Surgery

Match each postoperative clinical presentation following cardiothoracic or vascular surgery with its corresponding pathophysiological mechanism or definitive diagnosis.

A 48-year-old woman comes to the emergency department due to a 24-hour history of severe, colicky abdominal pain, nausea, and bilious vomiting. She has not passed flatus or stool since the pain began. Her medical history is notable for a laparoscopic appendectomy 10 years ago. She takes no daily medications. Her temperature is 37.3°C (99.1°F), blood pressure is 114/76 mm Hg, pulse is 106/min, and respirations are 18/min. Physical examination reveals an asymmetrically distended abdomen. It is highly tympanitic to percussion and moderately tender diffusely, but there is no guarding or rebound tenderness. Bowel sounds are high-pitched and hyperactive. A plain radiograph of the abdomen demonstrates a markedly dilated, comma-shaped loop of bowel originating in the right lower quadrant and projecting toward the left upper quadrant. There is a single air-fluid level within the loop and a paucity of gas in the distal colon. Which of the following is the most appropriate next step in management?

A 62-year-old male is evaluated in the surgical intensive care unit on postoperative day 8 following an open appendectomy for a perforated appendix. After an initially uncomplicated recovery with return of bowel function on day 4, he developed severe, constant abdominal pain, nausea, and bilious vomiting over the past 24 hours. He has not passed flatus since the onset of these symptoms.

His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is $125/\text{min}$, respiratory rate is $24/\text{min}$, and blood pressure is $88/55\text{ mmHg}$.

Physical examination reveals a distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent.

Laboratory studies show a leukocyte count of $19,500/\text{mm}^3$ with $85\%$ neutrophils, and a serum lactate of $4.6 \text{ mmol/L}$.

Supine and upright abdominal radiographs demonstrate multiple dilated loops of small bowel with prominent air-fluid levels and a paucity of colonic gas.

Which of the following is the most appropriate next step in management?

A 32-year-old female, gravida 1, para 0, at 35 weeks gestation, is brought to the trauma center following a high-speed motor vehicle collision. She was a restrained passenger. On arrival, she is lethargic, confused, and oriented only to her name. Her husband, who was driving and sustained minor injuries, is present in the trauma bay and demands that the medical team focus exclusively on saving the fetus. A card discovered in the patient's wallet legally designates her sister as her healthcare proxy.

Evaluation reveals a patent airway and symmetric vesicular breath sounds bilaterally. Vital signs include a heart rate of 142/min, respiratory rate of 26/min, and blood pressure of 76/40 mm Hg. Pulse oximetry is 98% on room air. The patient is placed on a backboard with manual left uterine displacement. An initial fluid bolus is administered with minimal hemodynamic improvement.

Extended focused assessment with sonography for trauma (E-FAST) demonstrates a large anechoic collection in the splenorenal recess. There is no evidence of pneumothorax. Fetal heart rate monitoring demonstrates a baseline of 105/min with minimal variability and recurrent late decelerations.

Which of the following is the most appropriate next step in the management of this patient?

A 74-year-old man is evaluated on postoperative day 3 following an open partial colectomy for colon cancer. He reports new-onset shortness of breath and a cough productive of yellowish sputum that started this morning. His medical history is significant for ischemic cardiomyopathy with an ejection fraction of 40% and chronic obstructive pulmonary disease. His temperature is 38.9°C (102.0°F), blood pressure is 118/74 mmHg, heart rate is 112/min, and respiratory rate is 24/min. Oxygen saturation is 90% on room air. Physical examination reveals a patient in mild respiratory distress. Jugular venous pressure is not elevated. Auscultation of the lungs reveals bronchial breath sounds and crackles over the right lower lung field. The surgical incision is clean, dry, and intact. There is no lower extremity edema. Based on the most likely diagnosis, which of the following are the most appropriate next steps in this patient's management? (Select 2)

A 45-year-old female weighing 70 kg is brought to the emergency department after being rescued from a house fire. She sustained deep partial-thickness and full-thickness thermal burns over 40% of her total body surface area (TBSA). The injury occurred approximately 1 hour prior to arrival. Upon initial evaluation, her blood pressure is 110/70 mm Hg, heart rate is 115/min, and oxygen saturation is 96% on room air. She is speaking in a hoarse voice, has singed nasal hair, and carbonaceous sputum is noted. Arrange the following management steps in the correct chronological sequence for this patient's acute and subacute burn care.

Following an assault, a 29-year-old woman is evaluated in the emergency department for a deep stab wound to the right side of her neck. On arrival, she is confused and diaphoretic. Her blood pressure is 80/40 mmHg and her pulse is 130/min. Physical examination reveals an actively expanding, pulsatile hematoma in the right anterior cervical triangle. There is a continuous stream of bright red blood oozing through the applied pressure dressing. The patient's airway remains patent and breath sounds are bilateral. Which of the following is the most appropriate next step in management?

A 28-year-old woman is brought to the emergency department after falling from a fourth-story balcony. She was intubated at the scene due to a depressed level of consciousness. Upon arrival, her temperature is 36.1°C (97.0°F), blood pressure is 72/40 mm Hg, and pulse is 138/min. Physical examination reveals a 7-mm, nonreactive right pupil and a 3-mm, briskly reactive left pupil. The trachea is midline, and breath sounds are present and equal bilaterally. The pelvis is stable to anteroposterior and lateral compression. The left thigh is visibly swollen and deformed. Focused assessment with sonography for trauma (FAST) demonstrates an anechoic stripe in the hepatorenal recess. A peripheral intravenous line is established, and 1 L of warmed lactated Ringer solution is rapidly infused; her blood pressure remains 70/40 mm Hg. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old male is brought to the emergency department via ambulance after being kicked directly in the abdomen by a horse. On arrival, he is groggy but follows simple commands. His temperature is 36.5°C (97.7°F), blood pressure is 78/40 mm Hg, and pulse is 132/min. Oxygen saturation is 99% on room air. Large-bore intravenous access is established, and 1 liter of crystalloid fluid is rapidly administered. Following the fluid bolus, his blood pressure remains low at 82/45 mm Hg. Physical examination reveals a large contusion over the epigastrium. The abdomen is markedly distended with diffuse rebound tenderness and involuntary guarding. A focused assessment with sonography for trauma (FAST) exam demonstrates a large amount of free fluid in the hepatorenal recess and the splenorenal recess. Which of the following is the most appropriate next step in management?

A 68-year-old man is evaluated in the intensive care unit on postoperative day 14 following an emergency open repair of a ruptured abdominal aortic aneurysm. His postoperative course has been complicated by prolonged mechanical ventilation and the need for a continuous norepinephrine infusion to maintain adequate perfusion. Over the past 24 hours, his temperature has increased to $39.2$ °C ($102.6$ °F). His abdomen is distended, but deep sedation prevents a reliable assessment of tenderness. Laboratory studies show a leukocyte count of $19,500/mm^3$, a total bilirubin of $3.2$ mg/dL, and an alkaline phosphatase of $350$ U/L. A bedside right upper quadrant ultrasound demonstrates a markedly distended gallbladder with a wall thickness of $5$ mm and the presence of pericholecystic fluid. No echogenic structures with acoustic shadowing are seen within the gallbladder lumen, and the common bile duct measures $4$ mm in diameter. Which of the following is the most appropriate next step in the management of this patient?

A 45-year-old man is brought to the emergency department via ambulance after falling approximately 20 feet from a roof. Upon arrival, he is moaning in pain and appears confused. His temperature is 36.1°C (97.0°F), blood pressure is 78/40 mmHg, pulse is 135/min, and respirations are 26/min. The airway is patent, and breath sounds are equal bilaterally. Physical examination reveals severe ecchymosis over the lower abdomen and perineum. The pelvis is mechanically unstable to gentle anteroposterior compression. The right lower extremity is shortened and externally rotated. A focused assessment with sonography for trauma (FAST) examination reveals no intraperitoneal or pericardial fluid. An anteroposterior radiograph of the pelvis demonstrates a 4-cm diastasis of the pubic symphysis and widening of the right sacroiliac joint. A pelvic binder is immediately applied, and a massive transfusion protocol is initiated. After receiving 2 units of uncrossmatched packed red blood cells and 1 unit of fresh frozen plasma, his blood pressure remains 80/42 mmHg and pulse is 130/min. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation and breast pathology findings with the most appropriate surgical or overall management strategy.

For each of the following acute trauma scenarios, identify the most appropriate and definitive initial management step based on Advanced Trauma Life Support (ATLS) principles.

A 28-year-old man is brought to the emergency department by ambulance after a high-speed motorcycle collision. He was not wearing a helmet. On arrival, he is unresponsive with irregular, shallow respirations. His blood pressure is 185/105 mm Hg, and his pulse is 52/min. Neurologic examination reveals a 7-mm, nonreactive right pupil and a 3-mm, reactive left pupil. He exhibits decerebrate posturing on the left side in response to painful stimuli. Arrange the following steps in the most appropriate sequential order for the acute management of this patient.

A $34$-year-old male construction worker is brought to the emergency department after falling approximately $6\text{ meters}$ ($20\text{ feet}$) from a scaffold. He is fully alert and reports severe lower abdominal and pelvic pain. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $115/78\text{ mm Hg}$, and pulse is $98/\text{min}$. A focused assessment with sonography for trauma (FAST) reveals no free intraperitoneal fluid. Pelvic radiography demonstrates an unstable "open book" pelvic ring disruption with significant diastasis of the pubic symphysis. The orthopedic surgery team is preparing the patient for emergent open reduction and internal fixation (ORIF) of the pelvis. A retrograde urethrogram is performed and confirms an intact urethra. A transurethral Foley catheter is placed and drains frankly bloody urine. A subsequent computed tomography (CT) cystogram demonstrates contrast extravasation confined to the perivesical space in a "flame-shaped" pattern, with no contrast outlining the bowel loops. Which of the following is the most appropriate management of this patient's urologic injury?

Match each post-bariatric surgery clinical presentation with its most appropriate diagnostic or therapeutic next step.

A 42-year-old male is brought to the emergency department after falling 20 feet from a roof. He is groaning and does not open his eyes or follow commands. Blood is visible in his oropharynx, and he has gurgling respirations. His respiratory rate is 28/min. Breath sounds are absent on the right side, and his trachea is deviated to the left. His blood pressure is 80/40 mm Hg, and his heart rate is 135/min. Arrange the following management steps in the correct chronological order according to Advanced Trauma Life Support primary survey priorities.

Match each clinical presentation of a trauma patient to the most appropriate next step in management or diagnostic imaging.

A 42-year-old woman is evaluated in the post-anesthesia care unit $2$ hours after undergoing a total thyroidectomy for a multinodular goiter. The nursing staff calls urgently because the patient has developed acute respiratory distress. She is agitated, diaphoretic, and exhibits pronounced inspiratory stridor. Her oxygen saturation is $84\%$ on room air. Physical examination reveals a tense, rapidly expanding swelling beneath the cervical incision. Arrange the following management steps in the most appropriate chronological sequence for this patient's life-threatening complication, assuming each step is performed if the previous intervention fails to completely resolve the airway compromise.

A 48-year-old male is evaluated in the emergency department after experiencing an abrupt onset of agonizing, diffuse abdominal pain that started two hours ago. He reports that the discomfort is continuous and severely worsens with any physical movement. His medical history is significant for chronic osteoarthritis, which is managed with high-dose daily naproxen, and he is a current tobacco user. He recently noted a gnawing upper abdominal ache that would temporarily improve after meals. Currently, he is lying motionless on the examination table and taking shallow breaths. Vital signs indicate a temperature of 37.9°C (100.2°F), a pulse of 118/min, and a blood pressure of 105/65 mm Hg. Abdominal assessment is notable for board-like rigidity, generalized rebound tenderness, and absent bowel sounds. An upright chest radiograph reveals a distinct crescent of free air below the right hemidiaphragm. Following initial fluid resuscitation, which of the following is the most appropriate next step in management?