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: |
| Approved | Approved::Yes |
| Keyword | WBRKeyword::Acute coronary syndrome |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |