A patient with right upper quadrant pain and a positive Murphy sign. What is the most likely diagnosis and initial management?

• A. Acute pancreatitis.
• B. Acute cholecystitis; NPO, IV fluids, antibiotics, and surgical consultation.
• C. Appendicitis.
• D. Peptic ulcer disease.

Answer: (B)

Acute cholecystitis is most likely when right upper quadrant pain is accompanied by a positive Murphy sign, which reflects gallbladder inflammation often from gallstones. The initial plan focuses on supportive care and preparing for definitive treatment: keep the patient NPO to rest the gallbladder, provide IV fluids to correct dehydration and maintain perfusion, start broad-spectrum IV antibiotics to cover biliary flora, and obtain urgent surgical consultation for cholecystectomy (usually laparoscopic). Analgesia and antiemetics as needed help comfort the patient while these measures are initiated. This setting distinguishes itself from other causes of abdominal pain that don’t typically present with a Murphy sign or require immediate antibiotics and surgery.