Surgery

An on-call physician is asked to assess a 59-year-old female patient on the surgical ward. She is currently on her seventh day of recovery after undergoing an open resection of a perforated appendix. The nursing staff reports that she has developed excruciating, unremitting abdominal pain over the last few hours, accompanied by three episodes of vomiting dark green fluid. She confirms she has not passed gas or had a bowel movement since yesterday morning.

Vital signs show a temperature of 39.1°C (102.4°F), blood pressure of 92/58 mm Hg, heart rate of 128/min, and respiratory rate of 24/min. On physical examination, the patient appears acutely ill and lies completely still in bed. Her abdomen is significantly distended. Palpation elicits diffuse rigidity, involuntary guarding, and severe tenderness with sudden release of pressure. Auscultation reveals a complete absence of bowel sounds. Blood tests reveal a white blood cell count of 21,000/mm³ and an elevated venous lactate concentration. Plain abdominal radiographs display multiple loops of dilated small intestine containing prominent air-fluid levels, alongside an absence of distal colonic gas.

Which of the following are appropriate next steps in managing this patient's current condition? (Select all that apply)

A physician is called to the bedside to evaluate a 68-year-old male who developed acute shortness of breath. The patient underwent an uncomplicated partial bowel resection three days ago. His past medical history includes essential hypertension, hyperlipidemia, and a myocardial infarction four years ago. During the first two postoperative days, he received a total of 5 liters of isotonic crystalloid due to transient episodes of hypotension. Current vital signs show a temperature of 37.4°C (99.3°F), blood pressure of 162/95 mmHg, heart rate of 108/min, and a respiratory rate of 26/min. Pulse oximetry is 89% on room air. On physical examination, the jugular venous pressure is elevated. Lung auscultation reveals bilateral basilar crackles, and cardiac auscultation demonstrates a third heart sound (S3). The surgical incision is intact without erythema or drainage. Which of the following is the most appropriate next step in management?

Match each clinical presentation to its most appropriate definitive procedural or surgical management.

Match each of the following clinical presentations of urologic pathology with the most appropriate definitive surgical intervention.

Match each presentation of genitourinary trauma or iatrogenic injury with its most appropriate definitive surgical or clinical management step.

A 38-year-old woman is evaluated in the surgical intensive care unit on postoperative day 1 following an elective restorative proctocolectomy with ileal pouch-anal anastomosis for medically refractory ulcerative colitis. Her past medical history is significant for severe ulcerative colitis managed with high-dose oral prednisone for the past 8 months. The prednisone was tapered and completely discontinued 2 weeks prior to surgery due to the planned curative procedure.

Current vital signs are temperature 39.2°C (102.6°F), blood pressure 74/42 mm Hg, heart rate 126/min, and respiratory rate 22/min. Physical examination reveals a lethargic, somnolent patient. The abdomen is diffusely tender to deep palpation but remains soft, with no guarding, rebound, or rigidity. The surgical incision is clean, dry, and intact.

Laboratory studies show:

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

An 86-year-old multiparous woman is brought to the emergency department due to a 3-day history of progressive abdominal distension, intractable vomiting, and failure to pass flatus or stool. She resides in an assisted living facility and has a history of severe chronic obstructive pulmonary disease and profound, unintentional weight loss over the past 6 months. She also complains of pain radiating down the medial aspect of her right thigh, which is exacerbated by extending and internally rotating the right hip. Her temperature is $38.4^{\circ}\text{C}$ ($101.1^{\circ}\text{F}$), pulse is $122/\text{min}$, respirations are $24/\text{min}$, and blood pressure is $88/55\text{ mm Hg}$. Physical examination reveals a tympanic, distended abdomen with marked right lower quadrant tenderness and involuntary guarding. Bowel sounds are high-pitched and tinkling. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ with $15\%$ bands and a serum lactate level of $4.6\text{ mmol/L}$. An upright abdominal radiograph demonstrates multiple dilated loops of small bowel with prominent air-fluid levels, but no pneumoperitoneum. Which of the following is the most appropriate next step in management?

A $42$-year-old woman is evaluated in the hospital on postoperative day $2$ following a total thyroidectomy for a large toxic multinodular goiter. Her current medications include levothyroxine. She reports new-onset tingling around her mouth and in the fingertips of both hands. She also mentions mild nausea and states she has not had a bowel movement since before the surgery. She has no difficulty breathing or voice changes. Vital signs are temperature $38.0^{\circ}\text{C}$ ($100.4^{\circ}\text{F}$), blood pressure $122/78\text{ mmHg}$, heart rate $84/\text{min}$, and respiratory rate $14/\text{min}$. Physical examination reveals twitching of the ipsilateral facial muscles when the area just anterior to the earlobe is tapped. The surgical incision is clean, dry, and intact without erythema or fluctuance. The lungs are clear to auscultation. The abdomen is soft and non-distended with hypoactive bowel sounds.

Laboratory results are as follows:

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

During morning rounds on the surgical ward, a 62-year-old woman complains of new-onset pain around her incision and burning with urination. She is currently on postoperative day 6 following a total abdominal hysterectomy for symptomatic uterine fibroids. Her indwelling urinary catheter was removed 48 hours ago. Her temperature is 38.6°C (101.5°F), blood pressure is 122/78 mmHg, heart rate is 94/min, and respiratory rate is 16/min. Examination of the abdomen reveals significant erythema, induration, and a small amount of purulent drainage at the surgical incision site. Auscultation of the lungs reveals clear breath sounds bilaterally. Which of the following are the most appropriate next steps in the management of this patient? (Select all that apply)

A 72-year-old woman is seen by the surgical team on the fifth day following a right total hip arthroplasty. She complains of new, progressive aching pain in her right thigh and calf that began the previous evening. Her temperature is 38.3°C (100.9°F), blood pressure is 135/85 mm Hg, pulse is 96/min, and respiratory rate is 14/min. Pulse oximetry shows 98% on room air. Physical examination reveals asymmetric edema of the right lower extremity from the mid-thigh down to the ankle, along with localized tenderness over the posterior calf. The surgical incision over the lateral hip is well-approximated with no erythema, warmth, or discharge. Cardiopulmonary examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

During surgical rounds, an attending physician is reviewing the classic timeline of postoperative complications with the medical team to establish a diagnostic protocol. Arrange the following common causes of postoperative fever in the correct chronological order of their typical onset, starting with the earliest expected complication and ending with the latest.

Approximately 24 hours following an uncomplicated open appendectomy, a 34-year-old man is noted to have an elevated temperature. He has no significant past medical history and takes no routine medications. He currently complains only of expected mild pain at the surgical site. Vital signs show a temperature of 38.2°C (100.8°F), a heart rate of 90/min, blood pressure of 124/78 mm Hg, and a respiratory rate of 16/min. Oxygen saturation is 96% on room air. Auscultation of the chest demonstrates diminished breath sounds at the bilateral lung bases. Examination of the abdomen shows a dry, intact surgical dressing with no surrounding erythema or induration. Which of the following is the most appropriate next step in the management of this patient?

A 25-year-old male is brought to the emergency department via ambulance after a high-speed motorcycle collision. Upon arrival, his airway is patent and his breathing is spontaneous but rapid. His blood pressure is 75/40 mmHg, heart rate is 135/min, and respiratory rate is 24/min. Physical examination reveals a distended and rigidly tense abdomen with diffuse tenderness. Intravenous access is established, and 1 liter of warmed crystalloid solution is administered rapidly without improvement in his blood pressure. A Focused Assessment with Sonography for Trauma (FAST) examination reveals a large amount of free fluid in the hepatorenal and splenorenal recesses. Which of the following is the most appropriate next step in management?

A male patient in his late sixties is assessed on the second morning after undergoing an elective laparotomy for recurrent diverticulitis. His vital signs show a temperature elevation to 38.5°C (101.3°F), pulse of 88/min, respirations of 18/min, and blood pressure of 135/85 mm Hg. Auscultation reveals diminished aeration at both lung bases without any crackles or wheezes. The surgical wound appears to be healing well with no signs of induration, erythema, or purulent discharge. He reports that his abdominal pain is a 7 out of 10 and restricts him from taking deep breaths. Which of the following interventions are most appropriate at this time? (Select 2)

Match each classic clinical presentation following acute trauma with its most likely associated diagnosis.

A 59-year-old man is evaluated for a high fever one week after undergoing an elective partial colectomy with primary anastomosis for recurrent diverticulitis. He reports feeling generally unwell and has experienced nausea and worsening deep abdominal discomfort since yesterday. His temperature is 39.0°C (102.2°F), blood pressure is 122/76 mmHg, pulse is 108/min, and respirations are 18/min. Physical examination demonstrates a slightly distended abdomen with localized tenderness in the left lower quadrant, but no generalized peritonitis. The surgical skin closure is intact, dry, and shows no surrounding redness or discharge. A complete blood count reveals a leukocyte count of 17,200/mm³. Which of the following is the most appropriate next step in management?

Paramedics arrive at the trauma center with a 34-year-old construction worker who fell approximately 20 feet from a roof. The patient is moaning and clutching his abdomen. His temperature is 36.8°C (98.2°F), blood pressure is 82/45 mmHg, pulse is 128/min, and respirations are 22/min. Peripheral intravenous lines are placed, and fluid resuscitation is initiated. His airway is clear, and breath sounds are equal bilaterally. A bedside ultrasound evaluation of the abdomen demonstrates an anechoic fluid collection between the liver and right kidney. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old male is brought to the emergency department immediately after a high-speed motor vehicle collision. He is visibly distressed, tachycardic, and has multiple contusions on his chest and abdomen. According to the Advanced Trauma Life Support (ATLS) protocol, arrange the following initial assessment and management steps in the correct chronological order.

Match each of the following major cardiovascular conditions to its most characteristic clinical presentation and appropriate initial clinical context.

While on call for the surgical ward, you are urgently called to the bedside of a patient who underwent an open exploratory laparotomy six days ago. The patient had a severe coughing fit and reported feeling a sudden 'popping' sensation in the abdomen. On examination, the surgical dressing is saturated with serosanguinous fluid. When you carefully lift the dressing, you observe that the fascial layer has separated and loops of small intestine are protruding onto the abdominal wall. Arrange the following immediate management steps in the most appropriate chronological order.