When RUQ pain and tenderness suggest acute cholecystitis, assess Murphy 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, palpate the RUQ with the fingers of your right hand near the costal margin. If the liver is enlarged, hook your thumb or fingers under the liver edge at a comparable point. Ask the patient to take a deep breath, which forces the liver and gall bladder down toward the examining fingers. Watch the patient's breathing and note the degree of tenderness.

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