General Surgery Correlations and Clinical Scenarios - 1st
Edition
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To my grandparents, Purshottam Thacker and Zaver Rachh. Their guidance, love, and blessings
have inspired me to be the educator I am today.
CONTENTS
How to Use This Book
Chapter 1. Preoperative Evaluation
Case 1: Preoperative Assessment for Low-Risk Patients
Case 2: Preoperative Assessment for High-Risk Patients
Case 3: Malignant Hyperthermia Syndrome
Chapter 2. Hemodynamic Instability
Case 1: Septic Shock
Case 2: Hypovolemic Shock
Case 3: Hemorrhagic Shock
Case 4: Anaphylaxis
Case 5: Cardiogenic Shock
Chapter 3. Neurologic Emergencies and Head Trauma
Case 1: Epidural Hematoma
Case 2: Subdural Hematoma
Case 3: Subarachnoid Hemorrhage
Case 4: Idiopathic Intracranial Hypertension
Case 5: Normal-Pressure Hydrocephalus
Case 6: Syringomyelia
Case 7: Epidural Abscess
Case 8: Posterior Communicating Artery Aneurysm
Chapter 4. Trauma
Case 1: Pneumothorax
Case 2: Pericardial Tamponade
Case 3: Penetrating Abdominal Trauma
Chapter 5. General Abdominal Surgery
Case 1: Splenic Flexure Syndrome
Case 2: Appendicitis
Case 3: Diverticulitis
Case 4: Small Bowel Obstruction
Chapter 6. Endocrine
Case 1: Pituitary Disease
Case 2: Hyperparathyroidism
Case 3: Pheochromocytoma
Case 4: Gastrinoma
Case 5: Glucagonoma
Case 6: Insulinoma
Chapter 7. Esophageal Disorders
Case 1: Gastroesophageal Reflux Disease
Case 2: Boerhaave’s Syndrome
Case 3: Mallory-Weiss Tear
Case 4: Achalasia
Case 5: Esophageal Cancer
Case 6: Zenker’s Diverticulum
Case 7: Steakhouse Syndrome
Chapter 8. Stomach
Case 1: Upper Gastrointestinal Bleed
Case 2: Perforated Gastric Ulcer
Case 3: Mucosa-Associated Lymphoid Tissue Lymphoma
Case 4: Stomach Cancer
Chapter 9. Colon
Case 1: Colon Cancer
Case 2: Toxic Megacolon
Case 3: Volvulus
Case 4: Acute Mesenteric Ischemia
Case 5: Ischemic Colitis
Case 6: Chronic Mesenteric Ischemia
Chapter 10. Biliary Tract
Case 1: Biliary Colic
Case 2: Acute Cholecystitis
Case 3: Cholangitis
Case 4: Pancreatitis
Chapter 11. Urology
Case 1: Benign Prostatic Hyperplasia
Case 2: Kidney Stones
Case 3: Bladder Cancer
Case 4: Prostate Cancer
Case 5: Testicular Cancer
Chapter 12. Cardiovascular System
Case 1: Abdominal Aortic Aneurysm
Case 2: Aortic Dissection
Case 3: Peripheral Vascular Disease
Case 4: Pulmonary Embolism
Chapter 13. Orthopedics
Case 1: Carpal Tunnel Syndrome
Case 2: Fat Embolism
Case 3: Compartment Syndrome
Case 4: Anterior Cruciate Ligament Injury
Case 5: Achilles Rupture
Case 6: Ruptured Baker’s Cyst
Case 7: Hip Fracture
Case 8: Morton’s Neuroma
Chapter 14. Ophthalmology
Case 1: Open-Angle Glaucoma
Case 2: Angle-Closure Glaucoma
Case 3: Retinal Vein Occlusion
Case 4: Central Retinal Artery Occlusion
Case 5: Retinal Detachment
Case 6: Macular Degeneration
Case 7: Diabetic Retinopathy
Case 8: Orbital Cellulitis
Chapter 15. Dermatologic Diseases
Case 1: Cellulitis
Case 2: Necrotizing Fasciitis
Case 3: Skin Cancer
Chapter 16. Postoperative Complications
Case 1: Wind
Case 2: Water
Case 3: Walking
Case 4: Wound
Case 5: Deep Wound
Case 6: Wonder
Index
HOW TO USE THIS BOOK
The primary purpose of this book is to coach you in the precise sequence through time to manage the
computerized case simulation (CCS) portion of the step 3 exam, specifically for questions
pertaining to the specialty of Surgery. You will find directions on moving the clock forward in time
and the specific sequence in which each test or treatment should be done in managing a patient. This
will cover the order in which to give treatments, order tests, and how to respond to test results. All
CCS-related instructions appear in RED TYPE.
If you have never seen a particular case, this book is especially for you. It never has statements
about “using your judgment” because you basically do not have any in these areas. We have made a
cookbook that says “Do this, do that, do this.” We do not consider the term “cookbook” to be
inappropriate in this case.
You need to learn the basics of surgery. Less than ten percent of physicians are in this specialty,
but the other 90% need to have at least a working knowledge of it.
This book will prepare you for multiple-choice questions, which comprise the majority of the
exam, as well as the computerized clinical case simulations and the new basic science foundations
that have just been added to the exam.
USMLE Step 3 or COMLEX Part 3 is the last phase in getting your license. Most of you are in
residency and have no time to study. Here is how to best use this book.
First read about the disease or subspecialty in any standard text book. We personally suggest
either Master the Boards Step 3 book (Conrad Fischer) or the Current Medical Diagnosis and
Treatment book.
The cases in this book are meant to enhance your understanding of the subject. All initial case
presentations and their continuing scenarios appear in yellow boxes. There are also hundreds of
new multiple-choice questions that are not in anyone’s Q bank.
Every single case has related basic science foundations (which appear in blue boxes), so you
will get a solid grasp of these simply by following along in the case. You do not have to consult any
of your old step 1 books or basic science texts. The basic science correlates should be painless.
You need not search for extra information. Just learn what we have selected in these chapters.
We always wanted to write something specifically for CCS. This is it. Because new test
changes are frightening and the basic science questions are new for step 3, we made one book to
cover both the simulations and the basic science.
Niket Sonpal, MD
Conrad Fischer, MD
CHAPTER 1
PREOPERATIVE EVALUATION
CASE 1: Preoperative Assessment for Low-Risk Patients
Setting: Office
CC: “I am having a knee replacement.”
VS: BP, 106/54 mm Hg; R, 12 breaths/min; P, 75 beats/minute; T, 98.6°F
HPI: A 65-year-old woman presents after seeing her orthopedic surgeon 1 week earlier. Her
right knee osteoarthritis (OA) is no longer tolerable, and she is planning to undergo a total
right knee replacement next month. Her surgeon tells her she needs to have “clearance”
before surgery. She is only able to walk two blocks or climb one flight of stairs before feeling
tired. However, she denies shortness of breath and chest pain while walking.
PMHx:
• Right knee OA
• Mild obesity
PSH:
• History of smoking; quit 5 years ago
• Drinks socially
ROS:
• No chest pain on exertion
• No shortness of breath on exertion
Physical Exam:
• Crepitations on flexion and extension of right knee
• Swelling and pain to palpation of the lateral right knee
• Decreased range of motion in the right knee
• Antalgic gate favoring the left leg
Which perioperative risk category does a total knee replacement fit into?
a. High risk
b. Intermediate risk
c. Low risk
Answer c. Low risk
Surgeries involving the intraperitoneal and intrathoracic regions, carotid endarterectomy, head and
neck surgery, orthopedic surgery, and prostate procedures are all considered intermediate risk and
carry up to 5% perioperative risk. Low-risk or less than 1% perioperative risk for death are
endoscopic and superficial procedures, cataract surgery, breast surgery, dental procedures, and
ambulatory surgery. High-risk procedures that carry a greater than 5% perioperative risk are those
that involve peripheral vascular structures or the aorta.
Higher risk = Higher complication rate = Higher mortality rate
About which of the following lifestyle factors should this patient receive
counseling regarding the risk of perioperative complications?
a. Exercise
b. Smoking
c. Alcohol use
Answer a. Exercise
This patient has poor preoperative exercise tolerance. A patient’s ability to exercise is a strong
predictor of postoperative complications from neurologic or cardiac events. This patient does not
have shortness of breath, which in the setting of congestive heart failure (CHF) can prohibit surgery
if the ejection fraction is less than 35%. Her exercise tolerance is low; we want patients to be able
to walk more than four blocks or climb more than two flights of stairs. This patient would benefit
from preoperative physical therapy. Smoking any kind of tobacco increases the risk of pulmonary
complications after surgery. Therefore, if any patient smokes, he or she should be told to abstain for
at least 8 weeks before surgery. Outcomes data have shown abstinence for this period of time or
greater significantly decreases perioperative complications. This patient quit more than 5 years ago
and therefore does not need to be counseled on smoking cessation. Alcohol consumption increases
the risk of perioperative complications, especially in elderly adults. During all preoperative
evaluations, the evaluating physician must ask about the quantity, use, and times since the patient’s
last drink. Physicians should also assess the use of illicit substances. Our patient only drinks
socially, which on the USMLE means less than two drinks per week.
CCS TIP: In patients with non-urgent surgery, preoperative “tuning up” can be done, and
surgery can be delayed to improve outcomes.
Initial Orders:
• Physical therapy
• Bring the patient back in 1 month
• Acetaminophen for pain relief
Use non–nonsteroidal antiinflammatory pain relievers in elderly adults because of the risk of
peptic ulcer disease, renal disease, and aseptic meningitis.
The patient returns 1 month later. Her physical therapist reports her exercise tolerance has
improved to 4 blocks and 2 flights of stairs.
What is the best next step in the management of this patient?
a. Electrocardiography (ECG)
b. Liver function tests
c. Complete blood count (CBC)
d. Prothrombin time (PT)
e. Basic metabolic profile
Answer a. Electrocardiography (ECG)
The correct answer is to obtain ECG. In the absence of history or physical findings indicating
cardiac disease, ECG is recommended in men older than 40 years of age and women older than 50
years of age. Liver function tests are not indicated unless the patient has a history of chronic liver
disease; albumin should be checked in patients with poor nutritional status. A CBC should only be
checked when there is anticipation of major blood loss or if the patient has a history of anemia. The
PT or partial thromboplastin time (PTT) should only be checked when the patient’s history indicates
chronic liver disease, history of bleeding diaphysis, or known coagulopathy. A basic metabolic
profile to check for electrolytes is only indicated in patients who have renal disease, CHF, or are
taking medications that affect electrolytes (e.g., diuretics).
PTT = PiTT—measures the intrinsic pathway
PT = PeT—measures the extrinsic pathway
Order: ECG in the office
Turn the clock forward 15 minutes to get the result.
All patients ≥40 years undergoing preoperative assessment require:
• Blood urea nitrogen/creatinine
• Chest radiography
• ECG
The ECG obtained in the office demonstrates a normal sinus rhythm with no abnormalities.
CCS TIP: After ordering the appropriate tests in a preoperative assessment, change the
location to the hospital for surgery and turn the clock forward. The case will end.
CASE 2: Preoperative Assessment for High-Risk Patients
Setting: Office
CC: “I need my hip fixed.”
VS: BP, 185/60; HR, 95 beats/min; R, 20 breaths/min; T, 98.6°F
HPI: A 70-year-old man with a history of congestive heart failure (CHF) secondary to
nonischemic cardiomyopathy presents to the office for preoperative evaluation for total hip
replacement. The previous echocardiogram revealed an ejection fraction(EF) of 30%, and he
occasionally has shortness of breath with exertion.
PMHx: Cirrhosis
PSH:
• 60-pack-year smoking history
• 1 pint of whiskey daily
Medications: Noncompliant with all medications
ROS: Unable to provide ROS
Physical Exam:
• Jugular venous distention (JVD)
• Lateral and inferior displacement of the apex of the heart
• Barrel chest
• Faint crackles in bilateral lung fields
• 2+ pedal edema up to the mid calf
Which of the following factors in this patient’s history and physical examination
puts him most at a high risk for perioperative mortality?
a. EF <35%
b. Current smoker
c. History of cirrhosis
d. JVD
e. Chronic alcohol use
Answer a. EF <35%
All of these factors raise this patient’s perioperative mortality risk, but the one that raises it the
most is the cardiac findings. The EF of less than 35%, the findings of JVD, and shortness of breath
on exertion are all indicative of systolic dysfunction and CHF. His physical findings support a
diagnosis of CHF as well. Being a smoker raises the mortality risk but not as much as being a heart
failure patient; this patient’s history of cirrhosis does raise the mortality rate up to 40%, but
remember that a person can live with very little liver but cannot live without a heart (Table 1-1).
Table 1-1 Perioperative Mortality Risk Factors
Albumin and PT are surrogate markers of hepatic synthetic function. If their levels are
abnormal, the liver is damaged.
Which of the following is the best next step in the management of this patient?
a. Optimize cardiac medications
b. Smoking cessation counseling
c. Hepatology consult
Answer a. Optimize cardiac medications
The correct answer is to begin with medical management of this patient’s CHF. A combination of
beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, digoxin, and furosemide should be
prescribed to optimize cardiac function. Beta-blockers and ACE inhibitors reduce mortality, and in
advanced CHF (New York Heart class IV), spironolactone has been shown to reduce mortality
rates. With regard to the patient’s liver disease, a hepatology consult on the examination will not be
helpful for the CCS; on the CCS, it is better to provide alcohol abstinence counseling.
Myocardial infarction = no surgery for a minimum of 6 months.
Orders:
• Lisinopril
• Carvedilol
• Furosemide
• Digoxin
• Postpone surgery by not calling surgical consult
• Have patient return in 6 weeks
• Repeat examination upon return
• Order liver function tests
• Smoking counseling
• Alcohol cessation counseling
CCS TIP: Send the patient home and schedule a return to the office in 4 to 6 weeks. This is
how you assess if your therapy was correct. If it was, the patient will feel a bit better. Always
reexamine the patient.
The patient returns to the office and says he feels less shortness of breath. On examination,
he has fewer rales than previously and no pedal edema. The patient weighs less than before,
has given up smoking, and has not consumed alcohol since his last visit. Liver function tests
reveal bilirubin of 1.2 mg/dL, albumin of 3.2 mg/dL, and PT of 10 seconds.
Only on the CCS do patients actually do what the doctor says, so take advantage and counsel
them. You will gain points.
Which is the best next step in the management of this patient?
a. Clear the patient for surgery
b. Repeat echocardiography
c. Cancel surgery forever
