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Free notes, MCQs, tables & flowcharts for USMLE Step 3 Surgery
A 43-year-old Caucasian woman is admitted to the hospital with acute onset right upper quadrant (RUQ) pain. The pain started 6 hours ago after the patient had a large meal at a birthday party and has progressively worsened. She recalls having similar pain before but not so intense. No significant past medical history. Current medications are only oral contraceptive. Vitals are blood pressure 140/80 mm Hg, heart rate 79/min, respiratory rate 14/min, and temperature 37.6℃ (99.7℉). The patient’s BMI is 36.3 kg/m2. On exam, the patient appears slightly jaundiced. Her cardiac and respiratory examinations are within normal limits. Abdominal palpation reveals tenderness to palpation in the RUQ with no rebound or guarding, and there is an inspiratory arrest on deep palpation in this region. The remainder of the examination is within normal limits. Laboratory tests are significant for the following: RBC count 4.1 million/mm3 Hb 13.4 mg/dL Leukocyte count 11,200/mm3 ESR 22 mm/hr Platelet count 230,000/mm3 Total bilirubin 2 mg/dL Direct bilirubin 1.1 mg/dL ALT 20 IU/L AST 18 IU/L Amylase 33 IU/L Ultrasound of the abdomen shows the following result (see image): The common bile duct (CBD) (not shown in the image) is not dilated. Which of the following procedures is most appropriate for the treatment of this patient?
AShock wave lithotripsy
BLaparoscopic cholecystectomy
CEndoscopic retrograde cholangiopancreatography
DPercutaneous cholecystostomy
A 34-year-old patient presents with severe pain in the right upper quadrant that radiates to the right shoulder. During laparoscopic cholecystectomy, which of the following anatomical spaces must be carefully identified to prevent bile duct injury?
AForamen of Winslow
BLesser sac
CCalot's triangle
DMorrison's pouch
A 63-year-old woman is brought to the emergency department because of severe abdominal pain and vomiting for 3 hours. She had previous episodes of abdominal pain that lasted for 10–15 minutes and resolved with antacids. She lives with her daughter and grandchildren. She divorced her husband last year. She is alert and oriented. Her temperature is 37.3°C (99.1°F), pulse is 134/min, and blood pressure is 90/70 mm Hg. The abdomen is rigid and diffusely tender. Guarding and rebound tenderness are present. Rectal examination shows a collapsed rectum. Infusion of 0.9% saline is begun and a CT of the abdomen shows intestinal perforation. The surgeon discusses the need for emergent exploratory laparotomy with the patient and she agrees to it. Written informed consent is obtained. While in the holding area awaiting emergent transport to the operating room, she calls for the surgeon and informs him that she no longer wants the surgery. He explains the risks of not performing the surgery to her and she indicates she understands but is adamant about not proceeding with surgery. Which of the following is the most appropriate next step in management?
AConsult hospital ethics committee
BObtain consent from the patient's daughter
CObtain consent from the patient's ex-husband
DContinue with emergency life-saving surgery
ECancel the surgery
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