Surgery

A 28-year-old man is evaluated on postoperative day 1 after undergoing intramedullary nailing for a closed right tibial shaft fracture. Over the past 4 hours, he has developed severe, unrelenting pain in his right lower leg that is not relieved by intravenous morphine. His temperature is 37.8°C (100°F), blood pressure is 130/80 mmHg, and pulse is 108/min. On physical examination, the right leg is tense, visibly swollen, and firm to palpation. Passive plantar flexion of the toes elicits excruciating pain in the anterior leg. The pedal pulses are palpable bilaterally. Which of the following is the most appropriate next step in management?

A 24-year-old man is evaluated in the hospital 12 hours after sustaining a closed, comminuted midshaft fracture of the right tibia. The fracture was stabilized with a well-molded, long-leg fiberglass cast in the emergency department. He now reports severe, unrelenting right leg pain that is poorly localized and unresponsive to intravenous opioid analgesia. Physical examination reveals a tense, swollen right calf and severe pain exacerbated by passive dorsiflexion of the right toes. Dorsalis pedis and posterior tibial pulses are easily palpable. Arrange the following management steps in the most appropriate chronological order.

Emergency medical services transport a logging worker via helicopter to a regional trauma center after a heavy falling tree branch crushed his right lower extremity. The patient remains hemodynamically stable throughout transport. Upon initial trauma evaluation, the right knee exhibits a gross multi-ligamentous dislocation with severe instability. Vascular assessment reveals a pale, cold right foot with no palpable or Doppler-identifiable pulses in the dorsalis pedis or posterior tibial arteries. Because of the remote location of the accident, the estimated total warm ischemia time has already exceeded 5.5 hours. An urgent bedside closed reduction is performed, but subsequent Doppler re-evaluation confirms persistent absence of arterial flow. The surgical team immediately mobilizes to the operating suite for a limb salvage procedure. Arrange the following intraoperative interventions in the correct sequential order required to optimize limb preservation.

Match each postoperative clinical presentation with the most appropriate definitive management or next step in diagnosis.

A $54$-year-old woman is brought to the emergency department by her husband due to confusion, fever, and repeated episodes of vomiting over the last $12$ hours. She has a history of major depressive disorder treated with citalopram, and migraine headaches for which she recently started taking sumatriptan. Her husband notes she complained of some right-sided pelvic pain yesterday but thought it was a muscle strain. Temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), pulse is $128/\text{min}$, respirations are $24/\text{min}$, and blood pressure is $86/50 \text{ mm Hg}$. She is visibly diaphoretic and agitated. Neurologic examination reveals normal muscle tone without clonus. Abdominal examination reveals a non-distended, soft abdomen with normal bowel sounds. However, careful examination of the groin reveals a $3\text{-cm}$, firm, exquisitely tender, and violaceous mass located inferior to the right inguinal ligament and medial to the femoral artery pulse. Laboratory results reveal:

Leukocyte count: $19,200/\text{mm}^3$
Serum lactate: $5.4 \text{ mmol/L}$
Serum bicarbonate: $12 \text{ mEq/L}$

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

Match each patient's clinical presentation of nipple discharge or associated breast symptoms with the most appropriate next step in diagnosis or surgical management.

A $32$-year-old man comes to the emergency department due to an unrelenting, painful erection. He states that the condition started $6\text{ hours}$ ago while he was resting and has progressively worsened. The patient recently began taking trazodone for insomnia. His vital signs are stable. On examination, the corpora cavernosa are extremely rigid and tender to palpation, whereas the corpus spongiosum and glans penis remain soft. Diagnostic aspiration of the corpora yields dark, venous-appearing blood. A subsequent cavernosal blood gas analysis demonstrates a $pH$ of $7.15$, a $pO_2$ of $25\text{ mm Hg}$, and a $pCO_2$ of $75\text{ mm Hg}$. Which of the following is the most appropriate next step in management?

A ward nurse urgently pages the on-call surgical team regarding a hospitalized 51-year-old man. The patient was admitted three days ago for bacteremia secondary to a skin infection and has been receiving targeted intravenous therapy. Over the last eight hours, he developed severe, progressive mid-back pain and new-onset difficulty moving his legs. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$). Neurologic examination reveals $2/5$ motor strength in bilateral lower extremities, loss of pain and temperature sensation below the umbilicus, and a distended, palpable bladder. Immediate magnetic resonance imaging of the spine demonstrates a large, peripherally enhancing epidural fluid collection at the T9-T10 level compressing the spinal cord. Which of the following is the most appropriate next step in the management of this patient?

Match each of the following upper extremity orthopedic injuries with the peripheral nerve most commonly at risk for damage.

A 60-year-old man presents to the clinic to discuss the results of an abdominal computed tomography (CT) scan performed for chronic, nonspecific flank pain. The scan incidentally reveals a $5.5\text{-cm}$ right adrenal mass with heterogeneous contrast enhancement, irregular borders, and an attenuation of $32\text{ Hounsfield units}$. His blood pressure is $128/82\text{ mmHg}$ and his heart rate is $76\text{/min}$. The physical examination is unremarkable, with no striae, bruising, or central obesity. A comprehensive metabolic panel is within normal limits. Endocrine evaluation demonstrates a normal 1-milligram overnight dexamethasone suppression test, normal fractionated urinary metanephrines, and a normal plasma aldosterone-to-renin ratio. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old man presents to the emergency department with a severe, painful erection that has persisted for 8 hours without sexual stimulation. He has a history of sickle cell trait. On examination, the corpora cavernosa are extremely rigid and tender, while the glans penis and corpus spongiosum are flaccid. Arrange the following steps in the optimal sequential management of this patient's condition, from the initial diagnostic step to the progressive therapeutic interventions.

Match each highly complex clinical scenario with the most appropriate, guideline-directed surgical or interventional management step.

Match each clinical presentation with the most appropriate definitive procedural or surgical intervention.

An $81$-year-old man arrives at the emergency department accompanied by his son, who reports that his father has become increasingly confused and clumsy over the past month. The patient has a history of a mechanical mitral valve replacement, for which he takes warfarin, as well as hypertension.

On examination, the patient is lethargic but arousable. He exhibits a left-sided facial droop and $4/5$ strength in his left upper and lower extremities.

Laboratory analysis reveals an International Normalized Ratio (INR) of $3.4$.

A non-contrast computed tomography (CT) scan of the head reveals a $2.1$-cm thick crescent-shaped, hypodense extra-axial fluid collection over the right frontoparietal cortex causing a $9$-mm leftward midline shift.

What is the most appropriate sequence of interventions for this patient?

An 81-year-old male with a history of hypertension and a 50-pack-year smoking history is brought to the emergency department after a syncopal episode at home. Upon arrival, he reports sudden, severe, and constant abdominal and left flank pain. His current medications include lisinopril and hydrochlorothiazide. His temperature is 36.8°C (98.2°F), blood pressure is 82/45 mm Hg, pulse is 118/min, and respiratory rate is 22/min. He appears pale, diaphoretic, and lethargic. Physical examination reveals a distended abdomen with a palpable, pulsatile mass located above the umbilicus. A bedside focused assessment with sonography for trauma (FAST) demonstrates a 7.5-cm dilation of the infrarenal aorta with an adjacent anechoic fluid collection in the retroperitoneum. Two large-bore peripheral intravenous lines are placed, and fluid resuscitation is initiated.

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

A $58$-year-old male with poorly controlled type 2 diabetes mellitus is evaluated in the emergency department for severe perineal pain and swelling that has progressively worsened over the past $48$ hours. He reports subjective fevers, chills, and generalized weakness. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $90/60\text{ mmHg}$, heart rate is $118/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals a tense, swollen, and diffusely erythematous scrotum. There is a central $3\text{-cm}$ area of grayish-purple skin discoloration. Palpation of the perineum and scrotum elicits exquisite tenderness, and a distinct crackling sensation is felt beneath the skin. Laboratory studies demonstrate a leukocyte count of $24,000/\text{mm}^3$ and a serum glucose of $385\text{ mg/dL}$. Intravenous fluid resuscitation and broad-spectrum antimicrobial therapy are initiated. Which of the following is the most appropriate next step in the management of this patient?

A 26-year-old professional rugby player is transported to the trauma bay after sustaining a direct, high-velocity blow to his right knee during a match. He complains of excruciating leg pain. On physical examination, the right knee is visibly deformed. His right foot is pale and cool to the touch. He is hemodynamically stable and has no other systemic injuries. Arrange the following steps in the acute management of this patient's limb in the most appropriate chronological sequence.

A 68-year-old woman with a history of type 2 diabetes mellitus and a 30-pack-year smoking history presents to the clinic complaining of cramping pain in her left calf. She reports that the pain consistently occurs after walking two blocks and resolves entirely after five minutes of standing still. She denies any pain at rest or non-healing foot ulcers. On physical examination, her femoral pulses are $2+$ bilaterally, but her left popliteal and dorsalis pedis pulses are diminished ($1+$). Arrange the following steps in the most appropriate chronological sequence for the standard diagnostic and therapeutic management of this patient's condition.

A $28$-year-old man is brought to the emergency department by ambulance after a high-speed motorcycle collision. He was not wearing a helmet. On arrival, he is unresponsive. His blood pressure is $175/95 \text{ mmHg}$, heart rate is $52 \text{ /min}$, and respiratory rate is $10 \text{ /min}$ and irregular. Neurologic examination reveals a Glasgow Coma Scale score of $5$ (Eye opening: $1$, Verbal response: $1$, Motor response: $3$). His right pupil is $7 \text{ mm}$ and unreactive to light, while the left pupil is $3 \text{ mm}$ and briskly reactive. He exhibits decerebrate posturing on the left side. Arrange the following steps in the most appropriate chronological order for the management of this patient.

During a high school basketball tournament, a 16-year-old boy suddenly drops to the floor, gripping his groin. He is rushed to the nearest acute care center. Upon evaluation, he reports an abrupt onset of agonizing right-sided testicular pain accompanied by nausea and one episode of emesis. He denies any direct trauma to the groin during the game. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $130/80\text{ mm Hg}$, and pulse is $115/\text{min}$. Physical examination reveals a markedly swollen, tender, and erythematous right hemiscrotum. The right testis is significantly elevated compared to the left and rests in a transverse orientation. Stroking the superior medial aspect of the right thigh yields no elevation of the right testis, although the reflex is completely intact on the left side. Which of the following is the most appropriate next step in the management of this patient?