335) A 75 year old hispanic man presents with right upper quadrant abdominal pain for past two weeks. He reports that the pain is excruciating and sharp when he takes a deep breath. He denies any recent trauma or fever or night sweats or cough. He reports lack of appetite and 30 lbs weight loss in the past 3 months. He immigrated to United States from Mexico about 15 years ago. He has no significant medical problems and has never been to a doctor in the past 25 years. A chest x-ray does not reveal any significant abnormalities. An ultrasound of the abdomen shows normal appearing gall bladder with gall stones but no evidence of cholecystitis. Common bile duct is within normal limits. Murphy’s sign is negative. Laboratory investigations reveal:
Total Protein : 7.5gm%
Albumin : 4.0gm%
Total bilirubin : 0.4 mg% ( N = 0.3 to 1.0 mg%)
AST : 30U/L ( N= 5 to 40U/L
ALT : 28 U/L ( N= 8 to 55U/L)
Alkaline Phosphastase ( ALP) : 750 U/L ( N= 4 to 130U/L)
GGTP : 40U/L ( N= 3 to 60U/L)
Which of the following is the most appropriate next step in management ?
A) Laparoscopic Cholecystectomy
B) HIDA scan
C) Bone Scan and Prostate Specific Antigen
D) Quantiferon Gold Test
E) MRI of the Pancreas
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