If you’re preparing for the United States Medical Licensing Examination®️ (USMLE®️) Step 2 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series

Prep smart for the USMLE

Test your knowledge and get expert insights from Kaplan on commonly missed questions on USMLE examinations.

This month’s stumper

A 22-year-old African immigrant presents to the hospital with acute abdominal pain. The pain is worst in the left upper quadrant and is described as sharp. She has had this pain for the past several days. She has noticed these episodes frequently in the past but has chosen to ignore them until now. She has not seen a physician in many years, and her past medical history is unknown. She is not taking any medications. On physical examination, vital signs are: temperature 98°F (36.7°C), heart rate 102/min, BP 120/72 mm Hg, RR 18/min. Head and neck examination shows pale mucosa. Chest is clear to auscultation. Heart is tachycardic to auscultation, and a loud systolic murmur is heard throughout the precordium. Pain is elicited upon palpation of the left upper quadrant.

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Laboratory data are:

  • WBC: 5,700/mm3
  • Hct: 25 percent
  • Hb: 8 g/dL
  • Platelets: 250.000/mm3
  • Creatinine: 1.1 mg/dL
  • Total bilirubin: 4.9 mg/dL
  • Conjugated bilirubin: 1.0 mg/dL

Chest radiography demonstrates no consolidation; however, the vertebrae are noted to be H-shaped. An ultrasound of her abdomen is performed, demonstrating a shrunken spleen and several gallstones without evidence of cholecystitis. Which of the following is the most likely composition of these gallstones?

A.  Black pigment

B.  Brown pigment

C.  Calcium oxalate

D.  Cholesterol

E.  Uric acid



The correct answer is A.

Kaplan medical says why 

The correct answer is A. This patient has sickle-cell anemia and is having an acute pain crisis. The clues in the vignette are the H-shaped vertebrae (caused by bone infarctions), the shrunken spleen, and the unconjugated hyperbilirubinemia. Gallstone disease is common in patients with sickle-cell anemia, and the type of stones is black pigment stones composed of calcium bilirubinate. This is a consequence of excessive hemoglobin breakdown and incorporation into the bile. Precipitation of the breakdown pigments with calcium leads to black pigment stone formation. Most sickle-cell patients are asymptomatic, and while cholecystectomy can be considered, these patients are at increased risk for postoperative complications.

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Why you shouldn’t choose the other answers

Read these explanations to understand the important rationale for each answer to help you prepare with studying.

Choice B: Brown pigment stones are caused by chronic infection, often parasitic, of the biliary tree. These stones are composed of calcium salts of unconjugated bilirubin with small amounts of cholesterol and protein.

Choices C and E: Calcium oxalate and uric acid stones are most often associated with nephrolithiasis, not cholelithiasis.

Choice D: Cholesterol stones are the most common type of gallstones, accounting for approximately 80-85 percent of all gallstones. Women and obese individuals are predisposed to cholesterol gallstone formation.

One key tip to remember

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

The AMA selected Kaplan as a preferred provider to support you in reaching your goal of passing the USMLE®️ or COMLEX-USA®️. AMA members can save 30% on access to additional study resources, such as Kaplan’s Qbank and High-yield courses. Learn more.

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