Surgery

A surgical service is evaluating multiple patients with suspected vascular or cardiothoracic conditions. Match each patient's clinical presentation with the underlying pathophysiologic mechanism or anatomic lesion most likely responsible for their symptoms.

A series of patients present to the general surgery clinic with various complications following prior gastric resections and bariatric procedures. Match each clinical presentation with the most accurate underlying pathophysiologic mechanism.

A 60-year-old man presents to the urology clinic to establish care and discuss prostate cancer screening. He is in excellent health with no lower urinary tract symptoms. Arrange the following interventions in the most appropriate chronological order, representing the standard clinical pathway from initial screening to potential definitive surgical management for localized prostate cancer.

A 42-year-old man presents to the orthopedic clinic with a 2-month history of progressive left anterior hip and groin pain. The pain is exacerbated by climbing stairs and prolonged standing, and he frequently experiences aching at night that disrupts his sleep. His medical history is significant for severe persistent asthma, for which he has required multiple bursts of oral corticosteroids over the past 5 years. Vital signs are within normal limits. On physical examination, the patient walks with a noticeable antalgic gait. There is no erythema, warmth, or palpable effusion over the left hip. Passive internal rotation and abduction of the left hip elicit sharp pain, while straight leg raise is negative. Anteroposterior and frog-leg lateral radiographs of the left hip reveal normal joint space without evidence of fracture, subchondral sclerosis, or a crescent sign. Which of the following is the most appropriate next step in management?

A series of clinical scenarios highlight various classic presentations of cardiothoracic and vascular diseases. For each patient presentation described below, identify the correct diagnosis by matching it to the corresponding surgical pathology.

An ambulance arrives at the emergency department with a 75-year-old male who collapsed at home after a massive episode of hematemesis. His wife states he has been experiencing intermittent lower back pain and low-grade fevers for the past two weeks. His surgical history is significant for an abdominal aortic aneurysm repair with a synthetic graft five years ago. Currently, he is lethargic with cool, clammy extremities. Vital signs show a temperature of 37.2°C (99.0°F), a heart rate of 135/min, and a blood pressure of 74/42 mmHg. Fluid resuscitation with packed red blood cells and crystalloids is underway through two large-bore intravenous lines, but his systolic blood pressure remains below 85 mmHg. Which of the following is the most appropriate next step in the management of this patient?

A $27$-year-old man is evaluated in the surgical intensive care unit for acute-onset agitation and shortness of breath. Twenty hours ago, he underwent uncomplicated intramedullary nailing of a right mid-shaft femur fracture sustained in a high-speed motor vehicle collision. His temperature is $38.6^{\circ}\text{C}$ ($101.5^{\circ}\text{F}$), blood pressure is $118/76 \text{ mm Hg}$, heart rate is $126/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows $86\%$ on room air. Physical examination is notable for a petechial rash distributed over the anterior chest and axillae. The right thigh is moderately swollen but soft to palpation, and the surgical incisions are clean and dry. The right dorsalis pedis and posterior tibial pulses are intact bilaterally. Which of the following is the most appropriate management for this patient's current condition?

Match each clinical presentation of an acute abdominal condition with the most appropriate next step in management.

Match each patient's clinical presentation and findings with the most appropriate definitive neurosurgical or endovascular intervention.

A 22-year-old male is brought to the emergency department after a severe collision during a rugby match. On presentation, he is in severe pain. His vital signs are temperature 37.1°C (98.8°F), blood pressure 130/80 mmHg, heart rate 98/min, and respiratory rate 16/min. Physical examination reveals a grossly deformed left knee with a significant posterolateral prominence. The left foot is cool and pale, and both the dorsalis pedis and posterior tibial pulses are not palpable. Capillary refill is delayed. Assume that after initial interventions, the distal pulses return but remain asymmetric compared to the contralateral limb, and subsequent advanced imaging reveals a popliteal artery intimal flap. Arrange the following steps in the correct chronological order for the acute evaluation and management of this patient.

A $32$-year-old woman, who is $34$ weeks pregnant (gravida 1, para 0), is brought to the emergency department by ambulance after a high-speed motor vehicle collision. She was the restrained driver and struck the steering wheel. On arrival, she is restless, confused, and diaphoretic. Her medical history is notable for mild persistent asthma. Temperature is $37.0^\circ\text{C}$, blood pressure is $76/42$ mmHg, heart rate is $138/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry is $91\%$ on room air. Primary survey reveals a patent airway. The jugular veins are markedly distended. Auscultation of the lungs reveals diffuse expiratory wheezing. Heart sounds are distant and muffled. The gravid uterus is non-tender. A bedside Focused Assessment with Sonography for Trauma (FAST) reveals an anechoic fluid stripe surrounding the heart with inward collapse of the right ventricular free wall during diastole; there is no free intra-abdominal fluid. Continuous fetal monitoring shows a baseline heart rate of $155/\text{min}$ with minimal variability and recurrent late decelerations. Which of the following is the most appropriate next step in management?

An emaciated 79-year-old woman is evaluated in the emergency department for intractable vomiting and generalized abdominal pain that has progressively worsened over the past 48 hours. She has a long-standing history of anorexia nervosa, and her current body mass index is $15.2\text{ kg/m}^2$. Temperature is 38.4°C (101.1°F), blood pressure is 86/52 mmHg, pulse is 124/min, and respirations are 22/min. Physical examination reveals a distended abdomen with diffuse guarding and rebound tenderness. No masses are palpable in the bilateral groins or abdominal wall. During the examination, passive extension and medial rotation of her right hip elicits sudden, excruciating pain radiating down the anteromedial aspect of her right thigh. Laboratory studies show a leukocyte count of $16,800/\text{mm}^3$ and a serum lactate of $4.9\text{ mmol/L}$. An upright abdominal radiograph demonstrates multiple dilated loops of small bowel with prominent air-fluid levels and a paucity of colonic gas. There is no free subdiaphragmatic air. Which of the following is the most appropriate next step in management?

A nursing home resident is brought to the surgical evaluation unit due to a sudden decline in his clinical status. The 76-year-old male has a history of severe dementia, atrial fibrillation, and a remote open appendectomy. According to the accompanying staff, he has not had a bowel movement in three days and began vomiting dark, foul-smelling fluid this morning. Over the last hour, he has become increasingly lethargic. Vital signs show a temperature of 38.6 °C (101.5 °F), pulse of 122/min, respirations of 24/min, and blood pressure of 85/55 mm Hg. Physical examination reveals a rigid, markedly distended abdomen with diffuse rebound tenderness. Laboratory studies demonstrate a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate level of $4.2 \text{ mmol/L}$. An upright chest radiograph shows no free air under the diaphragm. A supine abdominal radiograph demonstrates significantly dilated loops of small bowel with prominent valvulae conniventes and an absence of colonic gas. Which of the following is the most appropriate next step in the management of this patient?

A frail $87$-year-old woman is brought to the emergency department from a nursing care facility due to a $48$-hour history of obstipation, intractable vomiting, and progressive abdominal distension. Over the past $12$ hours, she has also developed severe pain along the medial aspect of her right thigh that worsens when her hip is extended. Her medical history includes hypertension, osteoporosis, and significant unintentional weight loss over the past year. She has never had abdominal surgery. Her temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $96/60\text{ mmHg}$, pulse is $115/\text{min}$, and respirations are $22/\text{min}$. On examination, the abdomen is markedly distended, tympanitic, and diffusely tender with involuntary guarding. High-pitched bowel sounds are present. Movement of the right hip, particularly internal rotation and extension, exacerbates the medial thigh pain. Laboratory results are notable for a leukocyte count of $18,200/\text{mm}^3$ and a serum lactate of $4.1\text{ mmol/L}$. An upright abdominal radiograph reveals multiple dilated loops of small bowel with air-fluid levels and an absence of colonic gas. Which of the following is the most appropriate next step in the management of this patient?

A 54-year-old man is currently hospitalized in the intensive care unit for severe acute gallstone pancreatitis. On day 21 of his admission, he develops new-onset fevers, a leukocyte count of 22,000/mm³, and worsening hypotension requiring vasopressor support. A contrast-enhanced CT scan of the abdomen reveals extensive walled-off pancreatic necrosis containing multiple pockets of gas. The surgical team is consulted for management. Arrange the following interventions in the correct sequential order according to the modern 'step-up' approach for infected necrotizing pancreatitis.

A 72-year-old man is evaluated in the emergency department for severe, tearing pain in his lower back and abdomen that started suddenly 45 minutes ago. His medical history includes hypertension, tobacco use disorder, and a 5.0-cm abdominal aortic aneurysm (AAA) discovered incidentally on an ultrasound six months prior. On physical examination, he is lethargic, pale, and profusely diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 75/45 mmHg, pulse is 132/min, and respiratory rate is 24/min. Abdominal palpation reveals significant distension, diffuse tenderness with involuntary guarding, and a prominent, expansile periumbilical mass. The patient lacks decision-making capacity due to his lethargic state. His son, who holds a legally executed durable power of attorney for healthcare for the patient, urges the medical team to proceed with all necessary life-saving measures. Concurrently, the patient's estranged wife arrives and insists that no surgical interventions be performed. Which of the following is the most appropriate next step in management?

A 34-year-old right-handed male presents to the emergency department one hour after an altercation in which he was struck on the right upper arm with a heavy steel pipe. He complains of intense pain and an inability to use his right hand. His vital signs are within normal limits. On physical examination, the right arm reveals significant soft tissue swelling, ecchymosis, and a visible deformity over the mid-humerus. The skin is completely intact. Neurological examination of the right upper extremity reveals an inability to extend the wrist or fingers. Sensation to pinprick is diminished over the dorsal aspect of the first web space. The radial and ulnar pulses are $2+$ and symmetric. Capillary refill is less than $2$ seconds in all digits. Anteroposterior and lateral radiographs of the right humerus demonstrate a displaced transverse fracture of the middle third of the humeral shaft. Which of the following is the most appropriate next step in management?

A 25-year-old male is admitted to the neurosurgical intensive care unit following a severe traumatic brain injury sustained in a motor vehicle collision. He is intubated, mechanically ventilated, and receiving continuous infusions of propofol and fentanyl for sedation and analgesia. An intracranial pressure (ICP) monitor is in place. His ICP acutely rises to 28 mm Hg and remains elevated for 10 minutes despite the current sedation. His vital signs show a blood pressure of 130/80 mm Hg, heart rate of 85/min, and temperature of 37.2°C (99.0°F). Arrange the following interventions in the most appropriate stepwise sequence for managing this patient's elevated intracranial pressure, proceeding from initial, least invasive measures to final salvage therapy.

A 58-year-old man arrives at the emergency department reporting the sudden onset of agonizing, "tearing" chest pain that radiates to his back between his shoulder blades. He appears diaphoretic and in severe distress. Vital signs include a blood pressure of 195/115 mm Hg in the right arm and 145/90 mm Hg in the left arm, and a heart rate of 112/min. A new early diastolic murmur is auscultated at the right sternal border. Electrocardiography demonstrates sinus tachycardia without acute ischemic changes. A portable chest radiograph reveals a widened mediastinum.

Arrange the following management steps in the most appropriate sequential order for this patient.

A 48-year-old woman presents to the clinic with progressive weight gain, facial plethora, and easy bruising over the past year. Examination reveals central adiposity, prominent violaceous abdominal striae, and proximal muscle weakness. Her blood pressure is $155/95$ mmHg. Initial basic metabolic panel reveals mild hypokalemia. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient.