A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

A 46-year-old man is brought to the emergency department because of severe epigastric pain and vomiting for the past 4 hours. The pain is constant, radiates to his back, and is worse on lying down. He has had 3–4 episodes of greenish-colored vomit. He was treated for H. pylori infection around 2 months ago with triple-regimen therapy. He has atrial fibrillation and hypertension. He owns a distillery on the outskirts of a town. The patient drinks 4–5 alcoholic beverages daily. Current medications include dabigatran and metoprolol. He appears uncomfortable. His temperature is 37.8°C (100°F), pulse is 102/min, and blood pressure is 138/86 mm Hg. Examination shows severe epigastric tenderness to palpation with guarding but no rebound. Bowel sounds are hypoactive. Rectal examination shows no abnormalities. Laboratory studies show: Hematocrit 53% Leukocyte count 11,300/mm3 Serum Na+ 133 mEq/L Cl- 98 mEq/L K+ 3.1 mEq/L Calcium 7.8 mg/dL Urea nitrogen 43 mg/dL Glucose 271 mg/dL Creatinine 2.0 mg/dL Total bilirubin 0.7 mg/dL Alkaline phosphatase 61 U/L AST 19 U/L ALT 17 U/L γ-glutamyl transferase (GGT) 88 u/L (N=5–50 U/L) Lipase 900 U/L (N=14–280 U/L) Which of the following is the most appropriate next step in management?

Endoscopic retrograde cholangio-pancreatography

A 72-year-old woman comes to the emergency department because of upper abdominal pain and nausea for the past hour. The patient rates the pain as an 8 to 9 on a 10-point scale. She has had an episode of nonbloody vomiting since the pain started. She has a history of type 2 diabetes mellitus, hypertension, and osteoporosis. The patient has smoked 2 packs of cigarettes daily for 40 years. She drinks 5–6 alcoholic beverages daily. Current medications include glyburide, lisinopril, and oral vitamin D supplements. Her temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 138/86 mm Hg. Examination shows severe epigastric tenderness to palpation with guarding but no rebound. Ultrasonography of the abdomen shows diffuse enlargement of the pancreas; no gallstones are visualized. The patient is admitted to the hospital for pain control and intravenous hydration. Which of the following is the most appropriate next step in the management of this patient’s pain?

Patient-controlled intravenous hydromorphone

Transdermal fentanyl every 72 hours

Oral acetaminophen every 6 hours

Transdermal bupivacaine on request

A 21-year-old college student comes to the emergency department because of a two-day history of vomiting and epigastric pain that radiates to the back. He has a history of atopic dermatitis and Hashimoto thyroiditis. His only medication is levothyroxine. He has not received any routine vaccinations. He drinks 1–2 beers on the weekends and occasionally smokes marijuana. The patient appears distressed and is diaphoretic. His temperature is 37.9°C (100.3°F), pulse is 105/min, respirations are 16/min, and blood pressure is 130/78 mm Hg. Physical examination shows abdominal distention with tenderness to palpation in the epigastrium. There is no guarding or rebound tenderness. Skin examination shows several clusters of yellow plaques over the trunk and extensor surfaces of the extremities. Hemoglobin concentration is 15.2 g/dL and serum calcium concentration is 7.9 mg/dL. Which of the following is the most appropriate next step in evaluation?

Obtain an upright x-ray of the abdomen

Perform a pilocarpine-induced sweat test

Severity assessment in acute pancreatitis for USMLE Step 2 CK: High-Yield Internal Medicine Lessons

Initial Assessment - Gauging the Gut Punch

Immediate Triage: First, assess for Systemic Inflammatory Response Syndrome (SIRS) and organ failure (e.g., shock, respiratory distress). Their presence mandates ICU-level care.
Bedside Scoring - BISAP: Quick and reliable for early risk stratification. 📌 B-I-S-A-P
- BUN >25 mg/dL
- Impaired mental status (GCS <15)
- SIRS criteria met
- Age >60 years
- Pleural effusion on imaging

⭐ A BUN >25 mg/dL is a key BISAP component and a strong independent predictor of mortality.

Prognostic Scores - Rating the Rampage

SIRS Criteria (Systemic Inflammatory Response Syndrome): Presence of ≥2 criteria suggests severe disease course. Used in multiple scores.
- Temp <36°C or >38°C
- HR >90
- RR >20 or PaCO₂ <32
- WBC <4k or >12k
BISAP Score: Quick assessment at bedside within 24h. Score ≥3 indicates high risk.
- BUN >25 mg/dL
- Impaired mental status
- SIRS present
- Age >60
- Pleural effusion
Other Scores:
- Ranson's Criteria: Classic but cumbersome (requires 48h).
- APACHE II: Gold standard in ICU; too complex for initial assessment.

⭐ A BUN level >20-25 mg/dL on admission is one of the strongest independent predictors of mortality in acute pancreatitis.

Imaging & Biomarkers - Scans and Signals

Imaging Modalities:
- Abdominal Ultrasound: Best initial test to detect gallstones or biliary duct dilation.
- Contrast-Enhanced CT (CECT):
  - Timing: Optimal after 48-72 hours for assessing complications, not for initial diagnosis.
  - Role: Identifies pancreatic necrosis (lack of enhancement), fluid collections, and is used for the Balthazar score.
- MRCP: Excellent non-invasive tool for visualizing the biliary and pancreatic ducts if a stone is suspected.
Key Lab Markers:
- C-Reactive Protein (CRP): A level >150 mg/L at 48 hours is a marker for severe pancreatitis.
- Blood Urea Nitrogen (BUN): An increase in the first 24 hours signifies significant fluid sequestration.
- Procalcitonin: Elevated levels strongly suggest infected necrosis.

⭐ A rising BUN is one of the most important single predictors of mortality in acute pancreatitis.

Ranson criteria are assessed at admission and again at 48 hours; a score ≥3 suggests severe pancreatitis.

The APACHE II score is complex but can be used anytime to assess severity.

Persistent SIRS (≥2 criteria) for >48 hours is a strong predictor of mortality.

A rising BUN (e.g., >20-25 mg/dL) is a key single-marker predictor of severe disease.

Hemoconcentration (Hct >44%) indicates significant fluid sequestration and risk of necrosis.

CRP >150 mg/L at 48 hours correlates with pancreatic necrosis.

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