The Osler Institute

General Surgery Mock Oral Cases

The following are 214 sample cases covering the broad range of
general surgery. These cases are presented in an examination
styled format and are similar to cases used in the certification
examination of the American Board of Surgery. In these cases E
stands for the examiner and C stands for the candidate. Some of
the cases are very similar and are intended to show the different
direction the cases can take depending on the responses of the
candidate.
The Osler Institute makes no claim that the responses given by
the candidate are the best or only answers to the questions posed,
or that the questions given by the examiner are actual cases from
the American Board of Surgery certification examination. The
wide variety of surgical problems; however, represents a major
portion of what is likely in an oral exam.
E stands for Examiner.
C stands for Candidate.
Case 1:
E: A 35-year-old female presented to your office recovering from
cholecystitis.
C: Can I have her history and physical examination please?
E: The most pertinent thing besides her history of cholecystitis is
that she had a MI in the last three months and she was treated
conservatively.
C: Can I have the old records from the hospital where she had the
episode of cholecystitis so that I am certain that she did have
an episode of cholecystitis?
E: That could be done easily, however, the patient is very anxious
about undergoing a cholecystectomy since she is having these
bouts with cholecystitis.
C: I will assure her that I will treat her conservatively since she
recently had a MI. There is at least a thirty percent chance of a
repeat myocardial infarction if she is operated on within three
months of the previous myocardial infarction.
E: The patient is still very anxious about it.
C: I would assure her that right now she is stable and she had an
episode in the past. For that matter, I would treat her
conservatively.
E: The patient agreed to your comment and went home.
However, she returned within six days, again, she had right
upper quadrant pain.
C: Did she have any fever this time?
E: Yes.

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C: This time I would like to investigate her in detail. I would like
to have a CBC, ultrasound of the gallbladder, admit her to the
hospital, obtain some electrolytes, start her on IV fluids and
start her on broad-spectrum antibiotics.
E: What antibiotic are you going to start her on?
C: I am going to start her on an antibiotic, which would cover
both gram-positive and gram-negative bacteria. What are the
results of the labs that I ordered?
E: The white count is 18,000; the electrolytes are normal. The
gallbladder demonstrates a thickened gallbladder with some
pericholecystic type fluid.
C: In that case, she does have cholecystitis and she needs to be
operated on.
E: Would you like to have any more tests or investigations before
you proceed with surgery?
C: Yes, certainly. I would like to obtain an EKG and obtain a
cardiology consultation to rule out myocardial ischemia. In
addition, I would insert a Swan-Ganz catheter and start her on
intravenous nitroglycerin.
E: Why would you start her on nitroglycerin?
C: Nitroglycerin is an excellent coronary vasodilator and with her
history of myocardial infarction, this will certainly help her
throughout the operation.
Case 2:
E: A 25-year-old male who sustained a stab wound to the left
chest just below the nipple in the fourth intracostal space
presented to the ER. Currently, his BP is 90 and he is mildly
tachycardic.
C: I would start with the airway, breathing followed by
circulation into the primary survey quickly.
E: The secondary exam reveals a stab wound, with bilateral
breath sounds, which are equal.
C: I will quickly obtain a chest x-ray, order an ABG, and routine
lab.
E: The ABG reveals a PO2 of 60, and a PCO2 of 30. In addition,
the chest x-ray reveals a small amount of fluid in the left chest
but there is no evidence of a pneumothorax.
C: In that case, I would like to insert a chest tube immediately.
E: Fine, you got back 150 cc of blood; however, the BP of the
patient is still 90, and it looks like his neck vein is distended.
C: At this time, I would like to have an echo done as well.
E: You get an echo, which does not help you with the situation.
They are not sure whether there is some pericardial fluid.
C: Given the position of the stab wound, his BP, and his neck
veins; I think we need to go immediately to the OR and
perform a pericardial window.
E: Why would you not perform the pericardial window in the ER?
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C: The patient is relatively stable. I think if we perform a
pericardial window in the ER and he decompensates once the
pressure if relived, you would not have enough equipment,
meaning cardiopulmonary bypass backup, if need be.
E: You are in the OR, now what?
C: In the OR I would make sure the room is warm, we have blood
available, and we have large bore IVs available as well. I will
proceed with the pericardial window first, xiphoid position,
and depending on the findings, I will take the next step.
E: Well, the window demonstrates 150 cc of bloody fluid.
C: With this finding, I think a median sternotomy is warranted. I
will do a median sternotomy and obtain cardiac surgery help as
well.
E: You did the median sternotomy and you find there is a
laceration to the left anterior descending coronary artery, and a
laceration to the right ventricle as well next to the artery.
C: At this stage, I would like to have the cardiac surgeons around.
Ventricular laceration can be repaired using interrupted
pledgetted sutures. The pledget should be wide and I would
use 3-0 prolene. The left anterior decending artery many times
has to be ligated, if it is directly injured and then bypassed
distally. I will most likely use a vein graft. For that, I would
prefer that a cardiac surgeon be around.
Case 3:
E: A 33-year-old male with Crohns disease and a 100 to 150
pound weight loss presents to your office for the first time.
The patient is complaining of cramping and abdominal pain.
C: Since I am seeing this patient for the first time, I would like to
have a detailed history, followed by physical examination. I
would also like to know what other diagnostic studies he had
done in the past, and what medications he is on.
E: Well, he did not bring his medications so it will be difficult to
ascertain what medications he is on. What appropriate
diagnostic studies would you order?
C: In general, a patient with Crohns disease would undergo an
upper GI series, followed by a lower GI series. They might
also undergo an upper and lower endoscopy. In addition, I
would like to exam the patient to make sure there are no
perianal fistulae and no masses felt.
E: Actually, in his case, you can feel a right lower quadrant mass
on physical examination.
C: In case I dont find any appropriate diagnostic studies in the
past, I would like to have him undergo an upper GI series.
E: You did that, and basically it showed thickened mucosa in the
distal ileum.

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C: I will make the patient NPO and start him on a total parenteral
nutrition. (They might ask you the formulation of TPN at this
time)
E: You did that and the patients pain disappeared and the mass in
the right lower quadrant started to regress as well. However,
while being on TPN he develops jaundice. What do you think
the reason for this episode jaundice in this patient would be?
C: There could be multiple causes but, in his case, the most likely
cause is steatosis.
E: Since you are thinking about steatosis, how would you treat
that? Do you think we need to stop the TPN?
C: Right now I would not make any significant changes, and
would continue the TPN. I would certainly followup on his
liver function test now, and periodically after that.
Case 4:
E: A 36-year-old gentleman who was in your office, recently
underwent a barium enema because of nonspecific abdominal
pain
C: What did the barium enema show?
E: The barium enema demonstrated that the patient had multiple
polyps throughout the colon.
C: I would like to know the history of the patient, his
symptomology and especially if he had other family members
who had similar complaints or findings. In addition, I would
like to know if there are any pertinent physical findings.
E: Basically the physical exam is unremarkable and he does not
have any other family members who had similar symptoms.
By the way, what are you thinking doctor? What is your
working diagnosis at this time?
C: Sir, I think the most likely thing is the patient has familial
polyposis and I would tell the patient that he has 100% chance
of developing a carcinoma in the colon with these findings.
He needs to undergo a total abdominal colectomy.
E: What options could you give him with a total abdominal
colectomy?
C: Well, one is total abdominal colectomy with an end ileostomy,
second would be total abdominal colectomy with ileorectal
anastomosis and the third would be total abdominal colectomy
with ileoanal pull-through procedure.
E: Well, the patient is 36 years old and he has a 27 year old wife
and he does not want to end up impotent. What do you think
the best option would be in this scenario?
C: I would suggest ileoanal pull-through anastomosis. However,
if he insists the next best option would be the ileorectal
anastomosis.
E: Is there a problem with that?
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C: The ileorectal anastomosis has at least a 40% incidence of
developing carcinoma in the remaining rectal stump, and
would need a continued surveillance.
E: How often would you follow him?
C: Every six months with proctoscopy.
E: OK, you are in the operating room and you are doing the
ileoanal pull-through procedure, however, you are unable to
pull down the ileum to the anus.
C: Well, generally you would preserve the ileocolonic vessel, try
to dissect the mesentery in order to find the arteries going into
the ileum. If you are able to mobilize the distal ileum on the
vascular pedicle as far as you could, maintaining the vascular
pedicle and usually you are able to pull down the ileum to the
anus but again you could get into trouble.
E: What option do you have at that time?
C: The option at that time essentially is to perform an ileostomy
and the patient will have to live with a bag in the right lower
quadrant where the end ileosteum would come out.
E: In your opinion, the perianal procedure went very well and you
see the patient back in the office in three months. The patient
tells you that initially he was having 5-6 bowel movements a
day but now he is having 10-11 bowel movements. What do
you think the problem is?
C: My assumption is that the patient is having pouchitis and that
is probably giving him these frequent bowel movements.
E: How would you treat it?
C: I would start him on Flagyl 500 mg orally every 8 hours. In
addition, there is also the possibility that the patient has
developed stricture at the ileoanal anastomosis and I would of
course do a digital anal exam making sure the anastomosis is
patent.
Case 5:
E: You have a patient who is 34-years-old who had an ileoanal
anastomosis for familial polyposis, the patient has a child who
is 6, and one who is 8. Do you think there are any specific
concerns with these kids, and what do you need to tell the
family?
C: Essentially, both of these children would be at risk of
developing familial polyposis syndrome.
E: Well, how would you follow them?
C: At age eight, we would start performing proctoscopies on these
patients. This would mean if the rectum were without polyps,
possibly the colon would not have any polyps as well.
E: You scope the 8-year-old and he has ten to twelve polyps in
the rectum. How would you manage that child?

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C: I think eight years of age is too early to perform a colectomy
and I would prefer to watch the child in my office until at least
he has gone through the remainder of his growth spurt.
E: Well, when would you want to operate on this patient?
C: I think the appropriate time would be between the ages 14 to
16.
E: I forgot to tell you that the man who has the polyposis had
some tumors on his arms and was that something that I needed
to be concerned about with these other kids? Would I do
anything for that patient?
C: The tumors in the arms were probably dermoids; therefore, I
would not be concerned about them in the man or in these
children.
E: What would you tell this patient? Does he need to be
concerned twenty years from now?
C: My diagnosis would be Gardners syndrome because of the
presence of colonic polyposis with subcutaneous osteomas. Of
course, the concern is the colonic polyposis can become
carcinoma later on. Similarly, these patients have a high
incidence of small bowel especially duodenal and jejunal
polyps, which have a tendency of becoming malignant in the
range of 10 to 12%. Similarly, they have an incidence of
desmoid tumors in small bowel mesentery, which by
desmoplastic reaction causes obstruction and essentially are
the second most leading cause of death in these patients.
Case 6:
E: A 25-year-old female presents to the office with symptoms of
gross-bloody nipple discharge.
C: I would like to know the history of the patient, especially any
family history of cancer, any medications that she is on, age of
menarchy, any previous pregnancies, and if she is taking oral
contraceptives.
E: Essentially, all of that is negative.
C: In that case, I will proceed with a physical examination. I will
concentrate on the breast and axillary examination to rule out
any lymph nodes.
E: Well, on the physical examination, you find that the nipple
discharge was located in the right upper quadrant and there are
no other masses felt, in fact, there is no mass felt even in the
right breast where the nipple discharge is.
C: At this time, I would like to obtain a mammogram and send the
nipple discharge for cytology.
E: The mammography is negative, and the cytology is negative as
well.
C: I would like to obtain a galactogram.
E: Why would you do that?
General Surgery Mock Oral Cases 2011 The Osler Institute
2011 mock oral handout