First cover the right-hand side of the page (i.e., cover the answers). Then answer all the microvignettes on the left-hand side. Record the number answered correctly at the bottom of the page before reading the book (Pre-test) and then after finishing the book (Post-test). This will facilitate self-assessment of vignette subject knowledge and reveal what areas to restudy until the material is mastered.
Top 100 Clinical Surgical Microvignettes
Elderly woman, SBO, and air in biliary tract
Gallstone ileus
Elderly woman with pain down inner aspect of thigh
Obturator hernia (Howship–Romberg sign)
Abdominal pain, hypotension, and abdominal pulsatile mass
Ruptured abdominal aortic aneurysm (AAA)
Abdominal pain “out of proportion” to abdominal exam
Mesenteric ischemia
Arm pain and syncope with arm movement
Subclavian steal syndrome
Increasing creatinine on ACE inhibitor
Renal artery stenosis
Child with MIDLINE neck mass
Thyroglossal duct cyst
Child with LATERAL neck mass
Branchial cleft cyst
Crush injury and dark urine
Myoglobinuria
Emesis, chest pain radiating to back, and mediastinal air
Boerhaave's
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Lower GI bleed + technetium pertechnetate scan
Meckel's diverticulum
Flushing, diarrhea, and right-sided heart failure
Carcinoid
Pneumaturia and LLQ pain
ColoveSICUlar fistula
Desmoid tumor, osteoma, and colon cancer
Gardner's syndrome
Epigastric pain radiating to back and flank ecchymosis
Hemorrhagic pancreatitis
Pancreatitis and palpable epigastric mass
Pancreatic pseudocyst
Liver abscess with “anchovy paste”
Amebic abscess
RUQ pain, travel, and exposure to sheep
Hydatid cyst
Caput medusa
Portal hypertension
45-year-old woman with RUQ pain for 12 hours, fever, and leukocytosis
Acute cholecystitis
Elderly man with large nontender palpable gallbladder
Pancreatic cancer (Courvoisier's sign)
Female taking birth control pills with liver mass
Hepatic adenoma
Liver tumor with “central scar”
Focal nodular hyperplasia
Pancreatic mass, gallstones, diabetes, and diarrhea
Somatostatinoma
RUQ bruit and CHF in young adult
Liver hemangioma
Excruciating pain with bowel movement
Anal fissure
Abdominal pain, diarrhea, and anal fistulae
Crohn's disease
EKG with “peaked” T waves
Hyperkalemia
Buccal mucosa with pigmentation
Peutz–Jeghers syndrome
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LLQ pain, fever, and change in bowel habits
Diverticulitis
Elevated urine 5-HIAA
Carcinoid
Institutionalized, abdominal pain, vomiting, and distention, with proximal colonic dilation
Sigmoid volvulus
Infant with projectile vomiting
Pyloric stenosis
Newborn with failure to pass meconium in first 24 hours
Hirschsprung's
Infant with bilious vomiting
Malrotation
Newborn with abdominal defect and umbilical cord on sac
Omphalocele
Teenager with knee pain and “onion skinning” on x-ray
Ewing's sarcoma
Pulmonary capillary wedge pressure <18, CXR with bilateral pulmonary infiltrates, and PaO2:FiO2 ratio <300
Acute respiratory distress syndrome (ARDS)
Increased peak airway pressure, low urine output, and urinary bladder >25 mm Hg
Abdominal compartment syndrome
Newborn with inability to “pass an NGT”
Esophageal atresia
Traumatic blinding in one eye followed by blindness in the contralateral eye 2 weeks later
Sympathetic ophthalmia
Miotic pupil, ptosis, and anhydrosis
Horner's syndrome
Traumatic head injury, conscious in ER followed by unconsciousness
Epidural hematoma (“lucid interval”)
“Worst headache of my life”
Subarachnoid hemorrhage
Hematuria, flank pain, and abdominal mass (palpable)
Renal cell carcinoma
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60-year-old white man with painless hematuria
Bladder cancer
RUQ pain, jaundice, and fever
Cholangitis
Epigastric pain radiating to back, with nausea and vomiting
Pancreatitis
Chest pain radiating to back and described as a “tearing” pain
Aortic dissection
40-year-old man with tachycardia/hypertension and confusion on postoperative day #2
Alcohol withdrawal
Marfanoid body habitus and mucosal neuromas
MEN II-b
Psammoma bodies
Papillary thyroid cancer
Sulfur granules
Actinomyces infection
Thyroid tumor with AMYLOID tissue
Thyroid medullary cancer
PALPABLE neck tumor and hypercalcemia
Parathyroid cancer
Hypertension, diaphoresis (episodic), and palpitations
Pheochromocytoma
Jejunal ulcers
Zollinger–Ellison syndrome
Pituitary tumor, pancreatic tumor, and parathyroid tumor
MEN-I
Necrotizing migratory erythema
Glucagonoma
Medullary thyroid cancer, pheochromocytoma, and hyperparathyroidism
MEN-IIa
Hypokalemia refractory to IV potassium supplementation
Hypomagnesemia
Newborn with pneumatosis
Necrotizing enterocolitis (NEC)
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Child with abdominal mass that crosses midline
Neuroblastoma
Child <4 years of age with abdominal tumor that does NOT cross midline
Wilms' tumor
“Currant jelly” stools and abdominal colic
Intussusception
Femur fracture, respiratory failure, petechiae, and mental status changes
Fat embolism
Hearing loss, tinnitus, and vertigo
Ménière's disease
Adolescent boy with nasal obstruction and recurrent epistaxis
Juvenile nasopharyngeal angiofibroma
Child <5 years of age sitting upright and drooling, with “hot-potato” voice
Epiglottitis
Angina, syncope, and CHF
Aortic stenosis
Tobacco use, asbestos exposure, and pleuritic chest pain
Mesothelioma
Supracondylar fracture and contracture of forearm flexors
Volkmann's contracture
Tibia fracture, “pain out of proportion,” pain on passive foot movement, and palpable pulses
Compartment syndrome
25-year-old man with liver mass with fibrous septae and NO history of cirrhosis or hepatitis
Fibrolamellar hepatocellular carcinoma
EKG with flattening of T waves and U waves
Hypokalemia
Central pontine myelinolysis
Too-rapid correction of hyponatremia
Polydipsia, polyuria, and constipation
Hypercalcemia
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Factor VIII deficiency
Hemophilia A
Abdominal pain, fever, hypotension, HYPERkalemia, and HYPOnatremia
Adrenal insufficiency (addisonian crisis)
Massive urine output and HYPERnatremia
Diabetes insipidus
Increased urine osmolality, HYPOnatremia, and low serum osmolality
SIADH
IV antibiotics, fever, diarrhea
Clostridium difficile pseudomembranous colitis
Bleeding gums and wound dehiscence
Vitamin C deficiency
Fever, central line, and HYPERglycemia
Central line infection
Appendectomy followed by fever and abdominal pain on postoperative day #7
Peritoneal abscess
Advancing crepitus, fever, and blood blisters
Necrotizing fasciitis
High INTRAoperative fever
Malignant hyperthermia
Confusion, ataxia, and ophthalmoplegia
Wernicke's encephalopathy
Tracheal deviation, decreased breath sounds, and hyperresonance
Tension pneumothorax
Hypotension, decreased heart sounds, and JVD
Pericardial tamponade
Four ribs broken in two places and pulmonary contusion
Flail chest
Otorrhea (clear) and Battle's sign
Basilar skull fracture
Ulcer and decreased pain with food
Duodenal ulcer
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Vomiting, retching, and epigastric pain
Mallory–Weiss tear
Fever on postoperative day #1, with “bronze” weeping, tender wound
Clostridial wound infection
Hematochezia and tenesmus
Rectal cancer
Upper GI bleed, jaundice, and RUQ pain
Hemobilia
Gallstones, epigastric pain radiating to back, and nausea
Gallstone pancreatitis
18-year-old woman with bloody nipple discharge
Ductal papilloma
Irritability, diaphoresis, weakness, tremulousness, and palpitations
Insulinoma
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