Ease Into Prep with a USMLE^® Step 2 CK Question of the Day

The correct answer is B. This patient's presentation is consistent with acute pancreatitis. Gallstone pancreatitis is high on the differential in a 42-year-old female. The differential diagnosis list for acute abdominal pain is extensive and requires a thorough investigation. While waiting for the laboratory results, the best next step is to start IV fluids. When the laboratory results return, the diagnosis may become more evident, and some form of imaging will likely be necessary to elucidate the diagnosis. With acute pancreatitis, aggressive hydration in the first 48 hours can prevent necrotizing pancreatitis. Secondarily, pain relief may be provided with IV opiates. The patient is kept NPO to avoid stimulating pancreatic enzyme release in an already inflamed pancreas.

Abdominal ultrasound (choice A) may demonstrate an enlarged pancreas or a gallstone in the bile duct, but bowel gas patterns often preclude an accurate assessment of the pancreas and bile ducts. Again, the first priority is hydration.

CT scan of the abdomen (choice C) provides the best accuracy for determining the severity of pancreatitis, but this exposure to radiation may not be necessary if the diagnosis is obvious (elevated lipase and amylase) and if she responds well to treatment.

Endoscopic retrograde cholangiopancreatography (ERCP) (choice D) is the most accurate test for assessing biliary and pancreatic ductal pathology. Recommendations for ERCP in a patient with acute pancreatitis vary widely, as this procedure can exacerbate pancreatitis and can also resolve it through removal of a gallstone. At this point, aggressive fluid hydration remains the best next step.

Administering morphine for pain (choice E) may be appropriate after IV fluids have been administered. Sometimes, hydration alone reduces pain and may lead to using lower doses of opiates.