What questions should a consultant ask a surgery resident about patients with various conditions, including a 36-year-old female with an incisional hernia, a 43-year-old female with a recurrent incisional hernia, a 59-year-old male with a right diabetic foot ulcer, a 65-year-old male with a right solitary thyroid nodule, a 49-year-old male with a traumatic left hydrocele, a 20-year-old female with a right breast fibroadenoma, and a 19-year-old male with a pilonidal sinus?

Essential Questions for Surgical Consultant Rounds

A consultant must go beyond superficial "clearance" and provide comprehensive risk assessment with actionable recommendations that impact perioperative management, mortality, and long-term outcomes. 1

Framework for All Patient Presentations

Core Assessment Questions (Apply to Every Patient)

Patient Stability and Optimization:

• What active cardiac conditions exist that mandate stopping surgery? Specifically: unstable/severe angina (CCS III-IV), MI within 30 days, decompensated heart failure (NYHA IV), high-grade AV block, symptomatic arrhythmias, or severe valvular disease? 2
• What is the patient's functional capacity in METs? Can they climb two flights of stairs, walk up a hill, or perform heavy housework (≥4 METs)? 2, 3
• What is the complete medication list with exact dosages, including anticoagulation, antiplatelets, beta-blockers, and any herbal supplements? 1, 2

Surgical Risk Stratification:

• What is the surgical risk category: low-risk (ambulatory procedures), intermediate-risk (intraperitoneal/intrathoracic), or high-risk (vascular)? 2
• Is this emergent, urgent, or elective? If emergent, limit evaluation to vital signs, volume status, hematocrit, electrolytes, renal function, urinalysis, and ECG only. 1

Critical Communication Requirements:

• What specific perioperative medication changes are needed (not just "continue current medications")? 1
• What level of postoperative monitoring is required? 1
• Never use the phrase "cleared for surgery"—instead document cardiovascular stability status and whether the patient is in optimal medical condition within the surgical context. 2, 3

Patient-Specific Questions

36-Year-Old Female with Incisional Hernia

Hernia Characteristics:

• What is the defect size? (Critical for determining open vs. laparoscopic approach and recurrence risk) 4
• What was the original operation and how long ago? 4
• Is there loss of domain? (Requires preoperative pneumoperitoneum or Botox for abdominal wall preparation) 5
• Any symptoms: pain, obstruction risk, or skin breakdown? 6

Perioperative Risk:

• What are her cardiac risk factors and functional capacity? 2
• Is this elective or urgent? (14% of symptomatic incisional hernias develop obstruction) 6

43-Year-Old Female with Recurrent Incisional Hernia

Recurrence Pattern:

• How many prior repairs and what techniques were used (open vs. laparoscopic, mesh type)? (Recurrence rate is 20% overall, 40% after repair) 4, 6
• What is the current defect size? (Laparoscopic approach recommended for <8-10 cm defects after primary open repair) 4
• Was mesh used previously? What type and position? 4

Surgical Planning:

• Does the surgeon have sufficient laparoscopic experience for recurrent hernia repair? 4
• Is there loss of domain requiring preoperative preparation? 5

Cardiovascular Assessment:

• What is her Revised Cardiac Risk Index score? 2
• Any history of wound complications, diabetes, or obesity affecting healing? 5

59-Year-Old Male with Right Diabetic Foot Ulcer

Diabetes Control and Complications:

• What is the HbA1c and current glucose control? 2
• What is the extent of peripheral vascular disease? (Affects wound healing and amputation level decisions)
• Does he have coronary artery disease or autonomic neuropathy? (Diabetes is a major cardiac risk factor) 1, 2

Infection and Tissue Viability:

• Is there osteomyelitis requiring prolonged antibiotics vs. immediate debridement/amputation?
• What is the vascular supply: palpable pulses, ankle-brachial index, need for revascularization first?

Functional Status:

• What is his baseline mobility and functional capacity? 2, 3
• What is his renal function? (Diabetic nephropathy affects perioperative risk) 1

65-Year-Old Male with Right Solitary Thyroid Nodule

Nodule Characterization:

• What are the ultrasound characteristics and size?
• What are the fine needle aspiration results (Bethesda classification)?
• Any compressive symptoms: dysphagia, dyspnea, or voice changes?

Cardiovascular Risk:

• What is his functional capacity and cardiac history? 2, 3
• Is he on anticoagulation or antiplatelet therapy requiring perioperative management? 2
• Any history of atrial fibrillation or other arrhythmias? 1, 2

Thyroid Function:

• Is he euthyroid, hyperthyroid, or hypothyroid? (Hyperthyroidism must be controlled before elective surgery)

49-Year-Old Male with Traumatic Left Hydrocele

Trauma Mechanism and Timing:

• When did the trauma occur and what was the mechanism?
• Any associated testicular injury, hematocele, or concern for malignancy?
• Is this causing pain, infection risk, or cosmetic concern requiring urgent vs. elective repair?

Cardiovascular Assessment:

• What is his functional capacity? 2, 3
• Any cardiac risk factors: hypertension, diabetes, smoking, known CAD? 1, 2
• What medications is he taking? 1, 2

20-Year-Old Female with Right Breast Fibroadenoma

Lesion Characteristics:

• What is the size and imaging characteristics (ultrasound, mammogram if done)?
• Was core needle biopsy performed confirming fibroadenoma?
• Is this causing symptoms or rapid growth requiring excision vs. observation?

Perioperative Considerations:

• This is low-risk surgery—does she have any cardiac history or symptoms? 2
• Is she on oral contraceptives or other medications? 1
• Any bleeding disorders or family history of surgical complications?

19-Year-Old Male with Pilonidal Sinus

Disease Characteristics:

• Is this acute abscess requiring incision and drainage vs. chronic sinus requiring definitive excision?
• How many prior episodes or procedures?
• What is the extent of disease and planned surgical approach?

Perioperative Risk:

• This is low-risk surgery in a young patient—any cardiac symptoms or congenital heart disease? 2
• Any diabetes, immunosuppression, or factors affecting wound healing?
• Smoking history? (Critical for wound healing in pilonidal disease)

Critical Pitfalls to Avoid

Documentation Failures:

• Avoid consultations with no actionable recommendations beyond "cleared for surgery" (occurs in 40% of consultations). 1
• Avoid ordering tests that won't change management—only order tests if results will alter the surgical procedure, medical therapy/monitoring, or lead to postponement. 1, 2

Communication Breakdowns:

• Ensure direct communication with surgeon and anesthesiologist, not just written notes. 1, 2
• Document specific medication changes, not vague statements like "optimize medications." 1, 2

Risk Assessment Errors:

• Don't rely solely on the question asked—provide comprehensive cardiovascular evaluation even if consultation was for a specific ECG finding. 1
• Identify previously unsuspected CAD or heart failure that may require extensive evaluation before elective procedures. 1