Surgery

Match the following clinical presentations of urologic pathology with their most appropriate definitive surgical management.

An emergency medical services team brings a $62$-year-old female to the hospital due to excruciating right-sided back pain, rigors, and altered mental status that began $24$ hours ago. Her medical history includes multiple previous episodes of kidney stones. She visited an outpatient clinic $48$ hours prior for pain on urination, where empirical oral nitrofurantoin was prescribed and a urine culture was obtained. Upon arrival today, vital signs show a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of $85/55\text{ mm Hg}$, heart rate of $124/\text{min}$, and respiratory rate of $22/\text{min}$. Physical examination is notable for profound right costovertebral angle tenderness and dry mucous membranes. Blood tests indicate a leukocyte count of $22,000/\text{mm}^3$. A non-contrast computed tomography scan reveals an $11\text{-mm}$ stone lodged in the proximal right ureter causing pronounced hydronephrosis. The outpatient clinic faxes her urine culture results, confirming an infection with Escherichia coli ($>100,000\text{ CFU/mL}$). The organism is susceptible to ceftriaxone and ciprofloxacin, but resistant to ampicillin and nitrofurantoin. Rapid intravenous fluid resuscitation is commenced. Which of the following is the most appropriate next step in management?

On postoperative day 6 following a coronary artery bypass grafting for severe ischemic heart disease, a 64-year-old man is evaluated for worsening chest pain and progressive shortness of breath over the last 24 hours. The pain is exacerbated by deep inspiration and coughing. His medical history includes type 2 diabetes mellitus, chronic obstructive pulmonary disease, and obesity. Current medications include aspirin, metoprolol, and a sliding-scale insulin regimen. His temperature is $39.1^{\circ}\text{C}$ ($102.4^{\circ}\text{F}$), blood pressure is 108/64 mmHg, pulse is 114/min, and respirations are 24/min. Pulse oximetry shows 94% on room air. Physical examination reveals an erythematous sternal incision that is exquisitely tender to palpation. Purulent fluid can be expressed from the inferior aspect of the wound. There is palpable movement of the sternal edges relative to each other when the patient takes a deep breath. Lung auscultation reveals decreased breath sounds at the bases bilaterally, without wheezing. Cardiac auscultation reveals regular tachycardia without murmurs, rubs, or gallops. Laboratory testing shows a leukocyte count of $19,500/\text{mm}^3$. Which of the following is the most appropriate next step in the management of this patient?

Surgical consultation is requested for a 62-year-old man due to a change in his clinical status. The patient was admitted three days ago with a mechanical small bowel obstruction attributed to adhesions from a remote appendectomy. Initial computed tomography of the abdomen demonstrated a discrete transition point in the distal ileum with collapsed large bowel, lacking any signs of ischemia. He has been managed nonoperatively with intravenous fluid resuscitation, bowel rest, and nasogastric decompression.

Over the last 12 hours, the patient reports that his abdominal pain has transitioned from intermittent cramping to a severe, continuous ache localized to the periumbilical area. Concurrently, his nasogastric tube output has diminished abruptly from 800 mL to 150 mL daily, and he remains obstipated.

Temperature is 38.2°C (100.8°F), heart rate is 110/min, blood pressure is 135/85 mm Hg, and respiratory rate is 18/min. Abdominal examination reveals significant distension with localized periumbilical tenderness and involuntary guarding. Bowel sounds are absent.

Laboratory evaluation shows:
Leukocyte count: 14,500/mm³
Sodium: 140 mEq/L
Potassium: 4.1 mEq/L
Chloride: 104 mEq/L
Bicarbonate: 18 mEq/L
Blood urea nitrogen: 28 mg/dL
Creatinine: 1.3 mg/dL
Venous lactate: 1.9 mmol/L (Normal: 0.5–2.2 mmol/L)

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

A $58$-year-old man is evaluated in the emergency department for a $4$-day history of progressively worsening left lower quadrant abdominal pain, subjective fevers, and chills. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse is $96/\text{min}$, and blood pressure is $128/80\text{ mm Hg}$. Physical examination reveals marked tenderness in the left lower quadrant with a palpable, tender mass. There is voluntary guarding but no diffuse rigidity or rebound tenderness. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$. A CT scan of the abdomen and pelvis with intravenous contrast demonstrates severe sigmoid diverticulitis with an adjacent $5.5\text{-cm}$ well-defined, rim-enhancing fluid collection containing gas bubbles.

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

A $24$-year-old man is brought to the emergency department after sustaining a stab wound to the left anterior neck, midway between the cricoid cartilage and the angle of the mandible. He is agitated and has a hoarse voice. His respiratory rate is $28$/min and oxygen saturation is $92\%$ on room air. Blood pressure is $85/50$ mm Hg, and heart rate is $125$/min. Physical examination reveals a large, rapidly expanding hematoma on the left side of the neck with overlying pulsatile bleeding. Arrange the following management steps in the most appropriate chronological sequence for this patient.

Paramedics transport a patient to the trauma bay after he experienced a sudden loss of consciousness at his workplace. The patient's coworkers state that he abruptly grabbed the back of his head, complained of severe dizziness and nausea, and then collapsed. Medical records indicate he is 62 years old and has a long-standing history of medication nonadherence for essential hypertension. Currently, his blood pressure is 198/115 mmHg, and his heart rate is 54/min. Neurological assessment shows a profoundly lethargic patient who only localizes to painful stimuli and has irregular respirations. Non-contrast cranial computed tomography (CT) demonstrates a 4.2-cm hyperdense collection in the right cerebellar hemisphere, associated with compression of the fourth ventricle and significant dilation of the lateral ventricles. Which of the following is the most appropriate next step in management?

A 31-year-old male agricultural worker presents to the emergency department with a 3-day history of progressive pain and swelling in his left index finger. He reports sustaining a small puncture wound from a wire fence 5 days prior. His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, and pulse is $98/\text{min}$. Physical examination reveals a diffusely swollen, erythematous left index finger that the patient holds in a partially flexed posture. There is pronounced tenderness extending along the volar aspect of the digit down to the proximal palmar crease. Passive extension of the finger elicits excruciating pain. Sensation and capillary refill are intact in the affected digit. Radiographs of the hand show soft tissue swelling but no foreign body, fracture, or bony destruction. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation to the most likely underlying vascular or thoracic pathology.

A 68-year-old man presents to the emergency department with severe lower abdominal discomfort and an inability to pass urine for the past 14 hours. He reports a two-year history of progressive urinary hesitancy, nighttime awakenings to void, and a weak urinary stream. Vital signs are within normal limits. Physical examination reveals a visibly distended, exquisitely tender suprapubic mass. Arrange the following interventions in the most appropriate sequential order for the standard evaluation and management of this patient's condition, from immediate to definitive.

A 29-year-old woman is brought to the trauma center after being thrown from her motorcycle in a high-speed collision. The primary trauma survey reveals a patent airway, unlabored breathing, and intact circulation. Her vital signs are within normal limits. The secondary survey is notable for a severe right lower extremity injury. There is an obvious deformity of the midshaft tibia with a 14-cm full-thickness laceration. The underlying muscle is severely crushed, and exposed bone is stripped of its periosteum. The dorsalis pedis and posterior tibial pulses are palpable. Arrange the following steps in the most appropriate chronological sequence for the optimal management of this patient's limb injury.

A $61$-year-old woman is evaluated in the cardiovascular intensive care unit for acute-onset shortness of breath and lightheadedness. She underwent an open surgical mitral valve replacement $4$ days ago. Her postoperative recovery had been unremarkable until $2$ hours ago. Temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $82/64 \text{ mmHg}$, pulse is $122\text{/min}$, and respiratory rate is $24\text{/min}$. Pulse oximetry shows $94\%$ on room air. On examination, the patient appears anxious and diaphoretic. Jugular venous pulsations are visibly distended while she is sitting upright. The lungs are clear to auscultation bilaterally. Heart sounds are distant, and the point of maximal impulse is difficult to palpate. The surgical incision is clean, dry, and intact. Extremities are cool to the touch with delayed capillary refill. A portable chest radiograph reveals a globally enlarged cardiac silhouette without focal pulmonary infiltrates. Which of the following is the most appropriate next step in management?

A surgical triage team is evaluating four patients presenting to the emergency department with acute abdominal pain. Match each patient's clinical and radiologic presentation with the most appropriate next step in management.

A $32$-year-old man is brought to the emergency department $20\text{ minutes}$ after sustaining a gunshot wound to the right groin. On arrival, he is confused and diaphoretic. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $76/40\text{ mmHg}$, heart rate is $138/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals a single penetrating wound just below the right inguinal ligament. There is a rapidly expanding, pulsatile hematoma measuring approximately $12\text{ cm}$ in diameter in the right groin. Active, bright red blood is oozing from the wound. The right foot is pale and cold to the touch, and the right dorsalis pedis and posterior tibial pulses are not palpable by Doppler ultrasound. Two large-bore intravenous lines are established, and a massive transfusion protocol is initiated. Which of the following is the most appropriate immediate next step in management?

A 52-year-old woman presents with a 3-week history of rapid-onset swelling, erythema, and a peau d'orange appearance of her right breast. Examination reveals diffuse induration, warmth, and enlargement of the right breast, along with palpable right axillary lymphadenopathy. Suspecting inflammatory breast cancer, arrange the following steps in the standard diagnostic and therapeutic sequence for this patient, from the initial step to the final step.

A 68-year-old man with a known history of metastatic prostate cancer is brought to the emergency department complaining of severe mid-back pain that has steadily worsened over the past two weeks. Over the last 6 hours, he has developed bilateral leg weakness and urinary incontinence. Vital signs are within normal limits. Neurologic examination reveals 3 out of 5 muscle strength in the lower extremities bilaterally, decreased sensation to pinprick below the umbilicus, and absent patellar and Achilles reflexes. Rectal examination demonstrates severely decreased anal sphincter tone. Arrange the following diagnostic and therapeutic steps in the most appropriate chronological order for managing this patient's condition.

An otherwise healthy $27$-year-old male arrives at the emergency room seeking urgent evaluation for sudden, intense genital pain. Approximately $30$ minutes prior to arrival, he experienced a distinct "cracking" sound during vigorous intercourse, which was immediately followed by rapid detumescence and swelling. He has been in exquisite pain and has intentionally avoided voiding since the event. Triage vital signs reveal a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $128/82\text{ mmHg}$, heart rate of $94/\text{min}$, and respiratory rate of $16/\text{min}$. Genitourinary examination demonstrates a markedly edematous and ecchymotic penis that is visibly deviated to the left. A single drop of fresh blood is noted at the external urethral meatus. Scrotal palpation reveals normal testes bilaterally without masses or tenderness. Preliminary laboratory analysis shows a hemoglobin level of $14.2\text{ g/dL}$ and a leukocyte count of $8,500/\text{mm}^3$. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old man presents to the emergency department with a 2-day history of worsening right knee pain, swelling, and fever. He underwent a primary right total knee arthroplasty 3 weeks ago for severe osteoarthritis. His early postoperative course was uncomplicated, and he had been progressing well with physical therapy until the onset of these symptoms. His temperature is 38.9°C (102.0°F), blood pressure is 125/80 mmHg, pulse is 105/min, and respiratory rate is 18/min. Physical examination reveals a markedly swollen, erythematous, and warm right knee. The surgical incision is well-healed with no active drainage. Range of motion is severely limited by pain. Laboratory studies show a leukocyte count of 14,500/mm³ and an erythrocyte sedimentation rate of 85 mm/hr. Arthrocentesis of the right knee yields cloudy fluid with a leukocyte count of 45,000/mm³ (90% neutrophils). Gram stain shows Gram-positive cocci in clusters. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old man presents to the clinic with a 6-month history of cramping pain in his right calf. The pain occurs consistently after walking approximately two blocks and is completely relieved after 5 minutes of rest. He has a history of hypertension, hyperlipidemia, and a 30-pack-year smoking history. Vital signs are within normal limits. On physical examination, the right dorsalis pedis and posterior tibial pulses are diminished compared to the left. Bilateral femoral and popliteal pulses are 2+ and symmetric. There is no evidence of dependent rubor, hair loss, resting pain, or non-healing ulcers on the lower extremities.

Arrange the following evaluation and management steps in the most appropriate sequential order for this patient over the course of his disease. Assume that his symptoms persist and become severely lifestyle-limiting despite full compliance with each preceding non-invasive intervention.

A 58-year-old man comes to the physician because of a 5-month history of progressive clumsiness in his hands and an unsteady gait. He frequently drops small objects and has difficulty fastening buttons. He has no history of trauma, fever, or preceding illness. Vital signs are normal. Neurological examination reveals decreased bulk and tone in the intrinsic muscles of both hands. Biceps and brachioradialis reflexes are 1+ bilaterally. In contrast, knee and ankle jerks are 3+ bilaterally, and sustained ankle clonus is present. Babinski sign is present bilaterally. Sensory examination shows decreased vibration and position sense in the toes. Which of the following is the most appropriate next step in management?