Mastering the cognitive knowledge within a field such as general surgery is a formidable task. It is even more difficult to draw on that knowledge, procure and filter through the clinical and laboratory data, develop a differential diagnosis, and finally, form a rational treatment plan. To gain these skills, the student often learns best at the bedside, guided and instructed by experienced teachers and inspired toward self-directed, diligent reading. Clearly, there is no replacement for education at the bedside. Unfortunately, clinical situations usually do not encompass the breadth of the specialty. Perhaps the best alternative is a carefully crafted patient case designed to stimulate the clinical approach and decision making. In an attempt to achieve this goal, we have constructed a collection of clinical vignettes to teach diagnostic or therapeutic approaches relevant to general surgery. Most importantly, the explanations for the cases emphasize the mechanisms and underlying principles rather than merely rote questions and answers.

This book is organized for versatility to allow the student “in a rush” to go quickly through the scenarios and check the corresponding answers, and to provide more detailed information for the student who wants thought-provoking explanations. The answers are arranged from simple to complex: a summary of the pertinent points, the bare answers, an analysis of the case, an approach to the topic, a comprehension test at the end for reinforcement and emphasis, and a list of resources for further reading. The clinical vignettes are purposely arranged by system to allow students to synthesize knowledge. A listing of cases is included to aid the student who desires to test their knowledge of a certain area or to review a topic, including basic definitions. Finally, we intentionally did not primarily use a multiple-choice question format to begin each case because clues (or distractions) are not available in the real world. Nevertheless, multiple-choice questions are included at the end of each scenario to reinforce concepts or introduce related topics.

HOW TO GET THE MOST OUT OF THIS BOOK

Each case is designed to simulate a patient encounter and includes open-ended questions. At times, the patient’s complaint differs from the issue of most concern, and sometimes extraneous information is given. The answers are organized into four different parts:

PART I

1. Summary: The salient aspects of the case are identified, filtering out the extraneous information. This is now in bullet form for easier reading. The student should formulate his or her summary from the case before looking at the answers. A comparison with the summation in the answer helps to improve one’s ability to focus on the important data while appropriately discarding irrelevant information, a fundamental skill required in clinical problem solving.

2. A straightforward answer is given to each open-ended question.

3. An analysis of the case consists of two parts:

   1. Objectives: A listing of the two or three main principles, which are crucial for a practitioner in treating a patient. Again, the student is challenged to make educated “guesses” about the objectives of the case after an initial review of the case scenario, which help to sharpen his or her clinical and analytical skills. We have included the entrustable professional activities (EPA) corresponding to the objective for instructors and curriculum overseers (see Table 1).

   2. Considerations: A discussion of the relevant points and a brief approach to a specific patient.

PART II

An approach to the disease process consists of three distinct parts:

1. Definitions: Terminology pertinent to the disease process

2. Surgical Synopsis: Clinical information (history, physical examination, laboratory values, imaging), main treatment, and indications for surgery

3. Clinical Approach: A discussion of the approach to the clinical problem in general, including tables, figures, and algorithms.

PART III

Comprehension Questions: Each case includes several multiple-choice questions, which reinforce the material or introduce new and related concepts. Questions about material not found in the text are explained in the answers.

PART IV

Clinical Pearls: A listing of several clinically important points, which are reiterated as a summation of the text and allow for easy review, such as before an examination.