A 49-year-old female is evaluated in the emergency department for a sudden onset of severe… — USMLE Step 2 CK

A 49-year-old female is evaluated in the emergency department for a sudden onset of severe upper abdominal pain that shoots directly into her back. The pain began approximately 5 hours ago, shortly after she consumed a heavy meal, and has been accompanied by two episodes of non-bilious vomiting. Her past medical history is notable for well-controlled type 2 diabetes mellitus and primary hypothyroidism, managed with daily metformin and levothyroxine.

Vital signs show a temperature of $37.2^\circ\text{C}$ ( $99.0^\circ\text{F}$ ), pulse of $108/\text{min}$ , blood pressure of $130/80\text{ mm Hg}$ , and respiratory rate of $16/\text{min}$ . Physical examination is significant for pronounced epigastric tenderness to palpation, with no guarding, rigidity, or rebound tenderness.

Laboratory evaluation reveals the following:

Laboratory Test	Result	Reference Range
Leukocyte count	$12,000/\text{mm}^3$	$4,000-11,000/\text{mm}^3$
Serum lipase	$4,100\text{ U/L}$	$10-140\text{ U/L}$
Thyroid-stimulating hormone	$2.8\text{ }\mu\text{U/mL}$	$0.4-4.0\text{ }\mu\text{U/mL}$
Free T4	$1.4\text{ ng/dL}$	$0.9-2.3\text{ ng/dL}$
Arterial pH	$7.41$	$7.35-7.45$
Arterial pCO₂	$40\text{ mm Hg}$	$35-45\text{ mm Hg}$
Arterial HCO₃⁻	$24\text{ mEq/L}$	$22-28\text{ mEq/L}$

A right upper quadrant abdominal ultrasound reveals gallstones within the gallbladder but a normal-caliber common bile duct without any pericholecystic fluid.

Which of the following is the most appropriate next step in the management of this patient?

A
Administration of intravenous piperacillin-tazobactam
B
Administration of intravenous levothyroxine
Initiation of aggressive intravenous fluid resuscitationAnswer
D
Surgical consultation for an immediate exploratory laparotomy
E
Administration of intravenous sodium bicarbonate

Answer

Initiation of aggressive intravenous fluid resuscitation is the correct next step in management.

This patient's presentation of severe epigastric pain radiating to the back and a serum lipase level greater than three times the upper limit of normal confirms the diagnosis of acute pancreatitis. The ultrasound indicates a gallstone etiology, which is the most common cause. The cornerstone of initial management for acute pancreatitis is aggressive intravenous fluid resuscitation (e.g., lactated Ringer solution) to counteract significant third-spacing and prevent pancreatic necrosis caused by hypoperfusion. Analgesia and bowel rest are also critical components of early supportive care.

Step-by-Step Solution

Evaluate the clinical presentation and laboratory results.

The patient has severe epigastric pain radiating to the back and a significantly elevated serum lipase level (>3 times the upper limit of normal).

To establish the primary diagnosis of acute pancreatitis.

Assess for signs of infection, surgical emergency, or complicated disease.

Vital signs show mild tachycardia but no fever; ultrasound shows gallstones without bile duct dilation or cholangitis, and the abdomen lacks rigidity or rebound.

To rule out the need for urgent procedural intervention or antibiotics.

Determine the most appropriate initial management for uncomplicated acute pancreatitis.

Aggressive intravenous fluid resuscitation.

Acute pancreatitis causes significant third-spacing of fluids and intravascular volume depletion, making early hydration the most critical initial therapy.

Key Concept

The initial management of acute uncomplicated pancreatitis focuses on supportive care, primarily aggressive intravenous fluid resuscitation.

Estimated Time:1m 0s

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