Surgery

A 42-year-old woman is brought to the trauma bay by helicopter emergency medical services after crashing her snowmobile into a fence at high speed. She complains of severe abdominal pain. Her temperature is 36.5°C (97.7°F), blood pressure is 76/45 mm Hg, and pulse is 128/min. She is lethargic but appropriately answers questions. The airway is clear, and the trachea is midline. Breath sounds are clear and equal bilaterally. Jugular venous pressure is not elevated. The abdomen is distended, rigid, and exhibits diffuse guarding. A bedside focused assessment with sonography for trauma (FAST) demonstrates a significant anechoic stripe in the hepatorenal recess. Two large-bore intravenous lines are established, and crystalloid fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

Emergency medical services transport a 30-year-old factory worker to the regional trauma center after an industrial flash fire. The primary survey confirms a patent airway, symmetric breath sounds, and stable hemodynamics. Secondary evaluation of the patient's integumentary system reveals partial-thickness and full-thickness burns covering the entire anterior aspect of his trunk as well as the entire anterior aspect of his left leg. The genital region, head, posterior torso, arms, right leg, and posterior left leg are completely spared. Based on the standard adult Rule of Nines, what is the estimated percentage of total body surface area affected by these burns?

A 68-year-old woman is examined on the fourth day of her recovery following an elective low anterior resection for rectal cancer. She reports experiencing new-onset lower abdominal discomfort over the past 12 hours. The patient has had an indwelling urethral catheter in place since the operation to prevent postoperative urinary retention. Her temperature is 38.4°C (101.1°F), blood pressure is 118/76 mm Hg, heart rate is 92/min, and respiratory rate is 16/min. Physical examination shows a soft abdomen with mild tenderness localized to the suprapubic region. The midline abdominal surgical incision is well-approximated, dry, and lacks any surrounding erythema or induration. The patient's lungs are clear to auscultation bilaterally, and there is no edema or tenderness in her lower extremities. Which of the following is the most appropriate next step in the management of this patient's fever?

A 24-year-old man is brought to the emergency department after sustaining a stab wound to the right upper quadrant of his abdomen during a physical altercation. On arrival, he appears confused, pale, and profusely diaphoretic. Vital signs are temperature 36.8°C (98.2°F), heart rate 138/min, blood pressure 75/40 mm Hg, and respiratory rate 22/min. Physical examination reveals a 3-cm linear laceration just below the right costal margin. The abdomen is notably distended with diffuse guarding and marked rebound tenderness in all four quadrants. Peripheral pulses are weak and thready. Which of the following is the most appropriate next step in the management of this patient?

Match the following classic trauma presentations with their most appropriate immediate next step in management or diagnosis.

Nursing staff requests an urgent assessment of a 62-year-old male on his sixth day of recovery following an open total gastrectomy and Roux-en-Y esophagojejunostomy for gastric adenocarcinoma. Over the preceding twelve hours, he has developed worsening shortness of breath accompanied by new-onset pain radiating to his left shoulder. His past medical history is notable for severe chronic obstructive pulmonary disease and diet-controlled type 2 diabetes mellitus.

Current vital signs demonstrate a temperature of 38.8°C (101.8°F), a heart rate of 124 beats per minute, a respiratory rate of 28 breaths per minute, and a blood pressure of 84/52 mmHg. Pulse oximetry shows an oxygen saturation of 88% on room air.

Physical examination reveals a diaphoretic and distressed patient. Pulmonary auscultation demonstrates absent breath sounds and dullness to percussion over the lower third of the left posterior hemithorax. The abdomen is tensely distended with severe diffuse tenderness, board-like rigidity, and rebound tenderness most pronounced in the left upper quadrant. Bowel sounds are absent. A bedside electrocardiogram reveals sinus tachycardia without ischemic changes.

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

A 33-year-old construction worker is brought to the emergency department after falling approximately 20 feet from scaffolding. On arrival, he is in severe respiratory distress and is unable to answer questions. His blood pressure is 74/42 mm Hg, and his heart rate is 138/min. Physical examination reveals severely distended jugular veins, a trachea that is deviated to the right, and completely absent breath sounds over the left hemithorax. Which of the following is the most appropriate immediate next step in the management of this patient?

During a severe thunderstorm, a 52-year-old male is struck by a heavy falling tree branch and sustains significant blunt force trauma to his torso. On presentation to the trauma bay, his blood pressure is 78/52 mm Hg and pulse is 132/min. He is tachypneic with a respiratory rate of 26/min and oxygen saturation of 94% on room air. The primary survey reveals equal breath sounds bilaterally and no tracheal deviation. His abdomen is rigid with severe, diffuse tenderness to palpation. A bedside ultrasound demonstrates an anechoic stripe between the right kidney and the liver. Which of the following is the most appropriate next step in the management of this patient?

A 71-year-old man is urgently assessed on the surgical ward due to sudden clinical deterioration. He is currently on postoperative day 5 following a small bowel resection for a benign stricture. For the last two days, he has experienced progressive abdominal distension, nausea, and failure to pass flatus. Over the past hour, his abdominal pain has become severe and constant. His temperature is 38.8°C (101.8°F), blood pressure is 84/50 mmHg, and pulse is 124/min. Abdominal examination reveals severe diffuse tenderness, board-like rigidity, and involuntary guarding. Bowel sounds are absent. Laboratory results are significant for a leukocyte count of $21,000/mm^3$ and a serum lactate of $4.5 \text{ mmol/L}$. Which of the following is the most appropriate next step in management?

A 31-year-old woman, G1P0 at 35 weeks gestation, is brought to the emergency department via ambulance following a high-speed frontal motor vehicle collision. She was the restrained driver. Upon arrival, her blood pressure is 78/42 mmHg, pulse is 128/min, and respirations are 24/min. She is pale, diaphoretic, and lethargic. Physical examination reveals a transverse ecchymosis across the lower abdomen. The abdomen is diffusely tender with involuntary guarding. The uterus is firm and exquisitely tender to palpation. Fetal heart rate monitoring demonstrates a baseline of 110/min with absent variability and recurrent late decelerations. An extended focused assessment with sonography for trauma (E-FAST) reveals a large volume of anechoic fluid in the hepatorenal space (Morison pouch). Which of the following is the most appropriate next step in the management of this patient?

During morning rounds, the surgical team examines a 55-year-old woman on her fourth day of recovery following an elective sigmoid colectomy. She is lethargic and her vital signs show a blood pressure of 80/45 mm Hg, heart rate of 125/min, and temperature of 39.2 C (102.6 F). Physical examination reveals a distended abdomen that is diffusely tender with marked rigidity and involuntary guarding. A diagnosis of acute septic shock secondary to an anastomotic leak is suspected. Arrange the following critical management steps in the most appropriate chronological sequence for this patient.

Match each classic burn trauma or post-resuscitation clinical presentation with its most appropriate immediate diagnostic or therapeutic next step in management.

A $78$-year-old man is evaluated in the surgical ward on postoperative day $4$ following an open reduction and internal fixation of a comminuted intertrochanteric femur fracture. His medical history includes hypertension, diet-controlled type $2$ diabetes mellitus, and chronic kidney disease stage II. Over the past $48$ hours, he has developed progressive, severe abdominal distension and nausea without vomiting. He has not passed flatus or had a bowel movement since the surgery. His pain is being managed with a patient-controlled intravenous hydromorphone pump.

Vital signs include a temperature of $37.1^\circ\text{C}$, heart rate of $88$/min, blood pressure of $135/85$ mmHg, and respiratory rate of $16$/min. On physical examination, the abdomen is massively distended and tympanitic to percussion throughout, with high-pitched, infrequent bowel sounds. There is diffuse mild tenderness but no rebound guarding or rigidity.

An initial portable supine abdominal radiograph demonstrates severe dilation of the entire colon, with the cecum measuring $10.5$ cm in diameter. A subsequent computed tomography (CT) scan of the abdomen and pelvis with water-soluble enteral contrast confirms marked colonic dilation without any transition point, mechanical obstruction, or signs of bowel ischemia, establishing the diagnosis of acute colonic pseudo-obstruction (Ogilvie syndrome).

Assuming the patient's condition ultimately proves refractory to each successive non-operative therapy without developing signs of peritonitis or perforation, arrange the following therapeutic interventions in the correct algorithmic sequence from first-line to last-resort management.

A 42-year-old woman is evaluated in the post-anesthesia care unit three hours after a total thyroidectomy for Graves disease. The nursing staff urgently requests an assessment because the patient has developed severe agitation and difficulty breathing. Vital signs show a heart rate of 118/min, respiratory rate of 28/min, and oxygen saturation of 86% on room air. Physical examination reveals a tense, rapidly expanding swelling of the anterior neck beneath the surgical incision, accompanied by significant inspiratory stridor. Arrange the following management steps in the most appropriate chronological sequence for this acute postoperative emergency.

A $64$-year-old woman is evaluated on postoperative day $5$ following a right total knee arthroplasty. She reports new-onset right calf pain that worsens when she attempts to walk. Her temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $130/80\text{ mm Hg}$, pulse is $88/\text{min}$, and respirations are $16/\text{min}$. Physical examination reveals right calf swelling, warmth, and tenderness to palpation. The surgical incision site is well-approximated, clean, and without purulent discharge or surrounding erythema. Her breath sounds are clear bilaterally. Which of the following is the most appropriate next step in the management of this patient?

A 19-year-old male is brought to the emergency department after a collision during a rugby match. While running, he was struck forcefully in the left upper quadrant of the abdomen by an opposing player's knee. He initially tried to continue playing but collapsed on the sideline due to lightheadedness and severe abdominal pain.

On presentation, his temperature is 36.6°C (97.9°F), blood pressure is 82/48 mm Hg, heart rate is 134/min, and respiratory rate is 22/min. He appears pale and diaphoretic. The airway is intact, and breath sounds are equal bilaterally. Cardiac examination reveals sinus tachycardia. His abdomen is rigid and diffusely tender with guarding and rebound tenderness, most pronounced in the left upper quadrant. The pelvis is stable to compression.

A focused assessment with sonography for trauma (FAST) examination demonstrates anechoic free fluid in the splenorenal recess and the rectovesical pouch. Two large-bore peripheral intravenous lines are established. Despite a 1-liter bolus of warmed isotonic crystalloid and initiation of an uncrossmatched blood transfusion, his blood pressure remains 84/50 mm Hg.

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

A 45-year-old man is brought to the emergency department after a propane tank explosion at his home. He is awake, alert, and complaining of severe pain. Physical examination reveals deep partial-thickness (second-degree) and full-thickness (third-degree) burns involving his entire posterior trunk and both of his entire upper extremities. There are also superficial (first-degree) burns involving his entire face and neck. The remainder of his body is unaffected. Based on the Rule of Nines, what is the estimated total body surface area (TBSA) percentage that should be used to calculate his initial fluid resuscitation requirements?

A $51$-year-old male is evaluated in the surgical oncology clinic for a newly discovered neck mass. Two weeks ago, he underwent a carotid duplex ultrasound as part of a workup for transient visual changes, which incidentally revealed a $2.6\text{ cm}$ solid nodule in the right thyroid lobe. The patient reports an $8$-month history of progressive fatigue, decreased libido, and feeling cold constantly. He has no personal or family history of head and neck irradiation or thyroid malignancy. His blood pressure is $108/68\text{ mmHg}$ and pulse is $54\text{/min}$. Physical examination shows a firm, non-tender nodule palpable in the right anterior neck. No cervical lymphadenopathy is present. Testicular examination reveals bilaterally small, soft testes. Laboratory studies show:

Thyroid-stimulating hormone (TSH): $0.12\text{ \mu U/mL}$ (normal: $0.4-4.0\text{ \mu U/mL}$)
Free thyroxine (T4): $0.5\text{ ng/dL}$ (normal: $0.9-1.7\text{ ng/dL}$)

Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's thyroid nodule?

A $22$-year-old man is brought to the emergency department by ambulance $15$ minutes after sustaining a stab wound to the left side of his chest during an altercation. On arrival, the patient is agitated and diaphoretic. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $82/40 \text{ mmHg}$, pulse is $132/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry shows $94\%$ on room air. Primary survey reveals a $3 \text{ cm}$ linear laceration in the left $6^{\text{th}}$ intercostal space at the midaxillary line. The trachea is midline. Breath sounds are markedly diminished on the left side of the chest. The abdomen is slightly distended and diffusely tender to palpation. A left-sided tube thoracostomy is placed, draining $400 \text{ mL}$ of gross blood and a small amount of bubbling air. Five minutes after chest tube placement, breath sounds are equal bilaterally, and oxygen saturation improves to $99\%$. However, his blood pressure remains $80/42 \text{ mmHg}$ and pulse is $135/\text{min}$ despite rapid intravenous infusion of $1 \text{ L}$ of warmed crystalloid solution. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large anechoic fluid collection in the splenorenal recess, with no pericardial effusion identified. Which of the following is the most appropriate next step in management?

A 35-year-old man is brought to the emergency department after being rescued from a closed-space house fire. He is coughing up carbonaceous sputum and has a hoarse voice. He has sustained deep partial-thickness and full-thickness burns covering his entire anterior trunk and bilateral upper extremities. According to standard trauma and burn management principles, arrange the following clinical interventions in the most appropriate chronological sequence.