WBR0561

Author	[[PageAuthor::Hardik Patel, M.D.]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Cardiovascular, SubCategory::Gastrointestinal, SubCategory::Hepatology
Prompt	[[Prompt::A 40-year-old man presents to the ER with abdominal pain in the right upper quadrant for the past 3 days. It is sharp pain of moderate severity that makes it difficult to breathe. He also reports frequent nausea, belching, and generalized malaise. He has been "partying" all weekend despite the pain. He has a past medical history of type II diabetes mellitus for which he takes metformin. He admits to being non-compliant with his medication. His social history is positive for smoking and alcohol and he is an ex-cocaine abuser. On physical examination, his temperature is 98.4°F, HR is 90/minute, BP is 148/92 mm Hg, and RR is 18/minute. His cardiovascular and respiratory exams are normal. Abdominal examination shows tenderness in the right upper quadrant area. What should be the most appropriate next step in the management of this patient after taking his blood and urine for analysis?]]
Answer A	AnswerA::Discharge the patient
Answer A Explanation	AnswerAExp::'''Incorrect:''' The patient should not be discharged without diagnosis and treatment of his pain.
Answer B	AnswerB::Helicobacter pylori titer
Answer B Explanation	[[AnswerBExp::Incorrect: An H. pylori titer may be useful for the long-term management of peptic ulcer disease or gastritis, which would not be the next step in management.]]
Answer C	AnswerC::Abdominal ultrasound
Answer C Explanation	[[AnswerCExp::Incorrect: The likelihood of there being pancreatitis, gallstones, urolithiasis, nephrolithiasis, or appendicitis is low compared to the more fatal ACS.]]
Answer D	AnswerD::Electrocardiogram
Answer D Explanation	AnswerDExp::'''Correct:''' See explanation.
Answer E	AnswerE::Hemoglobin A1c
Answer E Explanation	[[AnswerEExp::Incorrect: Hemoglobin A1c (glycosylated hemoglobin) is a useful parameter for monitoring long-term compliance to diabetic management.]]
Right Answer	RightAnswer::D
Explanation	[[Explanation::The patient is a male, a smoker, and a diabetic which consists of 3 definite coronary artery disease risk factors. He admits to cocaine abuse in the past and “partying” all weekend. He is also complaining of upper abdominal pain. The presence of diabetes is particularly important because it would mask the typical symptoms of acute coronary syndrome. An electrocardiogram should be done in order to rule out any cardiac contribution to his symptoms, as a myocardial infarction is more likely to be fatal than other problems. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Acute coronary syndrome
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::