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NBME 23 Answers

nbme23/Block 2/Question#48

A 45-year-old woman is brought to the emergency ...

Inspiratory pause on right upper quadrant palpation

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submitted by joonam(12),

Acute or chronic inflammation of gallbladder. Murphy sign: inspiratory arrest on RUQ palpation due to pain. Pain may radiate to right shoulder (due to irritation of phrenic nerve).􏰁ALP if bile duct becomes involved (eg, ascending cholangitis).

meningitis  To make sure, palpable Gallbladder is more in cholangiocarcinoma and Pancreatic Cancer? And if it were non-tender, could palpable gallbladder mean gallstones? +2  
yb_26  @meningitis, it is a Courvoisier sign of pancreatic adenocarcinoma: jaundice + palpable, nontender gallbladder +2  

 +0  upvote downvote
submitted by jboud86(6),

FA 2019 page 390. This patient is expressing symptoms of biliary colic due to neurohormonal activation by CCK after a fatty meal. The labs will be normal and ultrasound will show cholelithiasis. However, I think this can be confused with acalculous because it also presents with inspiratory arrest on RUQ palpation due to pain. Acalculous cholecystitis is seen in critically ill patients.

 -1  upvote downvote
submitted by thotcandy(14),

Ugh, I saw Low BP and thought gallstone pancreatitis w/ hemorrhage so I picked ecchymoses/Cullen's sign.