Murphy’s sign explained with heart: uses, steps, and meaning

If you've ever had that sharp, stop-you-in-your-tracks pain under your right ribs and wondered, "Is this my gallbladder?"you're not alone. Let's talk about Murphy's sign. It's a quick, hands-on test doctors use during a gallbladder exam to check whether right upper quadrant pain might be coming from an inflamed gallbladder (often acute cholecystitis). It's simple and surprisingly informative. But it's not perfect, and that's okaybecause it's meant to guide the next smart steps, not do the whole job by itself.

In this guide, you'll get: a down-to-earth definition, exactly how the exam is done (step by step), what a positive vs negative finding really means, how accurate it is, where it fits in diagnosing gallbladder issues, and practical next steps you can expect. I'll keep things human and warmbecause health information should feel like help, not homework.

What is it

At its core, Murphy's sign is an abdominal pain test. A clinician gently presses under your right rib cage while you breathe in. If your inflamed gallbladder bumps into their hand, it can trigger a sudden catch in your breathlike your body saying, "Nope, that hurts." That "inspiratory arrest," paired with tenderness, is what we call a positive Murphy's sign.

Where is this happening? Picture the right upper quadrant (RUQ), just under the right costal margin (the lower edge of your ribs), near the midclavicular line. Translation: a little below your right nipple line and under the ribshome base for the gallbladder.

What does it feel like? If the gallbladder is irritated or inflamed, as you inhale and your diaphragm pushes the liver and gallbladder downward, the contact with the examiner's hand can spark sharp pain. Many people reflexively stop inhaling. If your gallbladder isn't inflamed, you usually breathe through it just fine.

Why do clinicians use it? Because not all RUQ pain is gallbladder pain. Murphy's sign helps point toward cholecystitis versus other causes like stomach ulcers, kidney infections, or liver issues. It's part of a broader medical palpation techniqueone carefully choreographed set of touch-and-observe steps that help narrow the possibilities quickly at the bedside.

Let's also clear up some naming confusion. You may hear "sonographic Murphy's sign," which is similar in spirit but happens during an ultrasoundtenderness exactly where the probe presses over the gallbladder. That's different from the physical Murphy's sign your clinician does by hand. And "Murphy's punch"? That's a totally different test for kidney tenderness (costovertebral angle tenderness). "Murphy's point" isn't standard in modern practice and often just adds noise to the conversation.

How it's done

Here's the step-by-step version of the standard bedside Murphy's sign, shared so you can feel more at ease if you ever have this exam:

1) Positioning: You lie on your back (supine) on the exam table.

2) Hand placement: The examiner places fingers just under your right costal margin at the midclavicular line.

3) Breathing cue: You're asked to gently exhale (which relaxes the abdomen), then take a slow deep breath in.

4) Palpation: As you inhale, the examiner maintains gentle, steady pressure in that spot.

5) Observation: If you wince and stop breathing in because it hurts there, that's a positive Murphy's signan "inspiratory arrest." If you breathe through it comfortably, it's likely negative.

Sometimes, the clinician will compare right vs left under the ribs. If the right side is tender with inspiratory arrest but the left isn't, that adds specificityit's less likely you're just tense or sore everywhere.

Are there variations? Yes, a few. Historically, Murphy originally described a seated, deeper grip. Naunyn and Moynihan offered slight adaptations as the exam evolved. In modern practice, most clinicians use the comfortable supine approach described abovegentle, simple, and effective.

What about the ultrasound version? Sonographic Murphy's sign happens during a right upper quadrant ultrasound. If the spot exactly over the gallbladder lights up with maximal tenderness when the probe is there, clinicians consider that a positive sonographic Murphy's sign. Early research suggested it tends to be fairly specific (helpful when it's present), though sensitivity varies between studies. In other words: a strong clue, not a verdict.

Safety and comfort matter. Good clinicians coach your breathing, use gentle palpation, and stop if severe pain or instability shows up. If you're nervous, say soteamwork makes this more comfortable and more accurate.

What it means

Let's decode the result like a friend would:

Positive Murphy's sign: This leans toward acute cholecystitisgallbladder inflammation, often due to gallstones blocking the cystic duct. It can also occur with other biliary issues. If this happens, expect your clinician to order lab tests (like a CBC and liver function tests), and likely a right upper quadrant ultrasound. If the overall picture fits, a surgical consult may follow to discuss management, often early cholecystectomy when appropriate. It's not as scary as it sounds; many people go through this safely and feel much better once the problem is addressed.

Negative Murphy's sign: Don't stop the diagnostic story here. The differential remains broadthink choledocholithiasis (stones in the common bile duct), ascending cholangitis, pyelonephritis (kidney infection), peptic ulcer disease, hepatic causes, or even less common possibilities like FitzHughCurtis syndrome in select scenarios. A negative sign doesn't rule out cholecystitis, especially in older adults, people with diabetes, or in late-stage or gangrenous cases where nerve supply may be impaired.

Red flags regardless of result: If there's fever, jaundice, low blood pressure, confusion, or escalating pain, that's a "don't-wait" situation. These signs can indicate severe infection or sepsis and need urgent care.

How accurate

Medicine loves numbers, and for good reasonthey keep us honest. In general emergency department cohorts, Murphy's sign is often described as having good sensitivity (it helps catch many true cases) and useful negative predictive value when combined with the rest of the exam and history. But sensitivity can drop in older adults, meaning a negative result there is less reassuring and should never be used alone to rule out cholecystitis. For the ultrasound version, early literature suggested the sonographic Murphy's sign can be quite specificmore convincing when positive than when it's absent. Accuracy details can vary by study and setting, but the takeaway is steady: it's a strong bedside clue, not a stand-alone diagnosis.

Why is it still valuable? Because it's fast, requires zero equipment, and helps triage right upper quadrant pain in minutes. It contributes to a smarter plan when combined with your story (history), a thoughtful physical exam, and appropriate tests.

Limitations to keep in mind:

- It's not perfectly specific. Other causes of RUQ pain can occasionally trigger a similar response.

- False negatives happenespecially in elderly patients, in gangrenous cholecystitis, or if pain medications blunt the response.

- Technique matters. A rushed or rough exam may mislead; a calm, coached exam is more reliable.

- If a patient is unstable, don't delay definitive imaging or treatment waiting for a perfect exam.

Where it fits

Think of diagnosing gallbladder issues as a thoughtful sequence, not a onenote performance. Here's how the clinical workflow usually flows for RUQ pain:

History: Your clinician asks when the pain started, what it feels like, how long it lasts, whether it radiates to your back or shoulder, what triggers it (fatty meals are common culprits), and what makes it better or worse. They'll ask about risk factors you may have heard as the "four F's" (female, forty, fertility, fat), though real life is more nuancedanyone can develop gallstones.

Exam: This includes Murphy's sign, but also checks for guarding, rebound tenderness, fever, jaundice, or signs of dehydration. The whole picture matters more than any single detail.

Initial tests: Expect bloodworkCBC for infection markers, CMP/LFTs (bilirubin, AST/ALT, alkaline phosphatase), and sometimes lipase to rule out pancreatitis. The goto imaging is a right upper quadrant ultrasound. If the ultrasound is equivocal but suspicion remains high, a HIDA scan (hepatobiliary iminodiacetic acid scan) can be very helpful for cholecystitis diagnosis.

Diagnosing cholecystitis vs others: Clinicians combine your symptoms, Murphy's sign, lab results, and imaging to build the diagnosis. If you have a tender, positive Murphy's sign plus gallbladder wall thickening, pericholecystic fluid, or stones on ultrasound, that strengthens the case for cholecystitis. If labs show cholestasis or bilirubin spikes, choledocholithiasis (stones in the bile duct) may be in play. Fever and jaundice together raise concern for cholangitisa medical emergency.

Management after the exam: For suspected acute cholecystitis, antibiotics and admission are common, with early cholecystectomy often recommended. If obstruction is suspected in the bile duct, endoscopic retrograde cholangiopancreatography (ERCP) may be needed. If symptoms are mild and testing is reassuring, outpatient followup with clear safety instructions may be reasonable. Plans are tailoredyou're not a template.

Curious about the nuts and bolts of the medical palpation technique for Murphy's sign and how original descriptions have evolved? That overview walks through classic and modern approaches in a clinicianfriendly way and also maps how the "sonographic Murphy's sign" stacks up in practice.

Real insights

I've found that the best way to appreciate Murphy's sign is to see how it plays out in real lifewhere neat textbook rules meet messy human reality.

Case vignette 1: An older adult arrives with vague nausea, mild RUQ discomfort, and lowgrade fever. Murphy's sign is negative. It's tempting to relax. But the labs show inflammatory markers rising, and ultrasound is equivocal. A HIDA scan later confirms acute cholecystitis. The lesson? In older adults, Murphy's sign can be deceptively quiet. If the story and labs whisper "gallbladder," keep listening.

Case vignette 2: A younger person shows up with classic, sharp RUQ pain after a greasy meal. On exam, a firm inhalation triggers an obvious inspiratory arresttextbook positive Murphy's sign. Ultrasound shows stones and borderline wall thickening, but grayscale findings aren't definitive. The sonographic Murphy's sign is strongly positive exactly over the gallbladder. The care team treats early, and recovery goes smoothly. The lesson? When physical and sonographic findings point the same way, acting promptly can spare days of pain and complications.

Clinician tip: The quiet coaching is everything. "Exhale now slow deep breath in." That calm cadence helps the abdominal wall relax so the test is both kinder and more accurate. Sidebyside comparison (right then left) also cuts down on false alarms. And good documentationwhat you felt, where, and the patient's exact responsebuilds trust and clarity across the team.

Key distinctions

Murphy's sign vs sonographic Murphy's sign: The bedside version is an examinerelicited inspiratory arrest under the right costal margin. The sonographic version is tenderness exactly when the ultrasound probe is over the gallbladder, often with the patient saying, "That's the spot." They're related but not identical, and their accuracy profiles differ across studies.

Murphy's sign vs Murphy's punch: Totally different neighborhoods. Murphy's punch (also called CVA tenderness) looks for kidney inflammation by tapping over the back at the costovertebral angle. Don't let the similar names confuse youone is a gallbladder exam, the other checks the kidneys.

Other RUQ signs you might hear about: Boas' sign (increased sensitivity under the right scapula) sometimes gets a mention, though it's not a workhorse of modern diagnosis. Courvoisier's law (palpable gallbladder with painless jaundice) points clinicians toward possible malignant obstruction rather than stones. These signs can color the picture, but they're not the main characters anymore.

Risks and care

Who might have atypical results? Older adults, people with diabetes or compromised immunity, and those with severe or gangrenous cholecystitis may not show a classic positive Murphy's signeven when quite ill. Pain control can also blur the test response. That's why clinicians use Murphy's sign as a guidepost, not a gatekeeper.

When to seek immediate care: If you have severe right upper quadrant painespecially with fever, chills, jaundice (yellowing of skin or eyes), vomiting, confusion, or low blood pressuredon't wait. These can flag cholangitis or sepsis, which need urgent treatment. If your pain keeps returning after meals or is waking you from sleep, that's also a nudge to get checked sooner rather than later.

Trust and sources

Everything here is designed to supportnot replaceclinical judgment. In the medical world, we triangulate truth: your story, the exam, and the tests all talk to each other. Accuracy data and historical notes on Murphy's sign have been summarized from peerreviewed studies and trusted clinical overviews, including classic diagnostic accuracy research on physical exam findings and practical guides clinicians use at the bedside. You can find a clear synthesis of technique and performance in resources like the Life in the Fast Lane review of Murphy's sign and similar evidence summaries. These sources highlight both the strengths of the sign and its blind spotsespecially in older patients or advanced diseaseso we don't overpromise what a single exam can do.

Bottom line on trust: We're leaning into a peoplefirst, balanced approach. No single sign is a magic wand, but used thoughtfully, Murphy's sign is a reliable nudge in the right directionone that lets you and your clinician move efficiently to the labs and imaging that confirm the diagnosis and guide treatment.

Final thoughts

Murphy's sign is a small moment in a bigger storya quick, handson clue that helps clinicians zero in on gallbladder inflammation during a careful gallbladder exam. A positive Murphy's sign raises suspicion for cholecystitis, while a negative one doesn't completely rule it out, especially in older adults or severe, late presentations. The smartest path is a balanced one: let the sign guide, then confirm with labs and imaging like a right upper quadrant ultrasound or a HIDA scan when needed. If you're wrestling with upperright abdominal painparticularly if you've got fever, nausea, or yellowing of the eyesdon't sit on it. Get evaluated so you can move toward the right diagnosis and treatment sooner. What would help you most nexta printable set of exam steps, a patient checklist for appointments, or a deeper dive into imaging? Tell me, and we'll build it together.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.