Surgery

A 55-year-old woman is evaluated in the intensive care unit for fever and hypotension. She underwent an uncomplicated total abdominal hysterectomy three days ago for symptomatic uterine fibroids. Her temperature is 39.2°C (102.6°F), blood pressure is 85/50 mmHg, and heart rate is 125/min. She complains of severe right-sided flank pain. Physical examination shows exquisite right costovertebral angle tenderness. The abdomen is soft, non-distended, and non-tender, with normal active bowel sounds. Laboratory studies reveal a leukocyte count of 22,000/mm³. A bedside renal ultrasound demonstrates marked right-sided hydronephrosis. Intravenous fluid resuscitation and empiric broad-spectrum antibiotics are initiated, but her blood pressure remains 85/50 mmHg. Which of the following is the most appropriate next step in management?

A $49$-year-old woman is brought to the emergency department by her family due to severe right-sided flank pain, shaking chills, and increasing confusion over the past $24$ hours. She has a history of recurrent urinary tract infections but does not take any daily medications. Her temperature is $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), pulse is $128/\text{min}$, respirations are $24/\text{min}$, and blood pressure is $82/50\text{ mm Hg}$. Physical examination reveals marked right costovertebral angle tenderness and delayed capillary refill.

Laboratory studies show the following:

Following initial intravenous fluid resuscitation and empirical broad-spectrum antibiotic administration, a non-contrast CT scan of the abdomen and pelvis is obtained. The imaging demonstrates a $14\text{-mm}$ calculus lodged in the proximal right ureter with severe ipsilateral hydroureteronephrosis and perinephric fat stranding. Which of the following is the most appropriate next step in management?

Match each clinical presentation with its most likely cardiothoracic or vascular surgical diagnosis.

A 52-year-old man is brought to the emergency department by his wife due to the sudden onset of an excruciating headache and vomiting that began 2 hours ago. He also complains of blurry vision and difficulty seeing objects in his peripheral vision. His medical history is significant for decreased libido and profound fatigue over the last 6 months. On arrival, his blood pressure is 80/50 mmHg, and his heart rate is 118/min. Neurologic examination reveals a bitemporal hemianopsia. He appears lethargic but is oriented. Arrange the following steps in the most appropriate chronological order for the emergency evaluation and management of this patient:

A 41-year-old man presents with recurrent nephrolithiasis, episodic severe headaches, palpitations, and a 3-cm anterior neck mass. Laboratory evaluation shows a serum calcium of 11.6 mg/dL with an inappropriately elevated intact parathyroid hormone level. Fine-needle aspiration of the neck mass reveals malignant cells with amyloid stroma that stain positive for calcitonin. Genetic testing confirms a RET proto-oncogene mutation, establishing a diagnosis of Multiple Endocrine Neoplasia type 2A (MEN2A). The patient requires comprehensive surgical management. Arrange the following steps in the most appropriate chronological order for his evaluation and management:

A 58-year-old man arrives at the emergency center reporting sudden, severe, tearing chest discomfort that radiates directly between his scapulae. His blood pressure is 210/115 mmHg in the right arm and 170/90 mmHg in the left arm, with a pulse of 110/min. Physical examination reveals an early diastolic murmur at the right upper sternal border. An electrocardiogram shows no acute ischemic changes, and a portable chest radiograph demonstrates a widened mediastinum. Arrange the following management steps in the most appropriate chronological order.

A 42-year-old woman is evaluated on postoperative day 1 following a total thyroidectomy for a multinodular goiter. She complains of new-onset tingling around her lips and in her fingers. Her temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, pulse is $88/\text{min}$, and respiratory rate is $14/\text{min}$. Physical examination reveals a clean, well-approximated surgical incision without swelling. Brief twitching of the ipsilateral facial muscles is elicited when her cheek is tapped just anterior to the earlobe. Laboratory studies show:

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

Match each patient's clinical and histopathologic presentation to the most appropriate breast pathology diagnosis.

A 29-year-old man with a history of sickle cell disease presents to the emergency department with a painful, rigid erection that has persisted for the last 8 hours without sexual stimulation. He has not responded to oral analgesics or warm compresses at home. Arrange the following steps in the correct chronological sequence for the standard step-wise management of this condition, starting with the initial diagnostic step and progressing through escalating medical and surgical interventions.

A 48-year-old female patient is brought to the emergency department experiencing high fever, rigors, and intense right-sided back pain. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), heart rate is $118/\text{min}$, and blood pressure is $88/56\text{ mm Hg}$. A noncontrast CT scan of the abdomen and pelvis demonstrates an $8\text{-mm}$ calculus in the proximal right ureter with associated moderate hydronephrosis. Arrange the following clinical steps in the most appropriate chronological sequence for managing this patient.

A vascular surgery team is evaluating a 74-year-old man on his second day of recovery following an open repair of a 6.8 cm infrarenal abdominal aortic aneurysm. During the procedure, the inferior mesenteric artery was ligated to allow for adequate exposure and graft placement. Today, the patient abruptly develops severe left-sided abdominal pain accompanied by the passage of dark, bloody stool. Current vital signs include a temperature of 38.6°C (101.5°F), blood pressure of 94/58 mmHg, heart rate of 118/min, and respiratory rate of 22/min. Abdominal examination demonstrates exquisite tenderness over the left lower quadrant, accompanied by muscle rigidity, involuntary guarding, and rebound tenderness. Laboratory analysis reveals a leukocyte count of 19,200/mm³ and a serum lactate concentration of 4.5 mmol/L (Normal: 0.5-2.2 mmol/L). Based on these clinical findings, which of the following is the most appropriate next step in management?

A 42-year-old man presents with a 10-day history of worsening headaches and new-onset mild right-hand clumsiness. His temperature is $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), blood pressure is $128/82\text{ mm Hg}$, and pulse is $76\text{/min}$. He is fully awake, alert, and oriented with a Glasgow Coma Scale score of 15. Neurologic examination shows mild right upper extremity pronator drift but no other focal deficits. MRI of the brain with gadolinium reveals a single $3.2\text{ cm}$ centrally necrotic, ring-enhancing lesion in the left frontal lobe with moderate surrounding vasogenic edema and $3\text{ mm}$ of midline shift. There are no signs of impending brain herniation.

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

A 62-year-old woman is brought to the emergency department by her family due to a 2-day history of severe left flank pain, high fevers, and worsening confusion. She has a medical history of type 2 diabetes mellitus and hypertension. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $124/\text{min}$, blood pressure is $84/52\text{ mmHg}$, and respirations are $24/\text{min}$. Physical examination reveals a lethargic patient with dry mucous membranes and marked left costovertebral angle tenderness. Laboratory studies show a leukocyte count of $24,000/\text{mm}^3$, serum creatinine of $2.3\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$), blood urea nitrogen of $48\text{ mg/dL}$, and serum lactate of $4.5\text{ mmol/L}$. Urinalysis is positive for leukocyte esterase, nitrites, and numerous bacteria. A non-contrast computed tomography scan of the abdomen and pelvis reveals a $9\text{-mm}$ radiopaque calculus in the left proximal ureter with severe hydroureteronephrosis and extensive perinephric fat stranding. Aggressive intravenous fluid resuscitation and broad-spectrum antibiotics are initiated, but her blood pressure remains $86/54\text{ mmHg}$. Which of the following is the most appropriate next step in management?

A 62-year-old man is brought to the emergency department by emergency medical services due to sudden, severe, and tearing anterior chest pain that radiates to his back. The pain started 45 minutes ago while he was mowing the lawn. His medical history is significant for long-standing, poorly controlled hypertension. Upon arrival, he appears diaphoretic and in severe distress. Vital signs are temperature 37.1°C (98.8°F), blood pressure 86/50 mm Hg, pulse 118/min, and respiratory rate 22/min. Physical examination reveals distended neck veins. Lungs are clear to auscultation bilaterally. Heart sounds are muffled, and there is a faint early diastolic murmur appreciated at the right upper sternal border. Extremities are cool to the touch, with delayed capillary refill. A bedside focused assessment with sonography for trauma (FAST) reveals a large pericardial effusion with early diastolic collapse of the right ventricle, as well as an intimal flap in the ascending aorta.

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

A 62-year-old man is brought to the emergency department via ambulance due to the sudden onset of excruciating, tearing anterior chest pain that radiates to his interscapular region. Minutes after the pain began, he developed severe shortness of breath. His past medical history is significant for poorly controlled hypertension, hyperlipidemia, and severe chronic obstructive pulmonary disease. Upon arrival, he appears ashen, diaphoretic, and in severe respiratory distress. His temperature is 36.8°C (98.2°F), blood pressure is 82/45 mmHg in the right arm and 80/42 mmHg in the left arm, heart rate is 128/min, and respiratory rate is 34/min with an oxygen saturation of 86% on room air. Physical examination reveals elevated jugular venous pressure. Lung auscultation demonstrates diffuse bilateral crackles extending to the apices, along with prominent expiratory wheezing. Cardiac auscultation reveals a regular tachycardia with a loud, blowing, decrescendo diastolic murmur heard best at the right second intercostal space. The abdomen is soft and non-tender. Bilateral lower extremities are cool to the touch with faint pedal pulses. Electrocardiogram shows sinus tachycardia with non-specific ST-segment changes. Which of the following is the most appropriate next step in the management of this patient?

An otherwise healthy 62-year-old male is evaluated in the emergency department for a 6-hour history of acute, intense, colicky abdominal pain accompanied by several episodes of bilious vomiting. His past medical history is notable only for an open appendectomy performed 15 years ago for a ruptured appendix. On current evaluation, his temperature is 37.1°C (98.8°F), blood pressure is 135/85 mm Hg, pulse is 92/min, and respiratory rate is 16/min. The abdominal examination is significant for pronounced distention and high-pitched, hyperactive bowel sounds. Palpation elicits moderate, diffuse tenderness, though there is no evidence of guarding, rigidity, or rebound tenderness. Initial laboratory investigations reveal a leukocyte count of 9,500/mm³ and a serum lactate concentration of 1.1 mmol/L (Normal: 0.5 - 1.5 mmol/L). An abdominal and pelvic computed tomography scan with intravenous contrast reveals a distinct transition point in the distal jejunum with substantial upstream small bowel dilation. Additionally, a C-shaped, fluid-distended segment of small bowel is noted, and the corresponding mesenteric vasculature is seen tapering toward a central focal point. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man presents to the emergency department with a painful, rigid erection that has persisted for 10 hours. He denies any recent sexual activity or use of phosphodiesterase inhibitors, but reports a history of sickle cell trait. Penile blood gas analysis reveals a pO2 of 25 mmHg, pCO2 of 80 mmHg, and pH of 7.15, confirming the diagnosis of ischemic priapism. Non-invasive measures such as systemic analgesia and intravenous hydration have already been initiated.

Arrange the following stepwise interventions in the correct escalating order for managing this patient's condition.

A 25-year-old man is brought to the emergency department after a motorcycle collision. Examination reveals an obvious deformity of the right lower leg with a 4-centimeter laceration over the anterior tibia, exposing the underlying fractured bone. Distal pulses are palpable, and the patient has intact sensation in the foot. Arrange the following steps in the most appropriate chronological sequence for the acute management of this patient's open fracture.

Match each patient's clinical presentation and pancreatic cyst fluid analysis with the most accurate diagnosis and corresponding appropriate surgical management strategy.

Match each classic clinical and radiographic presentation with the most likely neurosurgical diagnosis or herniation syndrome.