for 12 weeks of the preceding 12 months with relief from defecation, change in frequency of bowel movements, or change in form of stool (loose, watery, pellet-like), linked to luminal and mucosal irritants that alter motility, secretion, and pain sensitivity.15
Diagnostic criteria for IBS
Anorexia, nausea, and vomiting accompany many disorders
from benign to more insidious, including pregnancy, diabetic ketoacidosis, adrenal insufficiency, hypercalcemia, uremia, liver disease, emotional states, and adverse drug reactions.
Induced vomiting without nausea
is more indicative of bulimia.
involuntary spasm of the stomach, diaphragm, and esophagus that precedes and culminates in vomiting, the forceful expulsion of gastric contents out of the mouth.
Retching
common symptom of GERD; however, it can also be a presenting symptom of esophageal stricture, Zenker diverticulum, or esophageal or gastric malignancy.
regurgitation
Vomiting and nausea with constipation or obstipation (severe constipation with inability to pass both stool and gas) is indicative of
bowel obstruction and warrants further imaging workup.
Hematemesis may accompany .
esophageal or gastric varices, Mallory–Weiss tears, or PUD
If fullness or early satiety, consider
diabetic gastroparesis, anticholinergic medications, gastric outlet obstruction, and gastric cancer
globus sensation,
The sensation of a lump or foreign body in the throat at rest that improves or disappears with swallowing, called a globus sensation, is not true dysphagia.
Xerostomia
(insufficient saliva) commonly present in older adult men and women ≥70 years can give rise to the sensation of difficulty swallowing food. For types of dysphagia,
Indicators of oropharyngeal dysphagia
delay in initiating swallowing, postnasal regurgitation or coughing from aspiration, and repetitive swallowing to achieve clearance. Causes may be neurologic like stroke, Parkinson disease, or amyotrophic lateral sclerosis; muscular like muscular dystrophy or myasthenia gravis; or structural as seen in esophageal stricture and hypopharyngeal diverticuli (Zenker diverticulum). Causes are generally structural in younger adults and neurologic/muscular in older adults.16
Ask the patient to point to where the dysphagia occurs.Pointing to below the sternoclavicular notch suggests
esophageal dysphagia
solid vs solid and liquid food
If solid foods, consider structural causes like esophageal stricture, webbing or narrowing (Schatzki ring), and neoplasm; if solids and liquids, a motility disorder like achalasia is more likely.
Consider esophageal ulceration from
from ingestion of aspirin or NSAIDs; caustic ingestion; radiation; or infection with Candida, cytomegalovirus, herpes simplex, or HIV.
excessive gas causes
Causes include excessive and repetitive air swallowing (aerophagia), ingestion of legumes or other gas-producing foods, intestinal lactase deficiency, and IBS.
(aerophagia),
excessive and repetitive air swallowing (aerophagia),
acute diarrhea
-persistent diarrhea
-chronic diarrhea
last less than 14 days
Acute diarrhea, especially foodborne, is usually caused by infection
-persistent diarrhea as lasting 14 to 30 days
-lasting more than 30 days.Chronic diarrhea is typically noninfectious in origin, as in IBS (Crohn disease and ulcerative colitis) or food allergy.
High-volume frequent watery stools are usually from the small intestine; small-volume stools with tenesmus or diarrhea with mucus, pus, or blood occur in rectal inflammatory conditions.
High-volume frequent watery stools are usually from the small intestine; small-volume stools with tenesmus or diarrhea with mucus, pus, or blood occur in rectal inflammatory conditions.
primary or functional constipation
the cause cannot be identified from the history and physical examination. Types include normal transit, slow transit, impaired expulsion (from pelvic floor dysfunction), and combined causes
Secondary or organic constipation
has an identified underlying cause, which may include medications, amyloidosis, diabetes, and central nervous system disorders
Thin, pencil-like stool occurs in
an obstructing “apple-core” lesion of the distal colon.
causes of constipation
Anticholinergic agents, antidepressants, calcium-channel blockers, calcium and iron supplements, and opioids can cause medication-induced constipation. Constipation also occurs with diabetes, hypothyroidism, hypercalcemia, hypomagnesemia, multiple sclerosis, Parkinson disease, and systemic sclerosis.
Ostipation
intestinal obstruction.
here is no passage of either stool or gas
is usually apparent when plasma bilirubin is >3 mg/dL.
jaundice
Carotenemia
the presence of the orange pigment carotene in the blood due to ingestion of carrots, presents as a yellow discoloration of the skin, especially palms and soles, but not the sclera or mucous membranes.
Rome IV criteria
constipation should be present for the last 3 months with symptom onset at least 6 months prior to diagnosis and should have at least two of the following conditions: less than three bowel movements per week, ≥25% or more defecations with either straining or sensation of incomplete evacuation, lumpy or hard stools, or manual facilitation.17,18
Painless jaundice points to
painless jaundice
malignant obstruction of the bile ducts, seen in duodenal or pancreatic carcinoma;
painful jaundice
ainful jaundice is commonly infectious in origin, as in hepatitis A and cholangitis.23
When excretion of bile into the intestine is completely obstructed, the stools become gray or light colored, or …, without bile.
acholic
Dark urine indicates.
impaired excretion of bilirubin into the GI tract
occurs in cholestatic or obstructive jaundice when bilirubin levels are markedly elevated
itching or pruritus
Does the skin itch without other obvious explanation? I
Risk Factors for Liver Disease
Infectious hepatitis: Travel or meals in areas of poor sanitation, ingestion of contaminated water or foodstuffs (hepatitis A); parenteral or mucous membrane exposure to infectious body fluids such as blood, serum, semen, and saliva, especially through sexual contact with an infected partner or use of shared needles for injection drug use (hepatitis B); illicit injection drug use or blood transfusion (hepatitis C). Hepatitis B is also endemic in certain regions of the world and can present in patients with no risk factors.Nonalcoholic steatohepatitis in patients with metabolic syndromeAlcoholic hepatitis or alcoholic cirrhosis: screen patients carefully about alcohol useToxic liver damage from medications, industrial solvents, environmental toxins, or some anesthetic agentsGallbladder disease or prior surgery that may result in extrahepatic biliary obstructionHereditary disorders such as family history of hemolytic anemia or liver disease, such as hemochromatosis, α-1-antitrypsin deficiency, Wilson disease
Involuntary voiding or lack of awareness suggests
cognitive or neurosensory deficits.
Paget disease of the breast
Asymmetry due to change in nipple direction suggests an underlying cancer. Eczematous changes with rash, scaling, or ulceration on the nipple extending to the areola occurs in Paget disease of the breast, associated with underlying ductal or lobular carcinoma
-This uncommon form of breast cancer usually starts as a scaly, eczema-like lesion on the nipple that may weep, crust, or erode. A breast mass may be present. Suspect Paget disease in any persisting dermatitis of the nipple and areola. Often (>60%) presents with an underlying in situ or invasive ductal or lobular carcinoma.
here are five broad categories of incontinence.
-In stress incontinence, increased abdominal pressure causes bladder pressure to exceed urethral resistance—there is poor urethral sphincter tone or poor support of bladder neck.
-In urge incontinence, urgency is followed by involuntary leakage due to uncontrolled detrusor contractions that overcome urethral resistance.
- In overflow incontinence, neurologic disorders or anatomic obstruction from pelvic organs or the prostate limit bladder emptying until the bladder becomes overdistended.
-Functional incontinence arises from impaired cognition, musculoskeletal problems, or immobility.
-Combined stress and urge incontinence is called mixed incontinence.
Pink–purple striae on the abdomen are a hallmark of
Cushing syndrome.
…..suggest portal hypertension from cirrhosis (caput medusae) or inferior vena cava obstruction.
dilated vein of the abdomen
Ecchymosis of the abdominal wall is seen in
intraperitoneal or retroperitoneal hemorrhage.
tympani sounds of abdomen on percussion
tympany usually predominates because of gas in the GI tract
-dullness from fluid and feces are also common
Dull areas on abdominal percussion
Dull areas characterize an intrauterine pregnancy, an ovarian tumor, a distended bladder, large volume ascites, or a large liver or spleen.
Signs of peritonitis
Guarding is a voluntary contraction of the abdominal wall, often accompanied by a grimace that may diminish when the patient is distracted.
-Rigidity is an involuntary reflex contraction of the abdominal wall from peritoneal inflammation that persists over several examinations.
-Rebound tenderness refers to pain expressed by the patient after the examiner presses down on an area of tenderness and suddenly removes the hand. To assess rebound tenderness, ask the patient, “Which hurts more, when I press or let go?” Press down with your fingers firmly and slowly, then withdraw your hand quickly. The maneuver is positive if withdrawal produces pain. Percuss gently to check for percussion tenderness.
splenic percussion sign (Castell sign).
A change in percussion note from tympany to dullness on inspiration is a positive splenic percussion sign, but this sign is only moderately useful for detecting splenomegaly
With the patient supine, press deeply and evenly in the LLQ. Then quickly withdraw your fingers.
Pain in the RLQ during left-sided pressure is a positive Rovsing sign.
Rovsing sign (indirect tenderness)-referred rebound tenderness
With the patient supine, place your hand just above the patient’s right knee and ask the patient to raise that thigh against your hand.
-Alternatively, ask the patient to turn onto the left side. Then extend the patient’s right thigh at the hip. Flexion of the thigh at the hip makes the psoas muscle contract; extension stretches it.
-Increased abdominal pain on either technique is a positive psoas sign, suggesting irritation of the right psoas muscle by an inflamed retrocecal appendix.
the psoas sign
Flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. Internal rotation of the hip is described on p. 643.
Right hypogastric pain is a positive obturator sign, from irritation of the right obturator internus muscle by an inflamed appendix located in the pelvis. This sign has very low sensitivity
obturator sign
tenderness at site two thirds of the distance between the umbilicus and the anterior superior iliac spine; seen in appendicitis.
McBurney sign
Murphy sign can be performed.
Deeply palpate the RUQ at the location of the patient’s pain. Ask the patient to take a deep breath, which forces the liver and gallbladder down toward the examining fingers.A sharp halting in inspiratory effort due to pain from palpation of the gallbladder on examination is a positive Murphy sign. When positive, Murphy sign triples the likelihood of acute cholecystitis.39 Of note, this finding is only useful in a patient who does not have tenderness in the RUQ with regular palpation.
Possible Acute Cholecystitis
a benign 2- to 3-cm gap in the rectus muscles often seen in obese and postpartum patients.
diastasis recti, which is
