Surgery

An obese male patient, aged $58$, with a $15$-year history of poorly controlled type $2$ diabetes mellitus, is evaluated in the emergency department for severe genital pain and progressive swelling that began $24$ hours ago. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $90/60 \text{ mmHg}$, pulse is $118 \text{ /min}$, and respirations are $22 \text{ /min}$. Physical examination reveals marked erythema, edema, and induration of the perineum extending anteriorly to the scrotum. Palpation of the affected area elicits exquisite tenderness and a distinct crackling sensation beneath the skin. A small area of dark, necrotic-appearing tissue is visible on the right hemiscrotum, exuding a malodorous discharge. Aggressive intravenous fluid resuscitation is immediately initiated. Which of the following is the most appropriate next step in the management of this patient?

A 72-year-old man is brought to the emergency department by ambulance due to a massive episode of hematemesis and hematochezia. He reports that earlier today he had a smaller episode of bloody emesis which he ignored. His medical history is significant for hypertension, hyperlipidemia, and an open abdominal aortic aneurysm repair with a synthetic Dacron graft performed four years ago. On arrival, he is lethargic and pale. Vital signs are temperature 37.1°C (98.8°F), blood pressure 75/40 mm Hg, heart rate 132/min, and respiratory rate 22/min. Physical examination reveals a soft, non-distended abdomen without guarding. Intravenous access is established and a massive transfusion protocol is initiated, but his blood pressure remains 78/42 mm Hg. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical presentation involving breast or endocrine pathology with the most appropriate definitive surgical or multidisciplinary management strategy.

A medical student is reviewing classic presentations of intracranial hemorrhages. Match the clinical presentation to the most likely corresponding intracranial hemorrhage.

Match each clinical presentation of genitourinary trauma to its most appropriate definitive management.

During a routine health maintenance visit, a 54-year-old woman is found to have an elevated serum calcium level of $11.4 \text{ mg/dL}$ (normal: $8.4-10.2 \text{ mg/dL}$), with a normal serum albumin of $4.0 \text{ g/dL}$. She has a past medical history significant for an episode of nephrolithiasis two years ago. She currently takes amlodipine for mild hypertension. She denies bone pain, abdominal pain, or changes in mood. To appropriately manage this patient, arrange the following diagnostic and therapeutic steps into the correct chronological sequence.

A 14-year-old boy is brought to the emergency department by his parents due to sudden-onset, severe left testicular pain that awoke him from sleep 2 hours ago. He reports one episode of nonbilious emesis since the pain started. Vital signs are temperature 37.1°C (98.8°F), blood pressure 118/76 mmHg, and heart rate 105/min. Physical examination reveals a swollen, exquisitely tender, and high-riding left testicle with a transverse lie. The cremasteric reflex is absent on the left side but intact on the right. Elevation of the left testicle does not relieve the pain. Which of the following is the most appropriate next step in management?

A 72-year-old man is evaluated in the surgical step-down unit for sudden-onset shortness of breath, confusion, and decreased urine output. He underwent a coronary artery bypass grafting and aortic valve replacement 6 days ago. His medical history includes chronic obstructive pulmonary disease and ischemic cardiomyopathy with a left ventricular ejection fraction of 35%. His temperature is 37.9°C (100.2°F), blood pressure is 80/55 mm Hg, pulse is 118/min, and respirations are 26/min. Pulse oximetry shows 91% on room air. Physical examination reveals distant heart sounds and distended jugular veins up to the angle of the mandible. The lungs have decreased breath sounds at the bases with scattered end-expiratory wheezes. His extremities are cool and clammy. Chest radiography shows an enlarged cardiac silhouette and small bilateral pleural effusions, unchanged from postoperative day 2. An electrocardiogram demonstrates sinus tachycardia and low-voltage QRS complexes. Arterial blood gas analysis on room air shows:

pH: 7.28
pCO2: 32 mm Hg
pO2: 60 mm Hg
Bicarbonate: 15 mEq/L

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

A 55-year-old woman presents to the clinic after discovering a firm, painless lump in her right breast 2 weeks ago. Physical examination reveals a 2.5-cm hard, irregular, and relatively fixed mass in the upper outer quadrant of the right breast. There is no nipple discharge, skin dimpling, or palpable axillary lymphadenopathy. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient.

A 22-year-old male is transported to the trauma bay via helicopter following a high-speed motorcycle collision where he was ejected and found without a helmet. Upon arrival, his blood pressure is 165/95 mm Hg, and his heart rate is 55/min. He does not open his eyes to pain, makes incomprehensible sounds, and exhibits extension of his arms and legs in response to painful stimuli. Examination reveals a 6-mm, nonreactive right pupil and a 3-mm, briskly reactive left pupil.

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

A medical student is rotating on the cardiothoracic and vascular surgery service. The attending physician describes four complex clinical scenarios involving acute thoracic and vascular pathologies. Carefully analyze each patient's presentation and physical exam findings. Match each clinical vignette with the most precise underlying pathophysiological mechanism.

An emergency response team is called to evaluate a 61-year-old male in the observation unit. Six hours earlier, the patient presented to the emergency department with a painful, non-reducible right groin mass that had been present for 10 hours. An emergency physician performed a bedside manual reduction under procedural sedation, which successfully flattened the groin bulge. However, the patient has since developed relentless, diffuse abdominal pain and two episodes of bilious emesis. Current vital signs are temperature 38.3°C (100.9°F), heart rate 124/min, blood pressure 92/58 mm Hg, and respiratory rate 22/min. Physical examination reveals an empty right inguinal canal with no overlying skin changes. The abdomen is markedly distended, with rigid musculature, diffuse rebound tenderness, and absent bowel sounds. Laboratory testing demonstrates a leukocyte count of 19,500/mm³ and a serum lactate of 4.6 mmol/L. Which of the following is the most appropriate next step in management?

A 65-year-old man is brought to the emergency department after experiencing three large episodes of painless, maroon-colored stool at home. He has a history of hypertension, hyperlipidemia, and osteoarthritis for which he takes naproxen daily. Upon arrival, he is lethargic. His temperature is 37.0°C (98.6°F), blood pressure is 85/50 mm Hg, and pulse is 122/min. Physical examination reveals pale conjunctivae and a non-tender, non-distended abdomen. Rectal examination shows gross maroon blood. Arrange the following interventions in the most appropriate chronological order for the optimal management of this patient, assuming the bleeding source remains elusive and persistent at each preceding diagnostic or therapeutic step.

A surgical team is establishing triage protocols for patients presenting to the emergency department with acute genitourinary symptoms. Match each patient scenario with the most appropriate immediate diagnostic or therapeutic intervention.

A 68-year-old woman is brought to the emergency department by paramedics after a syncopal episode at a local grocery store. Upon awakening, she reports sudden, agonizing lower back pain and left flank pain. Her medical history includes hypertension, hyperlipidemia, and a 40-pack-year smoking history. Vital signs show a heart rate of 128/min, blood pressure of 72/48 mmHg, and respiratory rate of 22/min. Physical examination reveals a diaphoretic and pale patient. Her abdomen is distended, and a pulsatile, tender mass is palpated in the epigastrium. Two large-bore peripheral intravenous catheters are successfully placed by the trauma team. Arrange the following steps in the most appropriate sequential order for the management of this patient.

Match each clinical and neuroimaging presentation of a suspected intracranial mass with its correct diagnostic entity and characteristic pathophysiological or histological feature.

Match each patient's clinical history and mechanism of spinal injury with the specific pattern of neurological deficits most likely to be observed on physical examination.

A $28$-year-old man comes to the emergency department due to severe penile pain and swelling. $1$ hour ago, during vigorous sexual intercourse, he heard a distinct 'snapping' sound followed immediately by a loss of erection and severe pain. He has not attempted to void since the incident. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $128/82\text{ mm Hg}$, and pulse is $92/\text{min}$. Physical examination shows a significantly swollen and ecchymotic penis that is deviated to the right side. The scrotum is normal. There is a small drop of blood visible at the urethral meatus. Which of the following is the most appropriate next step in management?

A 31-year-old woman is transported via helicopter to the regional trauma center after being extricated from a severe motor vehicle collision. En route, she received 1 liter of crystalloid solution. Upon arrival, she is lethargic but moans to pain.

The trachea is midline, and bilateral breath sounds are equal. A portable anteroposterior chest radiograph reveals a widened upper mediastinum, left apical pleural capping, and a fracture of the left first rib. Bedside focused assessment with sonography for trauma (FAST) demonstrates a 4-centimeter pocket of anechoic fluid in the Morison pouch and additional free fluid in the pelvis. The patient's blood pressure drops to $68/35\text{ mm Hg}$ despite the initiation of a massive transfusion protocol. Which of the following is the most appropriate next step in management?

A urology team is reviewing the charts of five patients presenting with various manifestations of nephrolithiasis and ureterolithiasis. Each patient requires a highly specific management approach based on stone size, location, concomitant comorbidities, and clinical stability. Match each patient's clinical presentation with the most appropriate definitive management step or surgical intervention.