Surgery

A 71-year-old man is brought to the emergency department by ambulance due to the sudden onset of severe abdominal pain that radiates to his lower back. He has a medical history of hypertension, hyperlipidemia, and an asymptomatic 6.2-cm abdominal aortic aneurysm diagnosed one year ago. Upon arrival, his blood pressure is 75/40 mmHg, and his heart rate is 122/min. He appears pale, confused, and diaphoretic. Physical examination reveals a distended abdomen with an exquisitely tender, palpable, pulsatile periumbilical mass. Which of the following is the most appropriate next step in management?

A 29-year-old man is brought to the trauma center by helicopter 40 minutes after a high-speed frontal motor vehicle collision. On arrival, he is comatose with a Glasgow Coma Scale score of 5 (Eye 1, Verbal 1, Motor 3). Vital signs are temperature 36.5°C (97.7°F), blood pressure 180/100 mmHg, heart rate 48/min, and respiratory rate 10/min with irregular breathing patterns. Physical examination demonstrates a 7-mm right pupil that does not respond to light, and a 3-mm left pupil with a brisk pupillary light reflex. Motor examination reveals decorticate posturing on the left side in response to painful stimuli. The patient's airway was secured with an endotracheal tube by emergency medical services at the scene. Bilateral breath sounds are clear and equal. Which of the following is the most appropriate next step in management?

Match the following classic clinical presentations with the most likely cardiothoracic or vascular surgical diagnosis.

A 38-year-old woman is evaluated in the emergency department due to the sudden onset of a severe headache that began 4 hours ago. She describes it as the "worst headache I have ever had in my entire life." She has no significant past medical history and takes no medications. Vital signs are temperature 37.0°C (98.6°F), blood pressure 150/90 mmHg, heart rate 92/min, and respiratory rate 16/min. On physical examination, she is awake, alert, and oriented (Glasgow Coma Scale score 15). Cranial nerve function is intact, and there are no focal sensory or motor deficits in the extremities. She exhibits marked photophobia and nuchal rigidity. A computed tomography scan of the head without contrast reveals no intracranial abnormalities. Which of the following is the most appropriate next step in management?

A $38$-year-old woman is referred to the general surgery outpatient department for evaluation of a swelling in her anterior neck. She first noticed the lump while swallowing in front of a mirror two weeks ago. The patient has no history of childhood neck radiation and no family history of thyroid malignancy. She reports feeling well and denies any recent changes in weight, palpitations, tremors, or heat intolerance. Vital signs are within normal limits. On physical examination, a mobile, non-tender, $3.0\text{ cm}$ nodule is palpable in the right lobe of the thyroid gland. There is no cervical lymphadenopathy. A comprehensive neck ultrasound confirms a $3.0\text{ cm}$ solid, isoechoic nodule in the right lobe with smooth margins and no microcalcifications. Concurrent laboratory testing reveals a serum thyroid-stimulating hormone (TSH) level of $0.03\ \mu\text{U/mL}$ (normal: $0.4-4.0\ \mu\text{U/mL}$). Which of the following is the most appropriate next step in the evaluation of this patient's nodule?

A 58-year-old woman is evaluated during morning rounds on the surgical ward. She was admitted 48 hours ago for management of a partial small bowel obstruction secondary to adhesions from a prior hysterectomy. Initial management included intravenous fluid resuscitation, bowel rest, and nasogastric tube decompression, which resulted in 600 mL of bilious output over the first day. Over the past 4 hours, the patient reports that her abdominal pain has transitioned from intermittent and crampy to constant and severe. Her temperature is 38.6°C (101.5°F), blood pressure is 98/60 mm Hg, pulse is 122/min, and respirations are 22/min. On physical examination, her abdomen remains distended but now exhibits marked tenderness and involuntary guarding in the periumbilical region. Bowel sounds are absent. Laboratory studies show a leukocyte count of 17,500/mm³ with a 15% bandemia, and a serum lactate of 3.8 mmol/L. Which of the following is the most appropriate next step in management of this patient?

An evaluation is requested for an 81-year-old resident of an assisted living facility who has exhibited a gradual decline in consciousness and right-sided hemiparesis over the last month. The nursing staff notes that the patient became non-verbal this morning. Medical history is significant for paroxysmal atrial fibrillation, for which the patient takes rivaroxaban. Vital signs are within normal limits except for a blood pressure of 162/95 mm Hg. Physical examination confirms dense right-sided weakness and a dilated, unresponsive left pupil. Urgent non-contrast head computed tomography reveals a 2.5-cm crescentic, low-attenuation fluid collection overlying the left cerebral hemisphere, resulting in uncal herniation and 14 mm of subfalcine shift. Which of the following is the most appropriate next intervention for this patient?

A 68-year-old woman is evaluated in the surgical clinic for a rapidly enlarging mass in the anterior neck that she first noticed 4 weeks ago. She reports a recent onset of hoarseness and difficulty swallowing solid foods. The patient has a 15-year history of Hashimoto thyroiditis but admits she stopped taking her prescribed levothyroxine 8 months ago because she "felt fine." Her temperature is 37.0°C (98.6°F), blood pressure is 132/82 mm Hg, pulse is 60/min, and respirations are 16/min. Physical examination reveals a massive, firm, fixed, and non-tender goiter. There is no palpable cervical lymphadenopathy.

Laboratory studies are as follows:

Ultrasound of the neck demonstrates severe, diffuse enlargement of the thyroid gland with marked hypoechogenicity and several irregular, solid areas. Which of the following is the most appropriate next step in the management of this patient?

A $31$-year-old woman, currently at $12$ weeks gestation, is evaluated in the surgical oncology clinic for a new, firm, $4\text{ cm}$ mass in the upper outer quadrant of her right breast. Physical examination confirms the presence of a fixed, non-tender breast mass and a palpable, hard ipsilateral axillary lymph node. Assuming her final pathology ultimately reveals an estrogen receptor-positive, HER2-negative invasive ductal carcinoma, arrange the following steps in the most appropriate chronological sequence for her diagnostic workup and therapeutic management.

A female resident of a skilled nursing facility in her late eighties is brought to the emergency department for severe nausea, intractable vomiting, and failure to pass flatus or stool over the last 48 hours. Her medical history includes vascular dementia, coronary artery disease, and profound age-related muscle wasting. Vital signs on arrival demonstrate a temperature of 38.1°C (100.6°F), blood pressure of 102/65 mmHg, and heart rate of 115/min.

On examination, the patient is confused and appears deeply uncomfortable. The abdomen is markedly distended with high-pitched, tinkling bowel sounds on auscultation. Palpation of the abdomen elicits generalized tenderness, though there is no involuntary guarding or board-like rigidity. When the physician passively extends and internally rotates her right hip, the patient winces and clutches the medial aspect of her right thigh.

Laboratory analysis is notable for a leukocyte count of 16,800/mm³ and a serum lactate concentration of 4.1 mmol/L. A computed tomography scan of the abdomen and pelvis reveals multiple dilated loops of small bowel measuring up to 4.5 cm in diameter. A discrete transition point is visualized in the right true pelvis, where a segment of the distal ileum extends between the pectineus and external obturator muscles. The wall of this herniated loop is thickened, with surrounding inflammatory stranding.

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

A 52-year-old man is admitted to the intensive care unit with severe acute gallstone pancreatitis. Over the past 48 hours, he has required aggressive intravenous crystalloid resuscitation for hemodynamic instability. He is mechanically ventilated. The nurse alerts the physician that the patient has become increasingly difficult to ventilate, with peak airway pressures rising from 25 to 45 cm H2O. Urine output over the last 4 hours is 30 mL. Physical examination reveals a tense, massively distended abdomen. Bladder pressure measurement reveals an intra-abdominal pressure (IAP) of 28 mmHg. Arrange the following management steps in the most appropriate sequential order, proceeding from initial, least-invasive measures to definitive interventions.

A 67-year-old woman is brought to the emergency department by her daughter due to a sudden onset of excruciating lower back and abdominal pain that began 45 minutes ago. She reports feeling profoundly dizzy and nearly fainted before arrival. Her past medical history is significant for a $4.8$ cm abdominal aortic aneurysm diagnosed two years ago, chronic obstructive pulmonary disease, and essential hypertension. Her temperature is $36.5^\circ\mathrm{C}$ ($97.7^\circ\mathrm{F}$), blood pressure is $74/42$ mm Hg, heart rate is $128$/min, and respiratory rate is $26$/min. On physical examination, she is diaphoretic and pale. Cardiopulmonary examination reveals regular tachycardia and prolonged expiratory wheezing. The abdomen is distended and diffusely tender, with a prominent, tender, pulsatile mass palpated in the epigastrium. Femoral pulses are weak bilaterally. Which of the following is the most appropriate next step in management?

A 34-year-old woman is evaluated in the neuro-intensive care unit. She was admitted 2 days ago following a severe traumatic brain injury sustained in a motor vehicle collision. On admission, her Glasgow Coma Scale score was 6. A non-contrast head CT showed diffuse cerebral edema and multiple punctate hemorrhages at the gray-white matter junction, consistent with diffuse axonal injury, but no mass lesion requiring surgical evacuation. An external ventricular drain (EVD) and a brain tissue oxygen monitor (PbtO2) were placed. She is currently sedated, paralyzed, and mechanically ventilated. She is receiving a continuous infusion of 3% hypertonic saline.

Current vital signs:
Temperature: 37.2°C (99.0°F)
Blood pressure: 82/48 mm Hg (mean arterial pressure: 59 mm Hg)
Heart rate: 118/min

Current neuromonitoring data:
Intracranial pressure (ICP): 27 mm Hg (normal: 5-15 mm Hg)
Brain tissue oxygen tension (PbtO2): 12 mm Hg (normal: >20 mm Hg)
EVD output: 5 mL/hr of clear cerebrospinal fluid

Laboratory results:
Serum sodium: 154 mEq/L
Serum osmolality: 318 mOsm/kg H2O
Urine output: 150 mL/hr

Which of the following is the most appropriate next step in the management of this patient's intracranial hypertension?

A $52$-year-old man with a $15$-year history of hemodialysis-dependent end-stage renal disease is evaluated for severe bone pain and a recent non-traumatic clavicle fracture. Preoperative laboratory studies demonstrate:

He undergoes a successful subtotal ($3.5$ gland) parathyroidectomy for tertiary hyperparathyroidism. On postoperative day $2$, the patient develops circumoral numbness and carpopedal spasms. Laboratory studies now show:

Despite a continuous intravenous calcium gluconate infusion, his serum calcium remains refractory, struggling to stay above $7.0$ mg/dL. Which of the following is the most likely primary mechanism for this patient's severe, refractory postoperative condition?

A $34$-year-old man is brought to the emergency department after a high-speed motorcycle collision. He has a heart rate of $122$/min and a blood pressure of $86/54$ mm Hg. Primary survey reveals an unstable pelvic ring fracture. Genitourinary examination demonstrates blood at the urethral meatus, a large scrotal hematoma, and a high-riding prostate on digital rectal examination. Arrange the following management steps in the optimal sequential order for this patient, proceeding from initial trauma resuscitation to definitive urologic repair.

For each described patient presentation, select the most likely breast diagnosis.

Paramedics bring a 48-year-old previously healthy female to the emergency department. She reports the abrupt onset of an agonizing headache that began during heavy lifting, which she describes as the most severe pain she has ever experienced. She exhibits marked photophobia and neck stiffness on examination. Her vital signs are stable, and she is fully alert without lateralizing neurologic deficits. Arrange the following interventions in the most appropriate chronological sequence for her evaluation and definitive care, from initial presentation to post-treatment management.

Match each clinical presentation of acute neurologic deterioration to the most likely underlying brain herniation syndrome.

A 26-year-old male is brought to the emergency department after a high-speed motorcycle collision. He sustained a severe posterior dislocation of his right knee and was trapped under the vehicle for 6 hours before extrication. On arrival, his blood pressure is 115/75 mm Hg and heart rate is 98/min. The right lower extremity is pale, cold, and lacks sensation. Dorsalis pedis and posterior tibial pulses are absent by palpation and Doppler ultrasound. The knee is immediately reduced in the emergency department, but the foot remains cold and pulseless. The patient is taken emergently to the operating room for limb-salvage surgery. Arrange the following operative steps in the most appropriate sequential order for managing this patient's combined injuries.

A 32-year-old male is immediately taken to the trauma resuscitation bay following an altercation in which he sustained a stab wound to the left anterior chest. He appears pale, diaphoretic, and extremely restless. Vital signs show a blood pressure of 72/40 mmHg, a heart rate of 138/min, and a respiratory rate of 28/min. Physical examination demonstrates engorged neck veins and faint, distant heart sounds. Breath sounds are clear and heard equally on both sides of the chest. Which of the following is the most appropriate next step in the management of this patient?