USMLE Question of the Week

Right Upper Quadrant Abdominal Pain in a 48-Year Old Woman

In Episode 54 of Med School Question of the Week for USMLE, Faustine Ramirez, MedSchoolCoach expert tutor, answers this medical school question: A 48-year-old woman presents to the emergency department with two days of worsening abdominal pain and decreased appetite. She woke up in the middle of the night last night with chills and has had two episodes of vomiting since then. She has a history of GERD and hypertension. She takes omeprazole occasionally and amlodipine daily. She drinks one glass of wine daily with dinner and denies illicit drug or tobacco use. Upon arrival she appears very uncomfortable. Temperature is 38.4 C, blood pressure is 128/74, heart rate is 106/min, and respiratory rate is 18/min. BMI is 33. Examination is notable for mild scleral icterus. The abdomen is soft and nondistended, with tenderness to palpation in the right upper quadrant, without rebound or guarding. Bowel sounds are normal. Laboratory studies reveal:
  • Hemoglobin – 13.2
  • Alkaline phosphatase – 462
  • AST – 65
  • Leukocyte count – 16,400
  • ALT – 73
  • Total bilirubin – 3.5
  • Creatinine – 1.2
  • Direct bilirubin – 2.8
Abdominal ultrasound reveals dilated biliary ducts and no fluid collections. IV fluids and piperacillin/tazobactam are initiated. What is the most appropriate next step?
  • Laparoscopic cholecystectomy
  • Change antibiotic regimen
  • Abdominal CT
  • HIDA scan
  • Transhepatic cholangiography
  • Endoscopic retrograde cholangiopancreatography
  • Exploratory laparotomy
Click to Reveal the Correct Answer

Endoscopic retrograde cholangiopancreatography

Faustine Ramirez

Faustine graduated from the University of Washington in Seattle with a B.A. in Medical Anthropology and Global Health. She attends medical school at University of California, San Francisco where she designed and taught a course on clinical reasoning skills, developed curriculum materials for the pre-clinical pediatrics course, and led case-based sessions in pediatrics and infectious disease. She received a 253 on Step 1 and a 266 on Step 2 CK, and she scored in the 90th percentiles on all of her shelf exams.

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