Surgery

A 62-year-old man is evaluated in the neurosurgical intensive care unit due to a sudden decline in consciousness. He underwent an uncomplicated right frontotemporal craniotomy for resection of a meningioma 48 hours ago. Over the past hour, the nurse noted that he became increasingly difficult to arouse. His temperature is 38.1°C (100.6°F), blood pressure is 180/100 mm Hg, pulse is 48/min, and respirations are 10/min and irregular. Glasgow Coma Scale score is 7 (E2, V2, M3), decreased from a baseline of 14. Neurologic examination reveals a 7-mm, unreactive right pupil and a new profound left-sided hemiparesis. The surgical incision site appears clean and intact. Which of the following is the most appropriate next step in management?

Match each clinical presentation to its most likely neurosurgical diagnosis.

A 72-year-old man is brought to the emergency department by his daughter due to sudden-onset, severe right leg pain that began 2 hours ago. He has a history of hypertension, type 2 diabetes mellitus, and atrial fibrillation. He is prescribed apixaban but admits to missing several doses over the past week. On physical examination, the right lower extremity is pale and cool to the touch from the mid-thigh down. Femoral, popliteal, and pedal pulses are nonpalpable on the right, while they are 2+ on the left. The patient has decreased sensation over the dorsum of his right foot and exhibits mild weakness when asked to dorsiflex his toes. Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A $24$-year-old man is brought to the emergency department after colliding with a tree while downhill skiing. He reports severe, continuous pain in his right flank and right upper quadrant. His temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $118/76$ mmHg, pulse is $92$/min, and respirations are $16$/min. Physical examination reveals a $15$-cm area of ecchymosis over the right flank with marked tenderness to palpation. The abdomen is soft without rebound tenderness or guarding. Urinalysis demonstrates gross hematuria. A focused assessment with sonography for trauma (FAST) is negative for intraperitoneal free fluid. Computed tomography of the abdomen and pelvis with intravenous contrast reveals a $3.5$-cm laceration of the right kidney that extends deep into the renal medulla and collecting system. Delayed-phase imaging demonstrates pooling of contrast medium in the perirenal space. There is a moderate, non-expanding perirenal hematoma, but no evidence of active arterial extravasation (blush). Which of the following is the most appropriate next step in management?

Match each clinical presentation below with the most appropriate definitive surgical intervention.

A 55-year-old woman is brought to the emergency department from a nursing facility due to fever, severe left-sided back pain, and altered mental status. Her blood pressure is 85/50 mmHg, heart rate is 122/min, and temperature is 39.4°C (102.9°F). Laboratory studies show a leukocyte count of 19,000/mm³. A non-contrast CT scan of the abdomen and pelvis reveals an 8-mm radiopaque calculus in the proximal left ureter with associated moderate hydroureteronephrosis and perinephric stranding. Arrange the following management steps in the most appropriate chronological sequence for this patient.

An ambulance brings a 48-year-old female to the emergency department following a sudden collapse at a grocery store. Bystanders report she grabbed her head and screamed about a sudden, explosive headache before briefly losing consciousness. In the ED, her blood pressure is 165/90 mm Hg and heart rate is 88/min. She is groggy, heavily photophobic, and strongly resists neck flexion. Neurologic examination reveals no focal motor or sensory deficits. Arrange the following diagnostic and therapeutic steps in the correct chronological sequence for the standard clinical management of this patient's suspected condition.

An ill-appearing 58-year-old man is evaluated in the emergency department for severe perineal pain, chills, and an inability to pass urine for the past 12 hours. His temperature is 39.2°C (102.6°F), blood pressure is 105/65 mmHg, and heart rate is 112/min. Digital rectal examination demonstrates an exquisitely tender, warm, and swollen prostate gland. A bedside bladder scan reveals 700 mL of retained urine. Arrange the following interventions in the most appropriate chronological sequence for the management of this patient, progressing from immediate medical steps to procedural intervention and definitive surgical management of potential complications.

A 32-year-old man is brought to the emergency department 45 minutes after being struck on the right side of the head with a heavy wrench during a workplace altercation. Witnesses report he lost consciousness for approximately one minute immediately after the impact, but then awoke and was able to converse normally. Over the past 15 minutes, he has become progressively lethargic and is now unresponsive to verbal commands. His blood pressure is 165/90 mmHg, and his pulse is 52/min. Neurologic examination reveals a dilated, unreactive right pupil and left-sided hemiparesis. A non-contrast CT scan of the head demonstrates a large, biconvex hyperdense mass over the right temporoparietal convexity with a 12-mm leftward midline shift. Which of the following is the most appropriate next step in the management of this patient?

A 45-year-old woman comes to the clinic after noticing a lump in the front of her neck two weeks ago. She has also experienced a 4-kg (8.8-lb) unintentional weight loss, intermittent palpitations, and increased sweating over the past month. Her temperature is 37.0°C (98.6°F), blood pressure is 135/85 mm Hg, and pulse is 108/min. Physical examination shows a 2.5-cm, firm, mobile nodule in the right lobe of the thyroid gland. There is no cervical lymphadenopathy. Laboratory studies show:

TSH: 0.05 mU/L (normal: 0.4-4.0 mU/L)
Free T4: 2.6 ng/dL (normal: 0.8-1.8 ng/dL)

An ultrasound of the neck demonstrates a 2.5-cm solid, hypoechoic nodule in the right thyroid lobe. Which of the following is the most appropriate next step in the management of this patient?

A $41$-year-old woman is referred to the endocrine surgery clinic after her primary care physician palpated a swelling in her lower neck. She has no palpitations, heat intolerance, or unexpected weight changes. Vital signs are within normal limits. Physical examination reveals a $3.5\text{-cm}$, firm, mobile nodule in the right thyroid lobe. Cervical lymph nodes are not palpable. Laboratory testing shows a thyroid-stimulating hormone (TSH) level of $1.8 \text{ mU/L}$ (normal: $0.4 - 4.0 \text{ mU/L}$) and a free thyroxine (T4) level of $1.3 \text{ ng/dL}$ (normal: $0.9 - 1.7 \text{ ng/dL}$). A neck ultrasound confirms a $3.5\text{-cm}$ solid, isoechoic nodule in the right lobe with a thin hypoechoic halo. A fine-needle aspiration (FNA) biopsy is performed, and cytology yields a highly cellular specimen composed of follicular cells arranged in microfollicles with scant colloid. No nuclear grooves or pseudoinclusions are identified. Which of the following is the most appropriate next step in management?

Emergency medical services arrive at the trauma bay with a 38-year-old construction worker who sustained a fall from a fourth-story scaffolding. En route, he received 1 liter of intravenous crystalloid. Upon arrival, the patient is obtunded and groaning painfully. Vital signs demonstrate a blood pressure of 78/42 mm Hg, a pulse of 138/min, and a respiratory rate of 28/min. Primary survey reveals profound pallor and diaphoresis. The trachea is midline, and jugular venous distention is absent. Auscultation of the chest demonstrates markedly absent breath sounds over the entire left hemithorax with accompanying dullness to percussion. Heart sounds are distinct and rapid. The pelvis is mechanically stable, and an extended focused assessment with sonography for trauma (eFAST) yields negative results for pericardial and intraperitoneal fluid.

A left-sided tube thoracostomy is rapidly placed, which immediately yields 1,750 mL of bright red blood. Following the administration of two units of uncrossmatched packed red blood cells, his blood pressure marginally improves to 82/48 mm Hg.

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

A 74-year-old man with a history of hypertension and atrial fibrillation treated with apixaban is brought to the emergency department by emergency medical services. His wife reports that he experienced a sudden, severe occipital headache and intractable vomiting 45 minutes ago before collapsing. Upon arrival in the trauma bay, he is unresponsive. His eyes do not open to pain, he makes incomprehensible sounds, and he exhibits abnormal extensor posturing to painful stimuli. His blood pressure is 220/115 mmHg, heart rate is 52/min, and respiratory rate is 10/min with irregular breathing patterns.

Arrange the following clinical interventions in the most appropriate, evidence-based sequential order for the acute management of this patient.

Correlate the following nuanced clinical presentations of abdominal pathology with their most appropriate definitive management strategy.

Vascular and cardiothoracic surgery encompasses a wide range of acute and chronic pathologies with distinct clinical presentations. Match the following classic clinical presentations with their most likely corresponding vascular diagnosis.

A 74-year-old woman with a history of atrial fibrillation, noncompliant with her apixaban, presents to the emergency department with sudden-onset, severe periumbilical abdominal pain. Her vital signs show a temperature of 38.4°C (101.1°F), blood pressure of 88/54 mmHg, and heart rate of 122/min. Physical examination reveals a rigid abdomen with diffuse guarding and rebound tenderness. Laboratory studies demonstrate a leukocyte count of 24,500/mm³ and a serum lactate level of 7.2 mmol/L. Arrange the following steps in the most appropriate sequential order for the definitive management of this patient's condition.

Match each clinical presentation of a scrotal or testicular mass to its most appropriate definitive management.

An 82-year-old woman is evaluated in the emergency department for a 4-day history of progressively worsening, colicky abdominal pain accompanied by nausea and feculent vomiting. Her medical history includes hypertension, osteoarthritis, and moderate dementia. She lives with her daughter, who is her legally appointed healthcare proxy. Her estranged son recently arrived at the hospital and has been demanding to direct her medical care.

Vitals:
Temperature: $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$)
Heart rate: $105/\text{min}$
Blood pressure: $110/70 \text{ mm Hg}$

Physical examination reveals a distended and tympanitic abdomen with high-pitched bowel sounds. There is mild, diffuse tenderness to palpation but no guarding, rigidity, or rebound tenderness.

Laboratory studies:
Leukocytes: $11,500/\text{mm}^3$
Lactate: $1.6 \text{ mmol/L}$
Liver function tests: Within normal limits

A computed tomography scan of the abdomen and pelvis without contrast reveals dilated loops of small bowel up to the terminal ileum, air in the biliary tree, and a $3.5\text{-cm}$ radiopaque, calcified mass impacted in the distal ileum. The colon is decompressed.

The son demands that the medical team transition her to comfort care, stating, 'She is too frail for any surgery, and I am the oldest child, so I make the decisions.' The daughter states, 'She has excellent quality of life at home. I want whatever is medically necessary to relieve this blockage.'

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

A 31-year-old man presents to the emergency department with a painful, fully rigid erection that has persisted for 18 hours. He admits to recreational cocaine use the previous evening. Physical examination reveals tense, tender corpora cavernosa with a completely flaccid glans penis and corpus spongiosum. Arrange the following diagnostic and therapeutic interventions in the correct escalating sequence for managing this condition, assuming each successive step fails to achieve permanent detumescence.

Match each clinical presentation of an acute abdominal emergency with the most appropriate definitive next step in management.