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A 55-Year-Old Man Is Brought to the Emergency Department with Severe

Question 372

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A 55-year-old man is brought to the emergency department with severe abdominal pain and vomiting for the last 24 hours.  The patient's abdominal pain began abruptly, and he describes it as a stabbing sensation radiating to his back.  He then developed malaise, chills, nausea, and several episodes of vomiting.  The patient's medical history includes hypertension, hyperlipidemia, and gout.  Medications include chlorthalidone, atorvastatin, and allopurinol.  Family history is unremarkable.  The patient occasionally uses alcohol and has smoked a half a pack of cigarettes a day for 20 years.  He does not use illicit drugs.  Temperature is 39.4 C (102.9 F) , blood pressure is 105/58 mm Hg, pulse is 110/min, and respirations are 18/min.  BMI is 27 kg/m2.  Physical examination shows a middle-age man in moderate distress.  The patient has scleral icterus, normal jugular venous pressure, clear lung fields, and distinct S1 and S2.  The abdomen is soft and tender to palpation over the midepigastrium and right upper quadrant.  There is no rebound tenderness, rigidity, hepatomegaly, or splenomegaly.  The remainder of the examination is normal.  Laboratory test results are as follows: A 55-year-old man is brought to the emergency department with severe abdominal pain and vomiting for the last 24 hours.  The patient's abdominal pain began abruptly, and he describes it as a stabbing sensation radiating to his back.  He then developed malaise, chills, nausea, and several episodes of vomiting.  The patient's medical history includes hypertension, hyperlipidemia, and gout.  Medications include chlorthalidone, atorvastatin, and allopurinol.  Family history is unremarkable.  The patient occasionally uses alcohol and has smoked a half a pack of cigarettes a day for 20 years.  He does not use illicit drugs.  Temperature is 39.4 C (102.9 F) , blood pressure is 105/58 mm Hg, pulse is 110/min, and respirations are 18/min.  BMI is 27 kg/m<sup>2</sup>.  Physical examination shows a middle-age man in moderate distress.  The patient has scleral icterus, normal jugular venous pressure, clear lung fields, and distinct S1 and S2.  The abdomen is soft and tender to palpation over the midepigastrium and right upper quadrant.  There is no rebound tenderness, rigidity, hepatomegaly, or splenomegaly.  The remainder of the examination is normal.  Laboratory test results are as follows:   Abdominal ultrasound demonstrates multiple small gallbladder stones and common bile duct dilation.  No stones are visualized in the biliary tree.  The pancreas is not well visualized due to gastric shadow.  Blood cultures are drawn.  The patient is admitted and treated with intravenous fluids and antibiotics.  Which of the following is the most appropriate next step in management of this patient? A) CT scan of the abdomen without contrast B) Endoscopic retrograde cholangiopancreatography C) Hepatobiliary scintigraphy D) Laparoscopic cholecystectomy E) Percutaneous cholecystostomy Abdominal ultrasound demonstrates multiple small gallbladder stones and common bile duct dilation.  No stones are visualized in the biliary tree.  The pancreas is not well visualized due to gastric shadow.  Blood cultures are drawn.  The patient is admitted and treated with intravenous fluids and antibiotics.  Which of the following is the most appropriate next step in management of this patient?


A) CT scan of the abdomen without contrast
B) Endoscopic retrograde cholangiopancreatography
C) Hepatobiliary scintigraphy
D) Laparoscopic cholecystectomy
E) Percutaneous cholecystostomy

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