Surgery

A previously healthy 6-year-old male child arrives at the emergency department accompanied by his parents. He complains of excruciating right knee pain that started 24 hours ago. He completely refuses to walk or bear any weight on the affected leg. His current temperature is 39.0°C (102.2°F). Physical examination reveals a right knee that is notably swollen, red, warm, and exquisitely tender during minimal passive flexion and extension. Plain radiography of the right knee demonstrates a prominent joint effusion but no osseous abnormalities. The clinical picture strongly suggests an acute bacterial joint infection. Arrange the following management steps in the correct chronological order from first to last.

A 38-year-old man is transported to the trauma center by helicopter emergency medical services following a high-speed motorcycle crash. He was intubated at the scene due to a Glasgow Coma Scale score of $6$. Upon arrival, his blood pressure is $78/40$ mmHg, and his heart rate is $135$/min. Physical examination reveals a rigid, distended abdomen and a large boggy hematoma over the left temporal region. A Focused Assessment with Sonography for Trauma (FAST) examination reveals a large volume of free fluid in the hepatorenal recess and pelvis. While the trauma team is administering a transfusion of uncrossmatched type O-negative blood, the patient's left pupil becomes fixed and dilated at $8$ mm, and he develops extensor posturing of the right upper and lower extremities in response to painful stimuli. Which of the following is the most appropriate next step in the management of this patient?

A 67-year-old male with severe chronic obstructive pulmonary disease requiring continuous home oxygen is evaluated for acute-onset, generalized abdominal cramping and bilious emesis over the past 24 hours. His surgical history is notable for an appendectomy and a partial colectomy for diverticulitis. Vital signs are temperature $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$), pulse $102/\text{min}$, respirations $22/\text{min}$, and blood pressure $118/76 \text{ mmHg}$. Physical examination reveals a distended abdomen with focal, severe tenderness and involuntary guarding in the right lower quadrant. Laboratory testing shows a leukocyte count of $14,500/\text{mm}^3$ and a serum lactate level of $3.4 \text{ mmol/L}$. Cross-sectional imaging with intravenous contrast demonstrates a transition point in the distal ileum, a twisting of the mesenteric vessels, and a focal segment of small intestine exhibiting reduced wall enhancement. Which of the following is the most appropriate next step in management?

A $48$-year-old woman is evaluated in the surgical step-down unit $4$ hours after undergoing an uncomplicated total thyroidectomy for a large, symptomatic multinodular goiter. The nurse urgently requests an evaluation because the patient has developed sudden-onset difficulty breathing.

Upon arrival, the patient is agitated, diaphoretic, and exhibiting high-pitched inspiratory stridor. Her temperature is $38.0^\circ\text{C}$ ($100.4^\circ\text{F}$), blood pressure is $165/95\text{ mm Hg}$, pulse is $118\text{/min}$, and oxygen saturation is $90\%$ on room air. Physical examination reveals a tense, rapidly expanding swelling deep to the cervical incision. The skin edges are intact and approximated with sutures, and no active superficial bleeding is visible.

Laboratory studies drawn $30$ minutes prior to this acute event show:
- Serum total calcium: $8.2\text{ mg/dL}$ (Reference: $8.4-10.2\text{ mg/dL}$)
- Serum albumin: $4.0\text{ g/dL}$
- TSH: $2.5\text{ }\mu\text{U/mL}$

The patient's husband, who is her designated healthcare proxy, stepped out of the hospital $10$ minutes ago and is currently unreachable by phone.

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

A 48-year-old man is evaluated in the surgical ward on postoperative day 2 following an open reduction and internal fixation of a closed, highly comminuted midshaft tibial fracture. Over the past 4 hours, he has complained of rapidly escalating pain in his right leg that is entirely unresponsive to intravenous morphine. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is $128$/min, blood pressure is $90/55$ mmHg, and respiratory rate is $24$/min. Physical examination reveals a markedly swollen right lower extremity. The skin surrounding the surgical incision is tense, erythematous, and notably discolored with scattered bullae containing dark fluid. Exquisite tenderness is present well beyond the margins of the erythema. Subcutaneous crepitus is palpable along the medial aspect of the tibia. Dorsalis pedis and posterior tibial pulses are faint but palpable. Laboratory studies show:

Leukocyte count: $28,000$/mm $^3$
Serum sodium: $129$ mEq/L
Blood urea nitrogen: $34$ mg/dL
Serum creatinine: $1.8$ mg/dL

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

A 45-year-old woman is brought to the trauma center following a high-speed motor vehicle collision where she was the unrestrained driver and struck the steering wheel. On arrival, she is alert but in severe respiratory distress, using accessory muscles to breathe. Her temperature is 36.8°C (98.2°F), blood pressure is 112/68 mm Hg, pulse is 122/min, and respirations are 38/min. Pulse oximetry demonstrates an oxygen saturation of 84% despite receiving 15 L/min of oxygen via a non-rebreather mask. Physical examination of the chest wall demonstrates a large contusion over the right anterior thorax with an adjacent segment of the rib cage that moves inward during inspiration. Auscultation reveals crackles over the right middle and lower lung fields. An emergent portable chest radiograph displays multiple segmental fractures of ribs 4 through 8 on the right, along with patchy airspace opacities in the underlying lung parenchyma. There is no visible pleural line or significant blunting of the costophrenic angles. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old man is evaluated in the cardiovascular intensive care unit due to a sudden onset of shortness of breath and confusion. He underwent a four-vessel coronary artery bypass grafting procedure three days ago. His medical history includes hypertension, hyperlipidemia, and chronic obstructive pulmonary disease. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $82/50\text{ mmHg}$, pulse $122\text{ /min}$, and respirations $24\text{ /min}$. Physical examination demonstrates distended jugular veins, muffled heart sounds, and clear lung fields bilaterally. His systolic blood pressure decreases by $18\text{ mmHg}$ during inspiration. Which of the following is the most appropriate next step in management?

During a weekend snowboarding trip, a 24-year-old man falls forward onto his outstretched right hand. He presents to an urgent care clinic three hours later reporting pain in his right wrist. On physical examination, there is mild swelling and focal tenderness over the dorsal radial aspect of the wrist, specifically in the depression bounded by the extensor pollicis longus and extensor pollicis brevis tendons. Range of motion is limited by pain, but there is no gross deformity. Sensation and radial pulses are intact. Initial anterior-posterior, lateral, and scaphoid views of the right wrist on radiography show no abnormalities. Which of the following is the most appropriate next step in management?

A primary care physician refers a $65$-year-old retired chemical worker to the urology service due to alarming urinary changes. Over the preceding four weeks, the patient noted three distinct episodes where his entire urinary stream was bright red. He reports no associated pain during urination, flank discomfort, fever, or weight loss. He has a history of essential hypertension and smoked one pack of cigarettes daily for $40$ years before quitting recently. In the clinic, his vital signs are stable. Examination of the abdomen and external genitalia shows no abnormalities, and digital rectal examination reveals a smooth, non-enlarged prostate. A catheter-free urinalysis demonstrates $>50$ red blood cells per high-power field, with absent leukocyte esterase. A multiphasic computed tomography urogram is subsequently performed, which outlines normally functioning kidneys and pristine ureters without any solid masses or nephrolithiasis. Which of the following is the most appropriate next step in management?

A 74-year-old individual with a history of persistent atrial fibrillation and nonadherence to systemic anticoagulation is rushed to the operating room with sudden-onset, severe abdominal pain that is entirely out of proportion to physical examination findings. Laboratory studies reveal a profound lactic acidosis. A clinical diagnosis of acute superior mesenteric artery (SMA) embolism is made. Arrange the following intraoperative steps in the correct sequential order required to optimize the patient's surgical outcome and minimize the long-term risk of short bowel syndrome.

A $52$-year-old man comes to the urology clinic to discuss the results of recent imaging. Two weeks ago, he presented to the emergency department with mild left lower quadrant abdominal discomfort. A CT scan of the abdomen and pelvis with contrast was performed to evaluate for diverticulitis; the colon appeared normal, but an incidental $3.4$-cm solid, heterogeneously enhancing, exophytic mass was discovered in the lower pole of the left kidney. He has a history of well-controlled hypertension and hyperlipidemia. His BMI is $28$ kg/m $^2$. Vital signs are within normal limits. Physical examination reveals a soft, non-tender abdomen without palpable masses. Serum creatinine is $0.9$ mg/dL, and urinalysis shows no abnormalities. There is no evidence of lymphadenopathy or vascular involvement on the imaging. Which of the following is the most appropriate next step in management?

Match each lumbosacral nerve root compression or spinal syndrome with its classic neurological examination findings. This clinical localization is essential for determining the appropriate neurosurgical intervention.

Match each classic vascular clinical presentation to its most likely underlying diagnosis.

Match each patient's clinical presentation of an acute abdomen with the most appropriate next step in management.

A $42$-year-old female patient arrives at the outpatient clinic reporting a $12$-month history of unexplained weight gain, severe fatigue, and frequent bruising. Her blood pressure is $155/95\text{ mm Hg}$. Physical examination is notable for central adiposity, facial plethora, and wide, purplish striae on the lower abdomen. She denies taking any medications, including topical, inhaled, or intra-articular corticosteroids. The physician suspects an endogenous endocrine disorder. Arrange the following interventions in the most appropriate chronological sequence for the diagnosis and surgical management of this patient's condition.

A $38$-year-old woman presents to the emergency department with a $6$-hour history of sudden-onset, severe, colicky periumbilical abdominal pain, accompanied by multiple episodes of bilious vomiting. Two years ago, she underwent an uncomplicated laparoscopic Roux-en-Y gastric bypass for morbid obesity. She takes a daily multivitamin. Temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $88/54\text{ mm Hg}$, pulse is $124/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals a moderately distended abdomen. There is marked tenderness to palpation in the periumbilical region with involuntary guarding and rebound tenderness. Bowel sounds are hypoactive.

Laboratory studies show:
Leukocyte count: $18,500/\text{mm}^3$
Serum bicarbonate: $16\text{ mEq/L}$
Lactic acid: $3.8\text{ mmol/L}$

An upright abdominal radiograph demonstrates multiple dilated loops of small bowel with air-fluid levels and a paucity of colonic gas.

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

Match each clinical presentation of a vascular disorder with its most likely underlying anatomic pathology or mechanism.

A 28-year-old man is brought to the trauma center following a high-speed motorcycle collision. His airway is intact, and his hemodynamics are stabilized with intravenous fluids. A pelvic binder is applied for a complex pelvic ring fracture. Physical examination reveals a scrotal hematoma and fresh blood at the urethral meatus. Digital rectal examination demonstrates a high-riding, nonpalpable prostate. He reports lower abdominal discomfort and a strong urge to void, but has not urinated since the accident. Arrange the following urologic interventions in the most appropriate chronological order for the evaluation and definitive management of this patient's genitourinary injury.

Match each specific orthopedic injury with its most commonly associated acute neurovascular physical exam finding.

A 35-year-old man is brought to the emergency department after sustaining a knife wound to his left medial thigh during an altercation. Paramedics placed a bulky pressure dressing at the scene. His temperature is 37.1°C (98.8°F), blood pressure is 112/72 mm Hg, and heart rate is 108/min. On physical examination, removal of the dressing reveals a 4-cm laceration over the medial thigh with active, pulsatile hemorrhage and a rapidly expanding hematoma. The left foot is cool to the touch, and the left dorsalis pedis and posterior tibial pulses are absent. The right lower extremity has normal 2+ pulses. Which of the following is the most appropriate next step in management?