Surgery

A 19-year-old college student presents to the urgent care clinic with right wrist pain after falling on an outstretched hand while skateboarding yesterday. Vital signs are within normal limits (temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, pulse 78/min, respirations 14/min). On physical examination, there is mild swelling over the radial aspect of the wrist and exquisite tenderness to palpation in the anatomical snuffbox. Sensation to pinprick is intact in all digits, and radial and ulnar pulses are 2+ and symmetric. Capillary refill is less than 2 seconds. Radiographs of the right wrist reveal no evidence of fracture or dislocation. What is the most appropriate next step in management?

An emergency medical response team brings a $58$-year-old female patient to the acute care bay for evaluation of progressively worsening abdominal pain and obstipation lasting $48$ hours. She states that her pain was initially crampy, intermittent, and manageable, but it abruptly transitioned into a severe, constant, and diffuse ache approximately $4$ hours prior to arrival. She has had multiple episodes of bilious emesis today. Her medical history is significant for stage IIB cervical cancer, which was managed with a radical hysterectomy and adjuvant pelvic chemoradiation $15$ years ago. Vital signs include a temperature of $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), a pulse of $124\text{ /min}$, a blood pressure of $92/60\text{ mmHg}$, and a respiratory rate of $24\text{ /min}$. On physical examination, the patient lies completely rigid on the stretcher and refuses to change positions. Her abdomen is markedly distended and tympanic. There is exquisite, diffuse tenderness to light palpation across all quadrants, accompanied by prominent involuntary guarding and rebound tenderness. Bowel sounds are absent. Laboratory evaluation reveals a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate concentration of $4.8\text{ mmol/L}$. An upright chest radiograph is negative for subdiaphragmatic free air. A supine abdominal radiograph demonstrates multiple dilated small bowel loops with prominent air-fluid levels and a complete absence of distal colonic gas. Which of the following is the most appropriate next step in management?

A 24-year-old man is brought to the emergency department following a high-speed motorcycle collision. He complains of severe pelvic pain and an inability to void. Vital signs are within normal limits, and he is hemodynamically stable. Physical examination reveals blood at the urethral meatus, a scrotal hematoma, and a 'high-riding' prostate on digital rectal examination. Pelvic radiography confirms a straddle fracture of the pelvis. Arrange the following steps in the most appropriate chronological sequence for the urologic management of this patient.

Match each clinical presentation of genitourinary trauma with the most appropriate next step in management or definitive treatment.

Emergency medical services bring a $68$-year-old male to the trauma bay due to the abrupt onset of occipital head pain and intractable vomiting. The patient's wife notes he was previously healthy except for a long-standing history of medication nonadherence for hypertension. In the triage area, his blood pressure is $215/115$ mm Hg with a heart rate of $54$/min. While being evaluated, his level of consciousness rapidly declines; he only opens his eyes to painful stimuli and mumbles incomprehensibly. Neurological assessment demonstrates pronounced left dysmetria and gaze-evoked nystagmus. A stat noncontrast head CT demonstrates a $4.5$-cm hyperdense collection in the left cerebellar hemisphere, accompanied by compression of the fourth ventricle and dilatation of the supratentorial ventricular system. Based on these findings, which of the following is the most appropriate next step in management?

Match each clinical presentation of lower extremity vascular disease to its most likely underlying anatomical pathology or diagnosis.

A 74-year-old man is brought to the emergency department by ambulance after being found unresponsive on the floor of his apartment by a neighbor. His medical history is significant for hypertension, type 2 diabetes mellitus, and atrial fibrillation, for which he has recently been noncompliant with his anticoagulant medication. His temperature is 37.1°C (98.8°F), pulse is 112/min and irregularly irregular, blood pressure is 110/70 mm Hg, and respiratory rate is 16/min. Physical examination of the right lower extremity reveals a cold, pale, and mottled leg from the mid-thigh distally. The skin staining does not blanch to pressure. The calf muscles are stiff and rigid to palpation. Neurologic examination shows a complete loss of sensation and motor function in the right foot and leg. Palpation of the femoral pulse is normal, but the popliteal, dorsalis pedis, and posterior tibial pulses are absent. Handheld Doppler ultrasound reveals no arterial or venous signals in the right lower extremity. Which of the following is the most appropriate next step in management for this patient?

A 42-year-old woman is evaluated in the surgical oncology clinic after a 2.5-cm left thyroid nodule was discovered during a routine physical examination. Fine-needle aspiration of the nodule reveals malignant cells with amorphous, eosinophilic extracellular material that stains positive with Congo red. She is scheduled for a total thyroidectomy and central neck lymph node dissection. The patient has no history of neck radiation and no family history of endocrine disorders. Her blood pressure is 125/80 mm Hg and pulse is 76/min. Which of the following is the most appropriate next step in the preoperative evaluation of this patient?

A 13-year-old boy is brought to the emergency department by his parents due to severe right-sided leg pain. For the past month, he has complained of a dull, intermittent ache in his right anterior thigh and knee, which he attributed to playing basketball. This morning, while walking down the stairs, he felt a sudden "pop" and experienced exquisite pain. He is now completely unable to bear weight on the right leg. His body mass index is $33 \text{ kg/m}^2$. Vital signs are within normal limits, and he is afebrile. Physical examination reveals a well-appearing boy in moderate discomfort. Inspection of the right knee shows no swelling, erythema, or localized tenderness. When the examiner attempts to passively flex the right hip to $90^\circ$, the thigh obligately rotates externally. There is significantly limited internal rotation of the right hip compared to the left. Which of the following is the most appropriate next step in management?

Match each clinical presentation and underlying pathophysiological mechanism to the correct brain herniation syndrome.

Emergency medical personnel transport an 83-year-old female resident of a skilled nursing facility to the acute care unit for intractable bilious vomiting and progressive abdominal distension over the past three days. Her medical history includes severe chronic obstructive pulmonary disease, type 2 diabetes mellitus, and osteoarthritis. She has not passed flatus or stool for 48 hours. Vital signs reveal a temperature of $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), a pulse of $112/\text{min}$, a blood pressure of $105/65\text{ mm Hg}$, and respirations of $22/\text{min}$. Physical examination shows a markedly distended, tympanitic abdomen with high-pitched, tinkling bowel sounds. There is diffuse tenderness to deep palpation, but no guarding or rigidity. Laboratory studies indicate a leukocyte count of $11,500/\text{mm}^3$ and a serum creatinine of $1.8\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$). A non-contrast computed tomography scan of the abdomen and pelvis reveals significantly dilated loops of small intestine with a transition point in the distal ileum. An ovoid, $3.5\text{-cm}$ calcified structure is impacted at this transition point. Furthermore, linear branching lucencies are noted centrally within the hepatic shadow. Which of the following is the most appropriate next step in the management of this patient?

A trauma surgery team frequently evaluates patients with acute spinal cord injuries following motor vehicle collisions and falls. Depending on the mechanism of injury and the specific anatomical tracts involved, distinct clinical patterns emerge. Match the following incomplete spinal cord and nerve root syndromes with their most characteristic neurological deficits.

A previously healthy 52-year-old male is evaluated in the trauma bay after complaining of a sudden, ripping sensation in his anterior chest that rapidly progressed to his interscapular region. Vital signs show a pulse of 118/min and blood pressures of 185/105 mm Hg in the right upper extremity and 145/88 mm Hg in the left upper extremity. Physical examination demonstrates a new high-pitched early diastolic murmur along the right sternal border. An electrocardiogram demonstrates sinus tachycardia and left ventricular hypertrophy. Arrange the following steps in the most appropriate chronological order for the management of this patient.

A $71$-year-old man presents to the emergency department with a $4$-day history of progressive abdominal distension, crampy lower abdominal pain, and an inability to pass stool or flatus. He has had two episodes of bilious vomiting today. He has not seen a physician in over ten years and has never undergone colorectal cancer screening. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $138/86\text{ mmHg}$, pulse of $88\text{/min}$, and respirations of $16\text{/min}$. Examination reveals marked abdominal distension with hyperactive, high-pitched bowel sounds. The abdomen is tympanic to percussion but soft, with no rebound tenderness, rigidity, or palpable masses. Digital rectal examination reveals an empty rectal vault and no gross blood. Assume advanced institutional capabilities (including interventional endoscopy) are available. Arrange the following steps in the most appropriate chronological sequence for the comprehensive evaluation and management of this patient's condition.

A 68-year-old man is evaluated in the hospital for right knee pain and swelling that has progressively worsened over the past 3 months. He underwent a right total knee arthroplasty 2 years ago for severe osteoarthritis. His medical history includes hypertension and diet-controlled type 2 diabetes mellitus. His temperature is 37.2°C (99.0°F), blood pressure is 132/82 mmHg, and pulse is 78/min. Physical examination of the right knee reveals a moderate effusion, erythema, and warmth over the joint. Range of motion is significantly limited by pain. Radiographs of the right knee demonstrate periprosthetic radiolucency. Joint aspiration is performed, and synovial fluid analysis reveals a leukocyte count of 65,000/mm³ with 85% neutrophils. Synovial fluid culture grows methicillin-susceptible *Staphylococcus aureus* (MSSA). The patient was started on empiric intravenous vancomycin upon admission. Which of the following is the most appropriate definitive management for this patient?

A 75-year-old man is brought to the emergency department by his family due to worsening confusion and severe lower abdominal pain over the past 24 hours. His family reports he has not urinated since yesterday morning. His medical history is significant for benign prostatic hyperplasia (BPH) and bipolar disorder, for which he takes tamsulosin and lithium. On presentation, his blood pressure is $155/95\text{ mm Hg}$, and his heart rate is $98/\text{min}$. Physical examination reveals a firm, tender suprapubic mass extending to the umbilicus.

Laboratory studies reveal:
Blood urea nitrogen: $88\text{ mg/dL}$
Serum creatinine: $4.8\text{ mg/dL}$ (baseline $1.1\text{ mg/dL}$)
Serum potassium: $6.3\text{ mEq/L}$
Urinalysis: negative for leukocyte esterase and nitrites

A urethral Foley catheter is placed, immediately yielding $1,800\text{ mL}$ of clear urine. He is admitted for monitoring. Over the next 4 hours, his urine output consistently remains between $1,000\text{ mL}$ and $1,200\text{ mL}$ per hour. His repeat blood pressure drops to $84/52\text{ mm Hg}$, and his heart rate increases to $122/\text{min}$. The patient appears pale, and his mucous membranes are severely dry.

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

A 50-year-old woman presents to the clinic after a 2.5-cm palpable nodule was found in the right lobe of her thyroid during a routine physical examination. She reports no palpitations, weight changes, dysphagia, or hoarseness. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient. Assume that her initial laboratory testing reveals a subnormal serum TSH level and that subsequent cytological testing indicates malignancy.

Match each clinical presentation of a urologic condition to the most appropriate definitive surgical or procedural intervention.

A $52$-year-old man with a history of poorly controlled diabetes mellitus presents to the emergency department with a $24$-hour history of severe right knee pain, swelling, and subjective fevers. His temperature is $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), blood pressure is $130/80\text{ mm Hg}$, and pulse is $110/\text{min}$. Physical examination reveals a markedly erythematous, warm, and swollen right knee held in slight flexion. Any passive range of motion of the knee elicits excruciating pain. A large joint effusion is palpable.

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

A 28-year-old male is brought to the emergency department via ambulance after being struck by a motor vehicle. He is confused and complains of severe right-sided chest pain and difficulty breathing. His blood pressure is $75/45$ mm Hg, heart rate is $135$/min, and respiratory rate is $28$/min. Oxygen saturation is $88\%$ on room air. Physical examination reveals large abrasions and severe bruising over the right lateral chest wall. The trachea is deviated to the left. Examination of the right hemithorax demonstrates decreased tactile fremitus, dullness to percussion, and absent breath sounds. The jugular veins are flat. Which of the following is the most appropriate next step in management?