Surgery

A resident is reviewing imaging studies and physical examination findings of patients with elevated intracranial pressure in the neurocritical care unit. Match each specific pattern of tissue displacement and associated clinical presentation with the correct brain herniation syndrome.

Match each clinical and diagnostic presentation with the most likely thyroid pathology.

A 74-year-old woman is evaluated in the clinic for a 6-month history of a slow, broad-based, shuffling gait, new-onset urinary incontinence, and mild cognitive decline. The physician suspects normal pressure hydrocephalus (NPH). Arrange the following diagnostic and therapeutic steps in the standard evidence-based sequence for managing this condition, from first to last.

A 68-year-old man comes to the physician because of a 3-month history of progressively worsening shortness of breath, a persistent "brassy" cough, and mild difficulty swallowing solid foods. He has a history of long-standing, poorly controlled hypertension and has smoked a pack of cigarettes daily for 40 years. His temperature is 37.0°C (98.6°F), blood pressure is 165/95 mm Hg, heart rate is 82/min, and respiratory rate is 18/min. Physical examination shows normal jugular venous pressure and no lower extremity edema. The lungs are clear to auscultation except for a faint, high-pitched expiratory sound heard predominantly over the central chest. Chest radiography reveals a significantly widened superior mediastinum and a prominent aortic silhouette. Which of the following is the most likely underlying cause of this patient's symptoms?

A 62-year-old woman is evaluated in the neurosurgical intensive care unit on postoperative day 5 following a right temporal craniotomy for glioblastoma resection. Over the past 12 hours, she has become progressively lethargic. She now only opens her eyes to painful stimuli and mutters incomprehensibly. Her temperature is 38.9°C (102.0°F), blood pressure is 145/88 mmHg, heart rate is 105/min, and respiratory rate is 16/min. Physical examination reveals pronounced nuchal rigidity. The surgical incision is well-approximated, clean, and has no fluctuance or drainage. An indwelling urinary catheter, placed prior to surgery, remains in situ. Which of the following is the most appropriate next step in management?

Match each clinical presentation with its most likely underlying vascular pathology or pathophysiologic mechanism.

A 59-year-old male with untreated hypertension arrives at the emergency department reporting the abrupt onset of a severe, tearing pain in his anterior chest that radiates straight to his interscapular region. His blood pressure is 210/115 mmHg, and his heart rate is 112/min. A portable chest radiograph demonstrates a widened mediastinum. Acute aortic dissection is highly suspected. Arrange the following clinical steps in the most appropriate chronological sequence for the evaluation and management of this patient.

Match each patient presentation involving a thyroid nodule or mass with the most appropriate surgical management or next step in intervention.

A $62$-year-old man with a history of poorly controlled hypertension is brought to the emergency department after suddenly developing a severe occipital headache, intractable vomiting, and an inability to walk. On presentation, his blood pressure is $210/110$ mm Hg, heart rate is $58$/min, and respiratory rate is $14$/min. His Glasgow Coma Scale (GCS) score is $14$. Neurologic examination shows marked left-sided dysmetria on finger-to-nose testing, horizontal nystagmus, and truncal ataxia. There is no limb weakness. Noncontrast CT of the head reveals a $4.2$-cm hyperdense acute hemorrhage in the left cerebellar hemisphere with complete effacement of the fourth ventricle. While in the emergency department, his level of consciousness rapidly declines, and his GCS score drops to $7$ (E2, V1, M4). The patient is immediately intubated for airway protection. Which of the following is the most appropriate next step in management?

A $72$-year-old man is brought to the emergency department due to severe lower abdominal pain and an inability to pass urine for the past $18$ hours. He has a history of benign prostatic hyperplasia for which he takes tamsulosin inconsistently. His temperature is $37.1^\circ\text{C}$, blood pressure is $155/92\text{ mmHg}$, pulse is $102/\text{min}$, and respiratory rate is $16/\text{min}$. Physical examination reveals a distressed patient in apparent pain. The abdomen is non-distended, but there is a palpable, tender, rounded mass extending from the pubic symphysis to the umbilicus. Digital rectal examination reveals a diffusely enlarged, smooth, and firm prostate without nodules. Which of the following is the most appropriate next step in management?

Correlate the following specific postoperative clinical presentations in cardiothoracic and vascular surgery patients with their precise underlying pathophysiologic mechanisms or anatomic etiologies.

A $52$-year-old woman is evaluated in the surgical clinic for a progressively enlarging anterior neck mass. Over the past $6$ months, she has noticed difficulty swallowing solid foods and a feeling of pressure in her neck when lying flat. During this time, she has also experienced profound fatigue, a $4$-kg ($8.8$-lb) weight gain, and occasional morning headaches. She has no prior medical history and takes no medications. Vital signs are temperature $36.8^\circ$ C ($98.2^\circ$ F), blood pressure $110/70$ mm Hg, pulse $64$/min, and respirations $14$/min. Physical examination reveals a large, firm, multinodular goiter. The lower border of the thyroid cannot be palpated above the sternal notch. A CT scan of the neck and chest without contrast demonstrates a massive multinodular goiter with significant tracheal deviation and substernal extension.

Preoperative laboratory results are as follows:

The surgeon plans to perform a total thyroidectomy to relieve the patient's compressive symptoms. Which of the following is the most appropriate next step in the management of this patient?

Family members bring a 68-year-old male to the emergency room due to a progressive decline in his mental status over the last 72 hours. He has a past medical history of normal pressure hydrocephalus, which was treated with the placement of a ventriculoperitoneal (VP) shunt four years ago. According to his relatives, he has been reporting severe, diffuse headaches and experienced two episodes of non-bilious vomiting this morning. Upon physical examination, the patient appears lethargic but localizes appropriately to painful stimuli. His temperature is $36.9^{\circ} \text{C}$ ($98.4^{\circ} \text{F}$), blood pressure is $170/92 \text{ mm Hg}$, pulse is $52/\text{min}$, and respiratory rate is $12/\text{min}$ and irregular. Funduscopic evaluation demonstrates bilateral blurring of the optic disc margins with absent venous pulsations. Which of the following is the most appropriate next step in the management of this patient?

Match the following clinical presentations and initial non-contrast head CT findings with the most likely specific type of intracranial hemorrhage.

A 55-year-old woman is brought to the emergency department due to a 1-day history of severe left flank pain, shaking chills, and confusion. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, pulse is $122/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals severe left costovertebral angle tenderness. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ with a left shift. A non-contrast computed tomography (CT) scan of the abdomen and pelvis reveals a 9-mm obstructing calculus in the proximal left ureter associated with moderate left hydroureteronephrosis and perinephric stranding. Arrange the following interventions in the most appropriate chronological order for the standard management of this patient.

A 58-year-old man undergoes a non-contrast computed tomography (CT) scan of the abdomen and pelvis in the emergency department for severe left flank pain. The scan reveals a 4-mm calculus in the left distal ureter, which he subsequently passes. Incidentally, a 3.2-cm mass is discovered in the right adrenal gland. The mass is homogeneous, has smooth margins, and shows an attenuation of 8 Hounsfield units (HU). He has a history of hypertension well-controlled on lisinopril. His blood pressure is 134/86 mm Hg, and his pulse is 76/min. Physical examination reveals a normal body habitus with no abdominal striae, proximal muscle weakness, or easily bruised skin. Which of the following is the most appropriate next step in the management of this patient's adrenal finding?

A 68-year-old man is brought to the emergency department due to rapidly progressive weakness in his legs over the past 24 hours. He is now unable to walk unassisted. He also reports lower abdominal discomfort and an inability to urinate since yesterday evening. For the last 3 months, he has had a constant, aching mid-back pain that frequently wakes him from sleep and is unrelieved by over-the-counter analgesics. His medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and a 50-pack-year smoking history. His temperature is 37.2°C (99.0°F), blood pressure is 158/92 mm Hg, pulse is 88/min, and respirations are 16/min. He is awake and fully oriented with a Glasgow Coma Scale score of 15. Neurologic examination shows 2/5 strength in the bilateral lower extremities with flaccid muscle tone. Deep tendon reflexes are 1+ at the patellae and absent at the Achilles tendons bilaterally. Plantar responses are absent. There is a distinct loss of pinprick and temperature sensation below the level of the umbilicus. A urethral catheter is placed, draining 750 mL of clear urine. Which of the following is the most appropriate initial step in the management of this patient?

Paramedics bring an 83-year-old female resident of an assisted living facility to the emergency department. She has experienced severe, colicky abdominal pain accompanied by nausea and intractable vomiting for the past four days. Staff note that her emesis, which initially contained partially digested food, has become dark brown and malodorous over the last 12 hours. She has not passed flatus or stool for two days. Her medical history includes hypertension, type 2 diabetes mellitus, and severe osteoarthritis. Her temperature is 37.8°C (100.0°F), blood pressure is 108/65 mm Hg, pulse is 112/min, and respirations are 18/min. Physical examination reveals a distended and tympanitic abdomen. Bowel sounds are high-pitched and hyperactive in rushes. There is diffuse mild tenderness to palpation, but no rebound guarding or rigidity. Groin examination reveals no palpable masses. Laboratory results show a leukocyte count of 13,500/mm³ and serum creatinine of 1.7 mg/dL. A noncontrast CT scan of the abdomen and pelvis demonstrates dilated loops of small bowel with a transition point in the distal ileum. There is a 3.5-cm radiopaque, lamellated structure intraluminally at the transition point, and branching radiolucencies are seen within the central liver. Which of the following is the most appropriate next step in management?

A $42$-year-old man is scheduled for a left-sided adrenalectomy after being diagnosed with a pheochromocytoma. He originally presented to the clinic with episodic headaches, profound sweating, and palpitations. His blood pressure during those episodes was often $\geq 180/110$ mm Hg. Laboratory evaluation confirmed elevated $24$-hour urine fractionated metanephrines. The patient is currently asymptomatic with a blood pressure of $145/90$ mm Hg. To prevent a life-threatening intraoperative cardiovascular complication, which of the following is the most appropriate initial pharmacological step prior to his surgery?

A $42$-year-old man with a history of Crohn disease and multiple prior ileal resections presents to the clinic for follow-up of a recent episode of right-sided flank pain. The pain began two days ago, radiated to his groin, and has since resolved completely after he took ibuprofen. He has chronic, non-bloody diarrhea but currently feels well. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $120/80 \text{ mm Hg}$, and pulse is $78/\text{min}$. Physical examination demonstrates a soft, non-tender abdomen with mild right costovertebral angle tenderness. Laboratory testing reveals a serum creatinine of $0.9 \text{ mg/dL}$. Urinalysis shows a pH of $5.0$, $15-20 \text{ RBCs/hpf}$, and no leukocyte esterase or nitrites. A kidney, ureter, and bladder (KUB) radiograph demonstrates no radiopaque abnormalities. A subsequent non-contrast CT scan of the abdomen and pelvis reveals a $1.6\text{-cm}$ calculus in the right renal pelvis causing mild hydronephrosis. Which of the following is the most appropriate next step in management of this patient's calculus?