495. A 49-year-old obese female presents with abdominal pain. Patient states the pain acutely onset several hours ago and describes it as constant, severe, localized around the umbilicus and radiating to her back. She says the pain feels better if she is sitting up and bending slightly forward. Patient also says she feels nauseous and vomited once after the pain began. No relevant past medical or surgical history. No current medications or allergies. Review of systems is significant for several recent episodes of abdominal pain after eating.
On exam, the patient is in distress, sitting upright, and leaning slightly forward. Vitals are temperature 38.3 °C (101.1 °F), blood pressure 110/78 mm Hg, pulse 105/min, respirations 25/min, and oxygen saturation 98% on room air. Cardiac exam is normal. Lungs are clear to auscultation. Abdominal exam reveals tenderness to palpation in the periumbilical region. Bowel sounds are diminished.
Laboratory values are:
Sodium 140 mEq/L
Potassium 4.0 mEqL
Chloride 100 mEq/L
Bicarbonate 25 mEq/L
BUN 35 mg/dL
Creatinine 1.1 g mg/dL
Glucose (fasting) 90 mg/dL
Calcium 7.0 mg/dL
Phosphorous 4.1 mg/dL
Bilirubin, conjugated 1.5 mg/dL
Bilirubin, total 3.0 mg/dL
AST (SGOT) 325 mU/mL
ALT (SGPT) 175 mU/mL
Alkaline Phosphatase 295 U/L
Amylase 250 U/L
Lipase 89 U/L
TSH 1.1 mIU/L
PTH 30 pg/mL
Troponin I (cTnI) <0.02 ng/mL
Lactate Deydrogenase (LDH) 750 U/L
C-reactive protein 45 mg/L
b-hCG <1 mIU/mL
WBC 19,000 / mm3
RBC 4 x 106/mm3
Hematocrit 45%
Hemoglobin 13.0 g/dL
Platelet Count 275,000 / mm3
Differential
Neutrophils (%) 85
Lymphocytes (%) 10
Monocytes (%) 5
Eosinophils (%) 3.5
Basophils (%) 1.5
Chest and KUB x-rays, and EKG are unremarkable.
Aggressive fluid resuscitation and supplemental 100% oxygen are given. Meperidine 150 mg intramuscularly is administered. Abdominal ultrasound reveals the presence of a gallstone in the common bile duct (CBD). Patient is kept NPO.
What is the next best step in management?
A. Contrast CT of the abdomen
B. Endoscopic retrograde cholangiopancreatography (ERCP)
C. Administer meropenem 1 g IV every 8 hours
D. Laparoscopic cholecystectomy
E. Magnetic resonance cholangiopancreatography (MRCP)
@hagemanGIstep2
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Archer USMLE Step 3 Blog 
Most probable diagnosis is Acute pancreatitis.
NPO , iv antibiotics , anti-emetic and Meperedine should be given .
ERCP is the definitive treatment of choice.