How to use this chapter
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
| 1. | Elderly female, SBO, and air in biliary tract | Gallstone ileus | | 2. | Elderly female with pain down inner aspect of thigh | Obturator hernia (Howship–Romberg sign) | | 3. | Abdominal pain, hypotension, and abdominal pulsatile mass | Ruptured abdominal aortic aneurysm (AAA) | | 4. | Abdominal pain “out of proportion” to abdominal exam | Mesenteric ischemia | | 5. | Arm pain and syncope with arm movement | Subclavian steal syndrome | | 6. | Increasing creatinine on ACE inhibitor | Renal artery stenosis | | 7. | Child with MIDLINE neck mass | Thyroglossal duct cyst | | 8. | Child with LATERAL neck mass | Branchial cleft cyst | | 9. | Crush injury and dark urine | Myoglobinuria | | 10. | Emesis, chest pain radiating to back, and mediastinal air | Boerhaave's |
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SCORE YOUR ANSWERS: Pre- and Post-Book Self-Assessment of Surgical Knowledge
Pre-test: ____/10
Cumulative: Pre-test: ____/10
Post-test: _____/10
Cumulative: Post-test: _____/10
| 11. | Lower GI bleed + technetium pertechnetate scan | Meckel's diverticulum | | 12. | Flushing, diarrhea, and right-sided heart failure | Carcinoid | | 13. | Pneumaturia and LLQ pain | Colovesical fistula | | 14. | Desmoid tumor, osteoma, and colon cancer | Gardner's syndrome | | 15. | Epigastric pain radiating to back and flank ecchymosis | Hemorrhagic pancreatitis | | 16. | Pancreatitis and palpable epigastric mass | Pancreatic pseudocyst | | 17. | Liver abscess with “anchovy paste” | Amebic abscess | | 18. | RUQ pain, travel, and exposure to sheep | Hydatid cyst | | 19. | Caput medusae | Portal hypertension | | 20. | 45-year-old female with RUQ pain for 12 hours, fever, and leukocytosis | Acute cholecystitis | | 21. | Elderly male with large nontender palpable gallbladder | Pancreatic cancer (Courvoisier's sign) | | 22. | Female taking birth control pills with liver mass | Hepatic adenoma | | 23. | Liver tumor with “central scar” | Focal nodular hyperplasia | | 24. | Pancreatic mass, gallstones, diabetes, and diarrhea | Somatostatinoma | | 25. | RUQ bruit and CHF in young adult | Liver hemangioma | | 26. | Excruciating pain with bowel movement | Anal fissure | | 27. | Abdominal pain, diarrhea, and anal fistulae | Crohn's disease | | 28. | EKG with “peaked” T waves | Hyperkalemia | | 29. | Buccal mucosa with pigmentation | Peutz–Jeghers syndrome |
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SCORE YOUR ANSWERS: Pre- and Post-Book Self-Assessment of Surgical Knowledge
Pre-test: ____/19
Cumulative: Pre-test: ____/29
Post-test: _____/19
Cumulative: Post-test: _____/29
| 30. | LLQ pain, fever, and change in bowel habits | Diverticulitis | | 31. | Elevated urine 5-HIAA | Carcinoid | | 32. | Institutionalized, abdominal pain, vomiting, and distention, with proximal colonic dilation | Sigmoid volvulus | | 33. | Infant with projectile vomiting | Pyloric stenosis | | 34. | Newborn with failure to pass meconium in first 24 hours | Hirschsprung's disease | | 35. | Infant with bilious vomiting | Malrotation | | 36. | Newborn with abdominal defect and umbilical cord on sac | Omphalocele | | 37. | Teenager with knee pain and “onion skinning” on x-ray | Ewing's sarcoma | | 38. | Pulmonary capillary wedge pressure <18, CXR with bilateral pulmonary infiltrates, and PaO2:FiO2 ratio <300 | Acute respiratory distress syndrome (ARDS) | | 39. | Increased peak airway pressure, low urine output, and urinary bladder >25 mm Hg | Abdominal compartment syndrome | | 40. | Newborn with inability to “pass an NGT” | Esophageal atresia | | 41. | Traumatic blinding in one eye followed by blindness in the contralateral eye 2 weeks later | Sympathetic ophthalmia | | 42. | Miotic pupil, ptosis, and anhidrosis | Horner's syndrome | | 43. | Traumatic head injury, conscious in ER followed by unconsciousness | Epidural hematoma (“lucid interval”) | | 44. | “Worst headache of my life” | Subarachnoid hemorrhage | | 45. | Hematuria, flank pain, and abdominal mass (palpable) | Renal cell carcinoma |
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SCORE YOUR ANSWERS: Pre- and Post-Book Self-Assessment of Surgical Knowledge
Pre-test: ____/16
Cumulative: Pre-test: ____/45
Post-test: _____/16
Cumulative: Post-test: _____/45
| 46. | 60-year-old white male with painless hematuria | Bladder cancer | | 47. | RUQ pain, jaundice, and fever | Cholangitis | | 48. | Epigastric pain radiating to back, with nausea and vomiting | Pancreatitis | | 49. | Chest pain radiating to back and described as a “tearing” pain | Aortic dissection | | 50. | 40-year-old male with tachycardia/hypertension and confusion on postoperative day #2 | Alcohol withdrawal | | 51. | Marfanoid body habitus and mucosal neuromas | MEN II-b | | 52. | Psammoma bodies | Papillary thyroid cancer | | 53. | Sulfur granules | Actinomyces infection | | 54. | Thyroid tumor with AMYLOID tissue | Thyroid medullary cancer | | 55. | PALPABLE neck tumor and hypercalcemia | Parathyroid cancer | | 56. | Hypertension, diaphoresis (episodic), and palpitations | Pheochromocytoma | | 57. | Jejunal ulcers | Zollinger–Ellison syndrome | | 58. | Pituitary tumor, pancreatic tumor, and parathyroid tumor | MEN-I | | 59. | Necrotizing migratory erythema | Glucagonoma | | 60. | Medullary thyroid cancer, pheochromocytoma, and hyperparathyroidism | MEN-IIa | | 61. | Hypokalemia refractory to IV potassium supplementation | Hypomagnesemia | | 62. | Newborn with pneumatosis | Necrotizing enterocolitis (NEC) |
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SCORE YOUR ANSWERS: Pre- and Post-Book Self-Assessment of Surgical Knowledge
Pre-test: ____/17
Cumulative: Pre-test: ____/62
Post-test: _____/17
Cumulative: Post-test: _____/62
| 63. | Child with abdominal mass that crosses midline | Neuroblastoma | | 64. | Child <4 years with abdominal tumor that does NOT cross midline | Wilms' tumor | | 65. | “Currant jelly” stools and abdominal colic | Intussusception | | 66. | Femur fracture, respiratory failure, petechiae, and mental status changes | Fat embolism | | 67. | Hearing loss, tinnitus, and vertigo | Ménière's disease | | 68. | Adolescent boy with nasal obstruction and recurrent epistaxis | Juvenile nasopharyngeal angiofibroma | | 69. | Child <5 years sitting upright and drooling, with “hot-potato” voice | Epiglottitis | | 70. | Angina, syncope, and CHF | Aortic stenosis | | 71. | Tobacco use, asbestos exposure, and pleuritic chest pain | Mesothelioma | | 72. | Supracondylar fracture and contracture of forearm flexors | Volkmann's contracture | | 73. | Tibia fracture, “pain out of proportion,” pain on passive foot movement, and palpable pulses | Compartment syndrome | | 74. | 25-year-old male with liver mass with fibrous septae and NO history of cirrhosis or hepatitis | Fibrolamellar hepatocellular carcinoma | | 75. | EKG with flattening of T waves and U waves | Hypokalemia | | 76. | Central pontine myelinolysis | Too-rapid correction of hyponatremia | | 77. | Polydipsia, polyuria, and constipation | Hypercalcemia |
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SCORE YOUR ANSWERS: Pre- and Post-Book Self-Assessment of Surgical Knowledge
Pre-test: ____/15
Cumulative: Pre-test: ____/77
Post-test: _____/15
Cumulative: Post-test: _____/77
| 78. | Factor VIII deficiency | Hemophilia A | | 79. | Abdominal pain, fever, hypotension, HYPERkalemia, and HYPOnatremia | Adrenal insufficiency (addisonian crisis) | | 80. | Massive urine output and HYPERnatremia | Diabetes insipidus | | 81. | Increased urine osmolality, HYPOnatremia, and low serum osmolality | SIADH | | 82. | IV antibiotics, fever, diarrhea | Clostridium difficile pseudomembranous colitis | | 83. | Bleeding gums and wound dehiscence | Vitamin C deficiency | | 84. | Fever, central line, and HYPERglycemia | Central line infection | | 85. | Appendectomy followed by fever and abdominal pain on postoperative day #7 | Peritoneal abscess | | 86. | Advancing crepitus, fever, and blood blisters | Necrotizing fasciitis | | 87. | High INTRAoperative fever | Malignant hyperthermia | | 88. | Confusion, ataxia, and ophthalmoplegia | Wernicke's encephalopathy | | 89. | Tracheal deviation, decreased breath sounds, and hyperresonance | Tension pneumothorax | | 90. | Hypotension, decreased heart sounds, and JVD | Pericardial tamponade | | 91. | Four ribs broken in two places and pulmonary contusion | Flail chest | | 92. | Otorrhea (clear) and Battle's sign | Basilar skull fracture | | 93. | Ulcer and decreased pain with food | Duodenal ulcer |
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SCORE YOUR ANSWERS: Pre- and Post-Book Self-Assessment of Surgical Knowledge
Pre-test: ____/16
Cumulative: Pre-test: ____/93
Post-test: _____/16
Cumulative: Post-test: _____/93
| 94. | Vomiting, retching, and epigastric pain | Mallory–Weiss tear | | 95. | Fever on postoperative day #1, with “bronze” weeping, tender wound | Clostridial wound infection | | 96. | Hematochezia and tenesmus | Rectal cancer | | 97. | Upper GI bleed, jaundice, and RUQ pain | Hemobilia | | 98. | Gallstones, epigastric pain radiating to back, and nausea | Gallstone pancreatitis | | 99. | 18-year-old female with bloody nipple discharge | Ductal papilloma | | 100. | Irritability, diaphoresis, weakness, tremulousness, and palpitations | Insulinoma |
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SCORE YOUR ANSWERS: Pre- and Post-Book Self-Assessment of Surgical Knowledge
Pre-test: ____/7
Total number of microvignettes answered correctly:
Pre-test: ____/100
Post-test: _____/7
Post-test: _____/100