Anatomy clinical correlates Quiz: Ace Your Exams

A 45-year-old woman comes to the emergency department because of abdominal pain and confusion for the past 24 hours. The pain is stabbing in character, worse in the upper abdomen, and is associated with nausea and non-bloody vomiting. Past medical history is significant for type 2 diabetes mellitus. Current medications include metformin and atorvastatin. Family history is noncontributory. Temperature is 38.9°C (102°F), pulse is 110/min, respirations are 20/min, and blood pressure is 85/55 mmHg. Physical examination shows that the patient is oriented to the person but not to time and place. Mucous membranes are dry and capillary refill is delayed. Skin and sclera are icteric. Abdominal examination shows marked tenderness in the right upper quadrant and epigastric region without rebound tenderness or guarding. Laboratory results are shown below. Ultrasound of the abdomen is suggestive of an impacted gallstone. Which of the following is the most likely location of gallstone impaction due to this patient’s symptoms?  

Laboratory features
Laboratory value	Result
Hemoglobin	14.5 g/dL
Leukocyte count	150,000/mm3
Platelet count	230,000 mm3
Serum electrolytes
Sodium	137 mEq/L
Potassium	4.5 mEq/L
Chloride	106 mEq/L
Bicarbonate	17 mEq/L
Bilirubin
Total	2.8 mg/dL
Direct	2.2 mg/dL
Alanine aminotransferase (ALT, GPT	65 U/L
Aspartate aminotransferase (AST, GOT	30 U/L
Lipase	65 U/L