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 # 371

371)  A 45 year caucasian man is evaluated in your office prior to surgery for refractory heartburn symptoms. He was diagnosed with Gastro-esophageal reflux disease 2 years ago. Initially, his disease was mild and was responsive to over the counter antacids. He was started on PPI ( proton pump inhibitor trial 6 months ago and has not responded. He switched physicians and tried different brands of proton pump inhibitors with no benefit. An endoscopy was performed a year ago and repeat endoscopy 3 months ago revealed erosions and inflammations consistent with reflux esophagitis with out any background of barrett’s esophagus. The patient is scheduled for fundoplication surgery and is here for pre-operative evaluation. Which of the following should be performed at this time ?

A) 24 hour esophageal pH monitoring

B) Barium esophagogram

C) Esophageal motility studies

D) No additional tests needed , clear patient  for surgery

E) H.Pylori Urea Breath Test

Question of the Week #124

Q124) A 50 year old man comes for regular health checkup. His family history is significant for colon cancer in his grandfather at the age of 70 and prostate cancer in his father at age 75. His mother had breast cancer at age 65. The patient recently underwent colonoscopy which was normal. During his visit, he asks you if there are any pills or medications that he could use to prevent cancer.  Which of the following have been shown to prevent cancer in a prospective clinical trial?

A)     Vitamin D

B)      Selenium

C)      Beta Carotene

D)     Finasteride

E)      Vitamin B-complex

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