Surgery

A trauma team evaluates a 32-year-old male construction worker who fell 15 feet from a scaffold, striking his head on a concrete slab. On primary survey, he does not open his eyes, makes incomprehensible sounds, and exhibits decorticate posturing to painful stimuli. His right pupil is 8 mm and nonreactive to light. Vital signs show a blood pressure of 190/110 mmHg, a heart rate of 48/min, and a respiratory rate of 8/min with irregular breathing patterns.

Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 68-year-old woman is evaluated in the hospital for new-onset, severe abdominal pain and distension. She was admitted four days ago for community-acquired pneumonia and has been receiving intravenous ceftriaxone and azithromycin. The patient has not had a bowel movement or passed flatus for the past 24 hours. Her medical history includes type 2 diabetes mellitus, hypertension, and an open total abdominal hysterectomy performed a decade ago. Temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $92/58 \text{ mm Hg}$, and pulse is $118/\text{min}$. Physical examination reveals a markedly distended abdomen with diffuse tympany. Palpation elicits severe diffuse tenderness with involuntary guarding and rebound tenderness. Bowel sounds are absent. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum bicarbonate of $15 \text{ mEq/L}$. A plain radiograph of the abdomen demonstrates multiple dilated loops of small bowel with air-fluid levels and a paucity of gas in the colon. Which of the following is the most appropriate next step in management?

A 54-year-old woman is evaluated in the neurosurgical intensive care unit for worsening somnolence over the past 12 hours. She was admitted 6 days ago with a subarachnoid hemorrhage secondary to a ruptured left middle cerebral artery aneurysm, which was successfully treated with surgical clipping. Over the last 24 hours, her urine output has been 4.5 liters.

Vitals:
- Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
- Blood pressure: $88/54 \text{ mm Hg}$
- Heart rate: $122/\text{min}$
- Respirations: $16/\text{min}$

Physical examination shows dry mucous membranes and poor skin turgor. Neurologic examination reveals a Glasgow Coma Scale of 13 (E3, V4, M6). She has a right-sided pronator drift and mild right facial droop, which are unchanged from her immediate postoperative baseline.

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

A 25-year-old man is transported to the trauma center after being struck on the right side of the head with a heavy metal wrench during an altercation. He experienced a brief loss of consciousness lasting approximately one minute at the scene, but was subsequently awake, alert, and answering questions appropriately during transport. Three hours after arrival, he becomes acutely lethargic and stops following commands. His blood pressure is 165/95 mmHg, and his heart rate is 55/min. Neurological examination reveals a Glasgow Coma Scale score of 6 and a right pupil that is 7 mm and unresponsive to light. A non-contrast head computed tomography scan demonstrates a hyperdense, lens-shaped collection over the right frontotemporal convexity that does not cross cranial suture lines. Which of the following is the most appropriate next step in management?

A 29-year-old man presents to the emergency department with acute, agonizing pain in his groin. He reports that 2 hours ago, during vigorous sexual intercourse, he heard a distinct "snapping" sound, which was immediately followed by a loss of erection and rapid swelling of his penis. He states that he has felt a strong urge to urinate since the event but has been unable to pass any urine. Vital signs are within normal limits. Physical examination reveals a markedly swollen, ecchymotic penis that is severely deviated to the right. The scrotum is unremarkable, but there is a visible drop of fresh blood at the external urethral meatus. Which of the following is the most appropriate next step in the management of this patient?

A $65$-year-old man comes to the clinic for a follow-up examination $6$ weeks after undergoing a radical cystectomy and urinary diversion via an ileal conduit for muscle-invasive urothelial carcinoma. Over the past two weeks, he has experienced progressive fatigue and generalized muscle weakness. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $118/76\text{ mm Hg}$, pulse is $88/\text{min}$, and respirations are $22/\text{min}$. Physical examination shows a well-healed abdominal incision. The stoma is pink and viable, outputting clear yellow urine into the ostomy bag. The lungs are clear to auscultation bilaterally.

Laboratory studies are obtained:

Arterial blood gas analysis on room air shows:
- pH: $7.28$
- pCO $_2$: $28\text{ mm Hg}$
- pO $_2$: $96\text{ mm Hg}$

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

A 58-year-old woman is evaluated in the surgical clinic after routine laboratory testing reveals a serum calcium level of 11.4 mg/dL (normal: 8.4-10.2 mg/dL). She has a history of nephrolithiasis and complains of generalized fatigue. Arrange the following steps in the most appropriate chronological sequence for the evaluation and definitive surgical management of this patient's condition.

A 74-year-old man with a history of atrial fibrillation and congestive heart failure is brought to the emergency department due to sudden-onset, severe abdominal pain. The pain began $4$ hours ago and was initially out of proportion to his physical examination findings. He has rapidly become lethargic. Vital signs show a blood pressure of $80/50 \text{ mm Hg}$, pulse of $130/\text{min}$ and irregularly irregular, and respiratory rate of $24/\text{min}$. Abdominal examination reveals a distended abdomen with diffuse rebound tenderness and involuntary guarding. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ and a serum lactate of $8.5 \text{ mmol/L}$. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 49-year-old postmenopausal woman presents to the surgical breast clinic due to a 5-week history of right breast swelling, redness, and a feeling of heaviness. She was initially evaluated by her primary care provider and completed a 10-day course of oral cephalexin for presumed mastitis, but her symptoms have progressively worsened. She has no personal or family history of breast cancer. Her temperature is 37.1°C (98.8°F). Physical examination reveals a diffusely enlarged right breast with prominent erythema covering approximately 60% of the breast surface. The skin demonstrates a pitted, edematous appearance resembling an orange peel (peau d'orange). A poorly defined, firm area is palpated deep within the central quadrant. A 1.5-cm firm, mobile lymph node is palpable in the right axilla. Arrange the following steps in the most appropriate chronological sequence for the optimal evaluation and definitive management of this patient.

A $35$-year-old woman is evaluated in the clinic for a routine follow-up $3$ months after undergoing a total thyroidectomy and central compartment lymph node dissection for classical papillary thyroid carcinoma. Her postoperative course was complicated by permanent hypoparathyroidism due to inadvertent parathyroid gland resection, requiring continuous calcium and active vitamin D supplementation.

The patient currently feels well and reports no muscle cramping, perioral numbness, or tingling. Her medications include levothyroxine $125$ mcg daily, calcium carbonate $1000$ mg three times daily, and calcitriol $0.5$ mcg twice daily.

Vital signs are within normal limits. Physical examination reveals a well-healed Kocher incision and negative Chvostek and Trousseau signs.

Laboratory studies show the following:
Serum calcium: $9.3$ mg/dL (normal $8.4$ - $10.2$ mg/dL)
Serum phosphorus: $4.2$ mg/dL (normal $2.7$ - $4.5$ mg/dL)
Serum albumin: $4.0$ g/dL
Thyroid-stimulating hormone (TSH): $0.3$ $\mu$ U/mL (normal $0.5$ - $5.0$ $\mu$ U/mL)
Intact PTH: $8$ pg/mL (normal $15$ - $65$ pg/mL)
$24$-hour urine calcium: $450$ mg/day (normal < $250$ mg/day)

Renal ultrasound demonstrates no nephrolithiasis.

What is the most appropriate next step in management to prevent long-term complications in this patient?

A 62-year-old male with stage 4 chronic kidney disease secondary to hypertensive nephrosclerosis presents to the emergency department with a 3-day history of progressively worsening shortness of breath, orthopnea, and lower extremity edema. He has a past medical history of chronic obstructive pulmonary disease (COPD) and tobacco use. Four weeks ago, he underwent surgical creation of a left brachiocephalic arteriovenous fistula in anticipation of starting hemodialysis.

Vital signs are temperature 37.0°C (98.6°F), blood pressure 162/65 mm Hg, heart rate 112/min, respiratory rate 24/min, and oxygen saturation 92% on room air.

Physical examination reveals elevated jugular venous pressure at 10 cm H $_2$ O. Pulmonary auscultation demonstrates bilateral basilar crackles and diffuse expiratory wheezing. Cardiac examination reveals a hyperdynamic precordium with a regular tachycardia and a grade 2/6 systolic ejection murmur at the left upper sternal border. The left arm has a prominent, palpable thrill and a loud, continuous bruit over the surgical site. The right arm and bilateral lower extremities are warm with 2+ pitting edema.

Which of the following hemodynamic profiles best explains this patient's acute respiratory presentation?

An ambulance brings a 62-year-old male to the emergency department after he developed sudden, agonizing pain between his shoulder blades. He is visibly uncomfortable and sweating profusely. Vital signs include a heart rate of 118/min and blood pressures of 198/112 mm Hg in the right arm and 148/92 mm Hg in the left arm. Portable chest radiography displays widening of the mediastinal silhouette. The clinical picture strongly points toward an acute aortic syndrome. Arrange the following interventions in the most appropriate sequential order for managing this patient.

A 76-year-old man is brought to the emergency department from a skilled nursing facility due to severe, intractable vomiting and diffuse abdominal pain for the past 48 hours. He has a history of an open appendectomy 40 years ago and atrial fibrillation, for which he takes warfarin. Over the last 4 hours, the nursing staff noted he became progressively lethargic and confused. On arrival, his temperature is 38.8°C (101.8°F), pulse is 138/min, blood pressure is 78/45 mmHg, and respirations are 28/min. Physical examination reveals an altered, diaphoretic man. The abdomen is markedly distended, rigidly board-like, and exquisitely tender with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Laboratory studies show a leukocyte count of 24,000/mm³, a serum lactate of 7.8 mmol/L, and an INR of 3.6. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 71-year-old woman with a history of nonvalvular atrial fibrillation is brought to the emergency department due to sudden-onset, severe left leg pain that began 4 hours ago. She admits to running out of her prescribed oral anticoagulant medication two weeks ago. On physical examination, the left leg is pale and cold to the touch from the mid-calf distally. Femoral pulses are 2+ bilaterally, but the left popliteal and pedal pulses are completely absent. The patient has decreased sensation over the dorsum of the left foot and is unable to actively dorsiflex her toes.

Arrange the following interventions in the most appropriate chronological sequence for managing this patient's primary condition and its most likely post-intervention complication.

While recovering in the surgical intensive care unit on postoperative day 1 following coronary artery bypass grafting, a 58-year-old woman experiences acute respiratory distress. Thirty minutes prior to this event, a right internal jugular central venous catheter was inserted for hemodynamic monitoring. Her blood pressure has dropped to 70/40 mmHg, and her heart rate is 135/min. On physical examination, breath sounds are absent over the right lung field, and the jugular veins are prominently distended. Which of the following is the most appropriate next step in management?

A $68$-year-old left-handed man presents to the cardiology clinic complaining of recurrent chest pain. He describes the pain as a severe, pressure-like sensation that reliably occurs when he plays tennis or performs strenuous overhead activities with his left arm. The pain completely resolves within $5$ minutes of rest. Interestingly, he reports that he can walk on a treadmill for $45$ minutes without experiencing any chest discomfort. His past medical history is significant for peripheral artery disease, tobacco use disorder, and severe coronary artery disease. He underwent coronary artery bypass grafting (CABG) $14$ months ago, receiving a left internal mammary artery (LIMA) graft to the left anterior descending (LAD) artery and a saphenous vein graft to the right coronary artery.

Vital signs include a heart rate of $72$/min. Blood pressure is $152/88$ mmHg in the right arm and $108/68$ mmHg in the left arm. Physical examination reveals a distinct bruit auscultated over the left supraclavicular fossa. An electrocardiogram obtained during an episode of pain shows new ST-segment depressions in the anterior leads, which resolve completely after rest.

Which of the following is the most appropriate definitive management for this patient's underlying condition?

An adolescent boy, age $16$, presents to the triage desk reporting severe right-sided scrotal pain that awoke him from sleep approximately $90$ minutes ago. He has no prior medical history and does not report any recent sexual activity or trauma. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), pulse is $105/\text{min}$, and blood pressure is $120/75 \text{ mm Hg}$. Genitourinary examination demonstrates a diffusely swollen, markedly tender right testicle with a transverse lie, positioned notably higher than the contralateral testis. Stroking the inner aspect of the right thigh produces no testicular elevation, whereas the reflex is intact on the left side. Which of the following is the most appropriate next step in the management of this patient?

A physician evaluates a patient in the surgical triage area. The patient is a male in his late 50s with a 15-year history of poorly controlled type 2 diabetes mellitus. He presents with rapidly worsening genital pain and swelling over the past 24 hours, accompanied by high fevers and general malaise. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse is $122/\text{min}$, and blood pressure is $92/58 \text{ mmHg}$. Physical examination reveals a markedly edematous, erythematous scrotum and perineum. There are several patches of dark, purplish skin necrosis over the right hemiscrotum. Palpation of the affected area elicits exquisite pain along with a distinct crackling sensation beneath the skin. Laboratory studies show a leukocyte count of $24,500/\mu\text{L}$ with $15\%$ bands, and a serum glucose of $385 \text{ mg/dL}$. Which of the following is the most appropriate immediate next step in management?

While recovering on the surgical floor 24 hours after a total thyroidectomy for a large, symptomatic multinodular goiter, a patient reports the onset of a "crawling" sensation around her lips and fingertips. Vital signs show a temperature of 38.2°C (100.8°F), pulse of 92/min, respirations of 16/min, and blood pressure of 115/75 mm Hg. Examination of the neck reveals a clean, dry, and intact surgical incision without any surrounding swelling, fluctuance, or erythema. The patient's voice is normal and there is no stridor. Tapping the area just anterior to the earlobe results in brief twitching of the ipsilateral facial muscles. Laboratory results drawn earlier this morning reveal:

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

A $46$-year-old man is referred to the surgical endocrinology clinic due to refractory hypertension. His blood pressure is consistently $\geq 160/100$ mmHg despite adherence to maximum doses of amlodipine, lisinopril, and hydrochlorothiazide. Recent laboratory evaluation demonstrated a serum potassium level of $3.1$ mEq/L. The patient has no family history of endocrine malignancies. Suspecting a primary hypersecretory disorder, the surgical team plans a comprehensive diagnostic and therapeutic pathway.

Arrange the following steps in the correct chronological sequence for the standard diagnostic workup and definitive surgical management of this patient's condition.