Surgery

Match each patient presentation of a lower extremity orthopedic injury with the most likely associated neurovascular complication and physical exam finding.

Paramedics bring a $31$-year-old male construction worker to the trauma bay shortly after he plunged $9$ meters ($30$ feet) off a roof. On primary survey, he is unresponsive, prompting immediate endotracheal intubation for airway protection. Before induction, his Glasgow Coma Scale score was calculated at $6$ (Eyes $1$, Verbal $2$, Motor $3$). Current vital signs demonstrate severe hemodynamic instability with a blood pressure of $72/40$ mm Hg and a heart rate of $142$/min. Cranial nerve assessment shows anisocoria; the right pupil is dilated to $8$ mm and fixed, whereas the left pupil is $3$ mm and sluggish. Palpation of the abdomen reveals board-like rigidity and significant distension. The pelvis is stable. Which of the following is the most appropriate next step in management?

Two hours following a total thyroidectomy for a large, compressive multinodular goiter, a nurse urgently pages the surgical resident to evaluate a patient in the recovery ward. The patient, a 54-year-old female, is profoundly agitated and exhibiting labored breathing. Vital signs show a heart rate of 115/min, blood pressure of 158/92 mm Hg, and an oxygen saturation of 86% on ambient air. Physical examination reveals prominent inspiratory stridor. The anterior cervical incision site demonstrates a tense, rapidly enlarging swelling beneath the surgical dressing, accompanied by fresh blood seeping through the bandages. Which of the following is the most appropriate immediate intervention for this patient?

A 68-year-old man is evaluated in the surgical step-down unit on postoperative day 6 following a coronary artery bypass grafting procedure. He reports worsening retrosternal pain and subjective chills over the past 24 hours. The pain is sharp, is exacerbated by deep breathing, and feels distinct from his initial postoperative discomfort. His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, pulse is $112/\text{min}$, and respirations are $22/\text{min}$. On physical examination, the sternal incision is erythematous with a small amount of cloudy, serosanguineous drainage. Firm palpation of the sternum elicits a clicking sensation and palpable movement of the bony edges when the patient coughs. The lungs are clear to auscultation bilaterally. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ with $85\%$ neutrophils. A chest radiograph demonstrates a widened mediastinum and a new, small left-sided pleural effusion. Which of the following is the most appropriate next step in management?

An evaluation is requested in the emergency department for a 54-year-old woman reporting two days of severe, colicky abdominal pain accompanied by progressive swelling of her abdomen. She notes an inability to pass stool or flatus over the past 24 hours and has experienced three episodes of bilious emesis today. Her past surgical history is notable for an open total abdominal hysterectomy performed five years ago. On presentation, her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse is $98/\text{min}$, and blood pressure is $110/70\text{ mmHg}$. Abdominal examination demonstrates marked distension and tympany with hyperactive, high-pitched bowel sounds. Palpation reveals diffuse mild tenderness, but there is no guarding, rigidity, or rebound tenderness. Initial laboratory evaluations show:

Leukocyte count: $11,200/\text{mm}^3$
Serum sodium: $136\text{ mEq/L}$
Serum potassium: $3.2\text{ mEq/L}$
Serum chloride: $96\text{ mEq/L}$
Serum bicarbonate: $28\text{ mEq/L}$
Serum lactate: $1.1\text{ mmol/L}$ (normal: $0.5$-$2.2\text{ mmol/L}$)

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

A 72-year-old man presents to the urology clinic with a one-week history of painless gross hematuria. He has a 40-pack-year smoking history. Vital signs are within normal limits, and physical examination is unremarkable. Office flexible cystoscopy reveals a completely normal bladder mucosa and urethra. Urine cytology returns positive for high-grade malignant cells. Arrange the following interventions in the correct chronological order for the definitive evaluation and management of this patient's condition.

A $24$-year-old man is brought to the emergency department after falling off his skateboard and striking the right side of his head. Witnesses report he had a brief loss of consciousness lasting approximately $1$ minute, followed by a period where he was awake and conversing. En route to the hospital, he became progressively lethargic and unresponsive. On arrival, his blood pressure is $170/95$ mmHg, heart rate is $52$/min, and respirations are $10$/min and irregular. His Glasgow Coma Scale score is $6$ (Eye: $1$, Verbal: $2$, Motor: $3$ with abnormal flexion). Physical examination reveals a right pupil that is $7$ mm and nonreactive to light, as well as left-sided hemiparesis. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 65-year-old man is evaluated in the clinic after a routine chest radiograph, obtained prior to an elective inguinal hernia repair, incidentally revealed a widened mediastinum and an enlarged aortic contour. He has a history of essential hypertension and a 40-pack-year smoking history but currently feels well, reporting no chest, abdominal, or back pain. His blood pressure is 148/92 mm Hg, and his heart rate is 78/min. Arrange the following steps in the most appropriate chronological order for the definitive evaluation and long-term management of this patient's suspected condition.

Match each clinical presentation of a pancreatic fluid collection or cystic lesion with its correct diagnosis and most appropriate surgical management step.

A $32$-year-old man is evaluated in the surgical intensive care unit for severe right lower extremity pain. $12$ hours ago, he underwent closed reduction and intramedullary nailing for a comminuted right tibial shaft fracture sustained in a high-speed skiing accident. He reports that the pain has progressively worsened over the last $3$ hours and is now "unbearable," describing it as a deep, burning ache. The pain is completely unresponsive to multiple doses of intravenous morphine. His temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $148/92 \text{ mmHg}$, pulse is $118/\text{min}$, and respiratory rate is $22/\text{min}$. On physical examination, the right leg is tensely swollen, shiny, and exceedingly firm to palpation. Passive plantar flexion of the right ankle and toes elicits excruciating pain. Sensation to light touch is markedly decreased over the first dorsal web space of the right foot. The dorsalis pedis and posterior tibial pulses are palpable and symmetric to the contralateral side. Which of the following is the most appropriate next step in management?

A 42-year-old woman is brought to the emergency department due to a 6-hour history of acute-onset, severe, colicky periumbilical pain that radiates to her back. She also reports multiple episodes of bilious vomiting. Her medical history is significant for morbid obesity treated with a laparoscopic Roux-en-Y gastric bypass 4 years ago, after which she lost 45 kg (100 lb). Current medications include a multivitamin and calcium supplementation. Her temperature is 37.1°C (98.8°F), blood pressure is 105/65 mm Hg, pulse is 118/min, and respirations are 20/min. Physical examination reveals a non-distended, soft abdomen with moderate periumbilical tenderness. There is no rebound tenderness or involuntary guarding. Bowel sounds are hyperactive. Laboratory studies show a leukocyte count of 12,500/mm³ and serum lactate of 2.1 mmol/L. A CT scan of the abdomen and pelvis with intravenous contrast demonstrates a cluster of dilated small bowel segments in the left upper quadrant, stretching and engorgement of the mesenteric vessels, and a small amount of interloop free fluid. Which of the following is the most appropriate next step in management of this patient?

A $34$-year-old woman is brought to the emergency department due to the sudden onset of severe, continuous periumbilical pain that radiates to her back. The pain started $4$ hours ago and is accompanied by intractable nausea and multiple episodes of bilious vomiting. Two years ago, she underwent an uncomplicated laparoscopic Roux-en-Y gastric bypass for morbid obesity, achieving a $50$-kg ($110$-lb) weight loss. Vital signs are temperature $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), heart rate $124/\text{min}$, blood pressure $88/56\text{ mm Hg}$, and respirations $22/\text{min}$. Physical examination reveals a slightly distended, rigid abdomen with diffuse guarding and marked rebound tenderness. Bowel sounds are absent. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate of $4.8\text{ mmol/L}$. An upright chest radiograph shows no free air under the diaphragm. Which of the following is the most appropriate next step in management?

A 68-year-old man presents to the emergency department with a 5-day history of progressively worsening mid-back pain. He reports that over the past 24 hours, his legs have felt "heavy" and he has had difficulty walking. He also mentions not having a bowel movement in 3 days and experiencing difficulty initiating urination. His medical history is significant for advanced prostate cancer diagnosed 2 years ago. His temperature is 37.1°C (98.8°F), blood pressure is 145/90 mm Hg, and pulse is 82/min. Neurologic examination reveals 3/5 strength in the bilateral lower extremities. Muscle tone is increased in the lower limbs, and deep tendon reflexes are 3+ at the knees and ankles. Plantar reflexes are upgoing bilaterally. Perianal sensation is decreased. Which of the following is the most appropriate next step in management?

A 71-year-old male is assessed in the intensive care unit on postoperative day 3 following an emergent open repair of a ruptured abdominal aortic aneurysm. His past medical history includes chronic obstructive pulmonary disease, ischemic cardiomyopathy, and hypertension. Over the past several hours, he has developed worsening generalized abdominal pain and just passed a large amount of dark, bloody stool. He also complains of new-onset shortness of breath. Vital signs are temperature 38.6°C (101.5°F), blood pressure 82/50 mm Hg, pulse 130/min, and respirations 26/min. Pulse oximetry is 92% on a nasal cannula. Physical examination reveals a markedly distended, rigid abdomen with diffuse tenderness and involuntary guarding. Bowel sounds are absent. Lung auscultation demonstrates scattered expiratory wheezes. Laboratory results are notable for a leukocyte count of 22,000/mm³ and a serum lactate of 6.8 mmol/L. Despite an initial bolus of intravenous crystalloid, his blood pressure remains 84/52 mm Hg. Which of the following is the most appropriate next step in management?

An emergency medical services team rushes a 71-year-old woman to the emergency department after she experienced an abrupt onset of agonizing, diffuse abdominal pain 2 hours ago. She has a medical history of paroxysmal atrial fibrillation (for which she has not been taking her prescribed oral anticoagulant), type 2 diabetes mellitus, and chronic bronchitis. Her temperature is 37.4°C (99.3°F), blood pressure is 82/50 mmHg, pulse is 134/min and irregularly irregular, and respirations are 28/min. Physical examination reveals a diaphoretic, lethargic patient writhing in pain. Lung auscultation demonstrates prolonged expiration with scattered end-expiratory wheezes. The abdomen is markedly distended and extremely tender to light palpation in all quadrants, with board-like rigidity and involuntary guarding. Bowel sounds are absent.

Arterial blood gas analysis on room air reveals:
pH: 7.18
$pCO_2$: 30 mmHg
$pO_2$: 65 mmHg
$HCO_3^-$: 11 mEq/L

Serum lactate is 9.2 mmol/L.

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

Match each post-operative cardiothoracic surgery complication to its characteristic clinical presentation or diagnostic finding.

Following a mountain biking accident, a 32-year-old man arrives at the emergency department reporting severe perineal pain. He fell forcefully onto the crossbar of his bicycle 2 hours ago and has been unable to void since the incident. Vital signs are temperature 37.0°C (98.6°F), blood pressure 130/80 mm Hg, and pulse 88/min. Inspection of the genital region reveals pronounced swelling and a characteristic butterfly-shaped ecchymosis confined to the perineum. A distinct drop of blood is visualized at the urethral meatus. Digital rectal examination demonstrates a non-tender, normally positioned prostate with intact rectal tone. Which of the following is the most appropriate next step in management?

An emergency medical team brings a 6-year-old female to the trauma bay after she sustained a fall from a playground structure onto an outstretched left arm. She is crying and refusing to move her left upper extremity. Physical examination reveals a significant "S-shaped" deformity and severe swelling around the left elbow. The left hand is pale and cool to the touch. Capillary refill is 4 seconds. Radial and ulnar pulses are absent on palpation and cannot be detected with a handheld Doppler. She is unable to flex the interphalangeal joint of her thumb. Radiographs confirm a completely displaced, extension-type supracondylar humerus fracture. Arrange the following management steps in the most appropriate chronological order for this patient.

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

Match each clinical scenario involving the biliary tract with the most appropriate surgical or endoscopic intervention.