{"id":4185,"date":"2024-08-21T20:25:50","date_gmt":"2024-08-21T20:25:50","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=4185"},"modified":"2025-10-01T11:38:22","modified_gmt":"2025-10-01T19:38:22","slug":"usmle-step-2-question-of-the-day-leukocytosis","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leukocytosis","title":{"rendered":"USMLE\u00ae Step 2 Question of the Day: Leukocytosis"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leukocytosis\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leukocytosis\/#Incorrect_answer_explanations\" >Incorrect answer explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leukocytosis\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leukocytosis\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leukocytosis\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Prepare for the USMLE Step 2 with a case of a 45-year-old woman presenting with right upper quadrant pain, fever, and a history of biliary colic. Learn how to identify key physical exam findings, such as a positive Murphy&#8217;s sign, that suggest acute cholecystitis, a common complication of gallstones.<br><\/em><\/strong><br>A 45-year-old woman presents to the primary care clinic with three days of right upper quadrant abdominal pain and fever. The patient has previously had three to four episodes of right upper quadrant pain, occasionally with vomiting, that were worse after eating and resolved within two to three hours. Vital signs include temperature of 38.6 \u00baC (101.5 \u00baF), heart rate of 108\/min, blood pressure of 140\/75 mmHg, respiratory rate of 18\/min, and SpO2 of 100% on room air. The patient is sent to the emergency department for bloodwork and imaging. Bloodwork shows leukocytosis. Which of the following findings on physical exam would be most suggestive of the underlying diagnosis?&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A.&nbsp;Positive Murphy sign&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B.&nbsp;Tenderness at McBurney point<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;Positive Rovsing sign<br><\/strong><br><strong>D.&nbsp;Positive&nbsp;Courvoisier sign<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E.&nbsp;Epigastric tenderness to palpation<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Scroll down for the correct answer!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_CK_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 2 CK Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A.&nbsp;Positive Murphy sign&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the&nbsp;<strong>Main Explanation<\/strong>, let&#8217;s see why the answer wasn&#8217;t B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_answer_explanations\"><\/span>Incorrect answer explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Today&#8217;s incorrect answers are&#8230;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B.&nbsp;Tenderness at McBurney point<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>Tenderness at McBurney point, which is&nbsp;1.5 to 2 inches from the anterior superior iliac spine on a straight line to the umbilicus, is indicative of acute appendicitis not acute cholecystitis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.&nbsp;Positive Rovsing sign&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>The patient most likely has a cough secondary to bronchial irritation caused by bradykinin accumulation. The best step is to discontinue the causative medication. A chest x-ray is not indicated at this time.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D.&nbsp;Positive&nbsp;Courvoisier sign&nbsp;&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>A positive Courvoisier sign is a palpable gallbladder in the presence of jaundice. This is most suggestive of pancreatic or gallbladder malignancy, not acute cholecystitis.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Epigastric tenderness to palpation<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:&nbsp;<\/strong>Both epigastric and right upper quadrant tenderness can be seen on physical exam in acute cholecystitis. However epigastric tenderness can also be seen in other conditions such as pancreatitis and peptic ulcer disease.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient has a history of three to four episodes of&nbsp;biliary colic, usually described as intense right upper quadrant abdominal pain that is typically constant and caused by&nbsp;gallstones. The pain typically occurs when the biliary duct contracts on an impacted gallstone\u2013often set off by eating, especially fatty foods, with increased pressure within the gallbladder. Patients often report associated nausea and vomiting.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Acute cholecystitis&nbsp;presenting as fever, right upper quadrant pain, and leukocytosis can develop as a complication of gallstones from&nbsp;gallbladder inflammation. Physical examination will show right upper quadrant tenderness to palpation or epigastric tenderness. A positive&nbsp;Murphy sign&nbsp;is highly suggestive of&nbsp;acute cholecystitis. It is tested for&nbsp;by palpating the gallbladder during deep inspiration and is considered positive if the pain significantly worsens or if the patient stops inspiring because of the pain.&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" height=\"552\" width=\"1024\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/positive-murphy-sign.png?w=1024\" alt=\"Positive Murphy Sign\nIf pain interrupts inspiration, consider gall bladder inflammation or infection.\" class=\"wp-image-4187\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/positive-murphy-sign.png 1244w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/positive-murphy-sign.png?resize=300,162 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/positive-murphy-sign.png?resize=768,414 768w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/positive-murphy-sign.png?resize=1024,552 1024w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Abdominal ultrasound&nbsp;should be performed when acute cholecystitis is suspected. The gallbladder will appear distended and thickened with surrounding edema and gallstones may be seen.&nbsp;Acute cholecystitis can be definitively diagnosed in the right clinical setting with demonstration of&nbsp;gallbladder wall thickening or edema&nbsp;on imaging, a&nbsp;sonographic Murphy sign, or failure of the gallbladder to fill during cholescintigraphy.&nbsp;&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Patients with a prior history of biliary colic from gallstones who present with fever, right upper quadrant abdominal pain, and leukocytosis should be evaluated for acute cholecystitis. A positive Murphy sign on physical exam is highly suggestive of acute cholecystitis.&nbsp;&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Baiu I, Hawn MT. Gallstones and Biliary Colic. JAMA. 2018 Oct 16;320(15):1612. doi: 10.1001\/jama.2018.11868. PMID: 30326127.&nbsp;<\/li>\n\n\n\n<li>Kiewiet JJ, Leeuwenburgh MM, Bipat S, Bossuyt PM, Stoker J, Boermeester MA. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology. 2012 Sep;264(3):708-20. doi: 10.1148\/radiol.12111561. Epub 2012 Jul 12. PMID: 22798223.\u00a0<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/osmosis.org\/clinical-sciences\" target=\"_blank\" rel=\"noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/06\/Blog_Display_Ads_MD3_2023-1.png?w=700\" alt=\"\" class=\"wp-image-5201\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/06\/Blog_Display_Ads_MD3_2023-1.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/06\/Blog_Display_Ads_MD3_2023-1.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more \u00a0USMLE\u00ae Step 2 CK practice questions?\u00a0Try Osmosis by Elsevier today! Access your\u00a0<a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>\u00a0and find out why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Prepare for the USMLE Step 2 with a case of a 45-year-old woman presenting with right upper quadrant pain, fever, and a history of biliary colic. Learn how to identify key physical exam findings, such as a positive Murphy&#8217;s sign, that suggest acute cholecystitis, a common complication of gallstones.A 45-year-old woman presents to the primary [&hellip;]<\/p>\n","protected":false},"author":202,"featured_media":4186,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,16,1370,45],"tags":[],"class_list":["post-4185","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-do","category-step-2-questions","category-step-2"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 2 Question of the Day: Leukocytosis - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-question-of-the-day-leukocytosis\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 2 Question of the Day: Leukocytosis - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"Prepare for the USMLE Step 2 with a case of a 45-year-old woman presenting with right upper quadrant pain, fever, and a history of biliary colic. 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