Kaplan USMLE Step 3 prep: Abdominal pain drives these 4 stumpers

Over the years, the AMA has run dozens of example questions from Kaplan Medical. If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 3 exam, you might want to know which questions are most often missed by test-prep takers. We’ve compiled four cases from Kaplan Medical involving abdominal pain as a major symptom. Each question comes with an expert explanation of the answer. You can check out all posts in this series.

The AMA and Kaplan have teamed up to support you in reaching your goal of passing the USMLE® or COMLEX-USA®. If you're looking for additional resources, Kaplan provides free access to tools for pre-clinical studies, including Kaplan’s Lecture Notes series, Integrated Vignettes, Shelf Prep and more.

Think you can answer these questions involving abdominal pain? Find out now.

1. Woman with abdominal and pelvic pain

   1. A 27-year-old woman comes to the clinic because of abdominal and pelvic pain. She has experienced pain for two weeks each month for the past six years. She describes the pain as being most severe during each menstrual period; the pain is sometimes associated with nausea.
   2. She also tells you that she and her husband have been unable to conceive for the past two years. She has no significant past medical history. Her last menstrual period was eight days ago. General physical and pelvic examinations are normal. A hysterosalpingogram performed as an outpatient demonstrates a normal uterus with normal fallopian tubes and spillage into the peritoneum. Which is the best next step in management?

2. Which test for epigastric pain?

   1. A 36-year-old man comes to see you with recurrent epigastric pain after treatment for multiple duodenal ulcers, for which he was treated with a PPI, amoxicillin, and clarithromycin. Follow-up stool antigen showed no evidence of active Helicobacter pylori infection.
   2. Today’s endoscopy shows three ulcers in the third and fourth portions of the duodenum near the ligament of Treitz. The ulcers are 2 cm in size. Serum gastrin level is elevated, and it does not drop after the administration of IV secretin. Which would be the most appropriate test for this patient?

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3. Man with alcoholism has severe abdominal pain

   1. A 49-year-old man with alcoholism comes to the emergency department complaining of severe abdominal pain. He explains that the pain is rated 10/10 and spreads from the mid-abdomen through to the back. It is constant and dull and has not been relieved by the quart of vodka the patient drank earlier in the evening. Serum amylase and lipase levels are markedly elevated, and the patient is admitted to the medicine ward for treatment.
   2. Three hours later he becomes severely hypotensive and is transferred to the intensive care unit for further management. Over the next two days the patient receives a total of 8 liters of lactated Ringer's solution, two units of fresh-frozen plasma, and 2 grams of calcium, which leads to a stabilization of his blood pressure. On hospital day three, the patient appears stable, though he still has 4/10 abdominal pain. Physical examination reveals a right-sided pleural effusion, midabdominal tenderness, and abdominal distention. Which is the most appropriate plan for this patient's nutritional needs?

4. Severe right lower quadrant pain

   1. A 22-year-old college student comes to the emergency department with severe right lower quadrant pain. She says the pain started about six hours ago and has progressively worsened. She has no significant medical problems and her only medication is oral contraceptive pills. She is sexually active with one partner, her boyfriend. Her last menstrual period was two weeks ago.
   2. Vital signs are: temperature 37 °C (98.6 °F), blood pressure 120/70 mmHg, pulse 80 beats per minute. Abdominal examination is significant for focal tenderness in the right lower quadrant. Pelvic exam reveals exquisite tenderness in the right adnexa, a closed cervical os, and clear vaginal discharge. Which is the most likely etiology of this patient's symptoms?

For more prep questions on USMLE Steps 1, 2 and 3, view other posts in this series.