USMLE Step 3 Question of the Week #495

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


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)


Question of the Week # 471

A 14-year-old girl with a history of Crohn’s disease presents with 2-day history of feeling ‘feverish’, malaise, lower abdominal pain and non-bloody diarrhea. She has about 10 episodes of diarrhea daily. She has had three similar episodes in the past 7 years. She denies any recent travel or sick contacts, rush, cough or other symptoms of infection. She has no known allergies and does not take any medications currently. She has been taking 5-ASA, but stopped 6 months ago as she had been asymptomatic for 10 months before that. On presentation, the patient is afebrile with a body temperature of 101.0 F and appears ill. Her blood pressure is 120/80 mmHg and heart rate of 90 beats/minute.  Abdominal examination is remarkable for abdominal tenderness in the lower abdomen, but no rebound or guarding. A subsequent CT scan shows dilatation of the left colonic lumen, as well as a thickened colon wall with pericolic fat stranding, particularly in the left colon. The admitting team determines the patient’s presentation is due to exacerbation of her disease. The patient is started on 5-ASA, metronidazole and prednisone and her condition improves within 10 days when she is symptom-free. What is the most appropriate plan after her symptoms have resolved?

A)     Continue 5-ASA, taper prednisone and discontinue metronidazole
B)      Continue 5-ASA and prednisone, discontinue metronidazole
C)      Discontinue ASA-5 and metronidazole and continue prednisone for 4 weeks, followed by taper
D)     Recommend therapy with infliximab an instruct to take 5-ASA when she starts experiencing symptoms, discontinue prednisone and metronidazole
E)      Continue 5-ASA and metronidazole for at least 4 weeks, taper prednisone

Question of the Week # 464

464) A 68 year old man with history of Diabetes Mellitus type II and diabetic gastroparesis  is evaluated in your office for lack of appetite, nausea, vomiting, weight loss and a feeling full after eating small amounts of food material. He has lost 10 lbs weight in past 2 months. He denies any rectal bleeding or melena. He does report some epigastric discomfort. On examination, he appears in no distress, blood pressure is at 120/80. Abdomen is mildly distended with slight tenderness in upper abdomen. Patient is admitted and started on IV hydration. A plain X-ray abdomen is shown below. Gastroenterology is consulted and an upper endoscopy is pending. What is the most appropriate evidence-based next step?


A) Arrange for Laparoscopy
B) Endoscopic removal
C) Give Coca-Cola
D) Give Pepsi or any other soda
E) Metoclopramide

Question of the Week # 462

462) A 39 year old man is seen in your office for swelling of the abdomen and shortness of breath of several months’ duration. He is an active smoker and smoked about 1 pack per day for 20 years. He drinks alcohol occasionally. He denies any cough or fever. On examination, he is afebrile with a temperature of 98.1F , respiratory rate of 18/min, pulse 88/min and blood pressure at 120/70 mm Hg. Cardiac examination reveals regular heart sounds and no S3 gallop. Chest examination shows decreased breath sounds, increased antero-posterior diameter and hyper-resonance to percussion.  Abdominal exam is significant for fluid wave and shifting dullness. Liver is enlarged. No splenomegaly.

Labs reveal :

Hemoglobin : 14.2gm%

Serum creatinine 1.0mg%

Albumin 3.2gm%

Total bilirubin 1.0 mg%

Alkaline phosphatase 90 U/L

AST ( Aspartate aminotransferase) 160 U/L

ALT (Alanine aminotransferase) 190 U/L

Which of the following is most helpful in establishing the diagnosis

A. Serum Ferritin

B. Serum Ceruloplasmin leve

C. Anti-Actin and Smooth muscle antibodies

D. 2D Echocardiogram

E. Serum Alpha-1 anti-trypsin level.

Question of the Week # 458

458) A 65-year-old man is brought to the emergency department after having two large bowel movements over the past hour that consisted of bright red blood and no stool in the past 3 hours. He denies any abdominal pain or nausea, but does recall having crampy abdominal discomfort after eating over the last several days. His past medical history is significant for hypertension and diabetes and his medications include lisinopril, metoprolol and metformin. He had a colonoscopy at the age of 55 which was unremarkable. On presentation, his temperature is 37.0°C (98.6°F), blood pressure is 80/60 mm Hg, and pulse is 110/min. His abdomen is soft and nontender. There is no guarding or rebound tenderness. There is fresh red blood in the rectum, but there are no palpable masses. Intravenous fluid boluses are started. Which of the following is the most appropriate next step in the management of this patient?
A. Perform upper gastrointestinal endoscopy
B. Order a CT scan of the abdomen
C. Order a nuclear bleeding scan of the colon
D. Perform a colonoscopy
E. Perform nasogastric aspiration

Question of the Week # 455

You are evaluating a 63-year-old female with a complaint of abdominal pain radiating to her back. She has diminished appetite and pruritus. Her past history is significant for a 40-year history of tobacco use. She has three glasses of wine once a week.

The patient is afebrile, with blood pressure of 123/85, and her heart rate is 74. She appears jaundiced, with scleral icterus. Her abdomen is tender to palpation in the epigastric region, and her liver is palpable 2 cm below the right costal margin. Laboratory tests reveal total bilirubin of 6.0. direct bilirubin of 4.8, alkaline phosphatase of 1000, and AST is 42, with and ALT of 40. Which of the following initial diagnostic test will you order?

A. Abdominal ultrasound

B. Percutaneous liver biopsy

c. Percutaneous transhepatic cholangiography

D. CT abdomen and pelvis

E. Endoscopic retrograde cholangio-pancreatography.

Question of the Week # 447

447) A 54 year old caucasian man is seen in your office for initial visit examination. He recently moved from Texas to your town and would like to establish care with you. He has no significant past medical problems except for Gastro-Esophageal Reflux Disease for twenty years. He previously suffered hearburn symptoms that were controlled with over the counter ranitidine . Later, his symptoms became refractory and he was started on omeprazole by his previous physician. He currently takes 20 mg of Omeprazole and is very happy that he has been asymptomatic for the past 1 year.  He has had colonoscopy 2 years ago and this was normal. His father died of Colon cancer at the age of 70. He does not smoke.

Which of the following is the most appropriate action at this time ?

A) Instruct him to continue Omeprazole and follow up in 1 year.

B) Refer to gastroenterology for Upper Endoscopy

C) 24 hour Esophageal pH monitoring

D) Stool Guaic test and Flexible Sigmoidoscopy

E) Stool test for H.Pylori antigen

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