A 48-year-old man presents to the emergency department with an 8-hour history of severe, u… — USMLE Step 3

A 48-year-old man presents to the emergency department with an 8-hour history of severe, unremitting epigastric pain that radiates to his mid-back. He reports that the pain is exacerbated by lying supine and is partially relieved by leaning forward. He has had two episodes of non-bloody, non-bilious emesis since the pain began. His medical history is notable for hypertension treated with amlodipine. He does not use tobacco but drinks 3-4 alcoholic beverages daily. His temperature is $37.8^\circ\text{C}$ ( $100^\circ\text{F}$ ), blood pressure is $138/86\text{ mmHg}$ , pulse is $105/\text{min}$ , and respiratory rate is $18/\text{min}$ . Physical examination shows a distressed patient with marked epigastric tenderness to palpation, but no rebound tenderness or guarding. Bowel sounds are hypoactive. Which of the following diagnostic tests should be included in the initial diagnostic workup of this patient? (Select all that apply)

Serum lipase measurementCevap
Right upper quadrant abdominal ultrasoundCevap
C
Contrast-enhanced computed tomography of the abdomen
D
Endoscopic retrograde cholangiopancreatography
E
Esophagogastroduodenoscopy

Cevap

The most appropriate initial diagnostic tests for this patient are serum lipase measurement and a right upper quadrant abdominal ultrasound.

The patient's presentation is highly suspicious for acute pancreatitis. The diagnosis of acute pancreatitis is established by the presence of at least two of three criteria: 1) characteristic acute-onset epigastric pain radiating to the back, 2) serum lipase elevation at least three times the upper limit of normal, and 3) characteristic findings on cross-sectional imaging (CT or MRI). Therefore, measuring serum lipase is an essential, non-invasive first step to confirm the diagnosis. Furthermore, because gallstones are the most common cause of acute pancreatitis, a right upper quadrant abdominal ultrasound is universally recommended as part of the initial evaluation in all patients to assess for cholelithiasis or biliary duct dilation.

Adım Adım Çözüm

Analyze the patient's clinical presentation.

The patient has acute-onset, severe epigastric pain radiating to the back, exacerbated by lying flat, along with a history of alcohol use. This is the classic presentation of acute pancreatitis.

Identifying the primary differential diagnosis dictates the required diagnostic criteria.

Determine the diagnostic criteria for acute pancreatitis.

Diagnosis requires two of the three following criteria: characteristic abdominal pain, serum lipase elevation (at least 3 times the upper limit of normal), and characteristic findings on cross-sectional imaging.

Guidelines specify that laboratory evaluation is the primary initial adjunct to the clinical history.

Select the appropriate initial laboratory and imaging tests.

Serum lipase must be drawn to fulfill diagnostic criteria. Concurrently, right upper quadrant ultrasound must be ordered to evaluate for gallstones, which are the most common cause of acute pancreatitis worldwide.

Initial tests should be highly sensitive, cost-effective, and non-invasive before progressing to advanced imaging or invasive procedures.

Anahtar Kavram

The initial diagnostic workup for suspected acute pancreatitis requires measuring serum lipase to confirm the diagnosis and performing a right upper quadrant abdominal ultrasound to assess for a biliary etiology.

Soru

Cevap

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Anahtar Kavram

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