Surgery

A $71$-year-old male is admitted directly to the resuscitation bay following an episode of profuse hematemesis at his residence. For the preceding $2$ weeks, he noted intermittent melena, subjective fevers, and a deep, gnawing lumbar ache. His surgical history is significant for a synthetic graft repair of an infrarenal abdominal aortic aneurysm $4$ years ago. On arrival, he is confused and diaphoretic. Vital signs include a temperature of $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), heart rate of $134/\text{min}$, blood pressure of $72/40\text{ mmHg}$, and respiratory rate of $22/\text{min}$. Abdominal examination reveals a well-healed midline scar and mild epigastric tenderness without guarding. Intravenous access is established, and aggressive fluid resuscitation is initiated, but his blood pressure remains $76/44\text{ mmHg}$. Which of the following is the most appropriate next step in management?

A 32-year-old man comes to the urology clinic after noticing a firm swelling in his left testicle approximately two weeks ago. He reports no pain, dysuria, urinary frequency, or recent trauma. He has no history of sexually transmitted infections. Vital signs are within normal limits. On physical examination, the overlying scrotal skin appears normal. Palpation of the left testicle reveals a $3\text{-cm}$, rock-hard, non-tender nodule located at the lower pole. The lesion does not transilluminate and cannot be separated from the testis. The right testicle and bilateral epididymides are soft and normal to palpation. A scrotal ultrasound confirms the presence of a solid, hypervascular, hypoechoic intratesticular mass. Serum laboratory testing demonstrates an alpha-fetoprotein (AFP) level of $145\text{ ng/mL}$ (normal $< 10\text{ ng/mL}$) and a $\beta$-hCG level of $92\text{ mIU/mL}$ (normal $< 2\text{ mIU/mL}$). Which of the following is the most appropriate next step in management?

A $71$-year-old man is transported to the resuscitation bay after collapsing at his home. His daughter, who witnessed the event, reports that he suddenly complained of an agonizing, tearing pain in the center of his chest that radiated to his upper back right before losing consciousness. His past medical history is significant for poorly controlled hypertension, chronic obstructive pulmonary disease, and a prior exploratory laparotomy for a small bowel obstruction.

On physical examination, the patient is lethargic, diaphoretic, and pale. Vital signs are:
Temperature: $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$)
Heart rate: $128\text{ /min}$
Blood pressure: $76/42\text{ mm Hg}$
Respiratory rate: $26\text{ /min}$
Oxygen saturation: $92\%$ on room air.

Cardiovascular examination reveals distended neck veins, faint heart sounds, and a newly appreciated high-pitched, blowing early diastolic murmur best heard at the right upper sternal border. Lung auscultation is clear bilaterally. The abdomen is soft and non-distended.

A bedside point-of-care ultrasound demonstrates a large pericardial effusion with right ventricular diastolic collapse, as well as a visible intimal flap in the proximal ascending aorta.

Based on the clinical and sonographic findings, what is the best initial intervention for this patient?

A 74-year-old man with a history of Parkinson disease and severe chronic constipation is brought to the emergency department by his family due to a 2-day history of progressive abdominal distention, crampy lower abdominal pain, and obstipation. Vital signs are temperature 37.2°C (99.0°F), blood pressure 135/85 mm Hg, pulse 92/min, and respirations 16/min. Physical examination reveals a markedly distended, tympanitic abdomen. The abdomen is non-tender, with no guarding, rigidity, or rebound tenderness. Laboratory studies show a leukocyte count of 11,000/mm³ and a normal serum lactate level. Arrange the following steps in the most appropriate chronological sequence for the standard definitive management of this patient's condition.

A 34-year-old construction worker arrives at the trauma center following a workplace accident. He was struck on the right arm by a swinging metal pipe. He reports severe pain in his right arm. His vital signs are within normal limits. Examination of the right upper extremity reveals marked swelling and an obvious angular deformity in the middle of the upper arm. The overlying skin is intact. When asked to move his hand, the patient demonstrates a "wrist drop" and cannot actively straighten his fingers at the metacarpophalangeal joints. He reports numbness over the back of his right hand near the thumb. Radial and ulnar pulses are strong and symmetrical. An X-ray confirms a closed, displaced transverse fracture of the midshaft of the humerus. Which of the following is the most appropriate initial management for this patient?

A 52-year-old woman is evaluated in the emergency department for abrupt, agonizing chest pain that she describes as 'ripping' and radiating to her mid-back. Her pulse is 115/min and blood pressure is 215/115 mm Hg in the right upper extremity and 175/90 mm Hg in the left. A plain chest radiograph demonstrates mediastinal widening. Arrange the following clinical interventions in the most appropriate chronological sequence for optimal management of this patient's suspected pathology.

Match each primary bone tumor with its most characteristic radiographic finding and classic anatomical location.

A 38-year-old man is brought to the emergency department after being struck by a motor vehicle while crossing the street. On arrival, he is confused but protecting his airway. His temperature is $36.5^\circ\text{C}$, blood pressure is $78/40\text{ mmHg}$, pulse is $135/\text{min}$, and respiratory rate is $26/\text{min}$. Oxygen saturation is $96\%$ on room air. Primary survey reveals equal and bilateral breath sounds. The abdomen is soft and non-distended. Examination of the pelvis reveals gross instability to anteroposterior compression. There is a large scrotal hematoma and a prominent drop of blood at the urethral meatus. An extended focused assessment with sonography for trauma (E-FAST) reveals no free fluid in the pericardial, pleural, or peritoneal spaces. A pelvic binder is immediately applied, and the patient is resuscitated with 2 liters of isotonic crystalloid and 2 units of uncrossmatched type O-negative packed red blood cells. Re-evaluation 15 minutes later shows a blood pressure of $82/45\text{ mmHg}$ and a pulse of $130/\text{min}$. Which of the following is the most appropriate next step in management?

A 64-year-old man is brought to the emergency department via ambulance due to sudden-onset, excruciating chest pain that he describes as 'ripping' and radiating to his interscapular region. He has a history of poorly controlled hypertension. His temperature is 37.1°C (98.8°F), blood pressure is 215/115 mm Hg in his right arm and 175/95 mm Hg in his left arm, heart rate is 118/min, and oxygen saturation is 96% on room air. Cardiac auscultation reveals a new early diastolic murmur at the right upper sternal border. An intravenous line is established. Arrange the following subsequent steps in the patient's evaluation and management in the most appropriate chronological order.

A 52-year-old woman presents to the emergency department with a 24-hour history of severe, sudden-onset abdominal pain, intractable nausea, and an inability to pass flatus or stool. Her past medical history is significant for systemic lupus erythematosus, for which she takes hydroxychloroquine and low-dose prednisone. She has never undergone abdominal surgery. Vital signs show a temperature of 37.4°C (99.3°F), blood pressure of 118/76 mmHg, and a heart rate of 105/min. Physical examination reveals a markedly asymmetric, distended abdomen with diffuse tympany to percussion. There is moderate tenderness to palpation in the mid-abdomen without rigidity or rebound. Laboratory results, including a complete blood count and basic metabolic panel, are within normal limits. An upright abdominal plain radiograph demonstrates a massively dilated, ectopic large bowel loop originating in the right lower quadrant and projecting toward the left upper quadrant, displaying a 'kidney bean' appearance. A single large air-fluid level is visualized, and there is a paucity of gas in the distal colon. Which of the following is the most appropriate next step in management?

A 64-year-old man presents to the clinic with a 3-week history of a left-sided scrotal mass. He reports a dull, dragging sensation in his scrotum but denies acute pain, dysuria, or fever. His medical history is notable for hypertension and a 40-pack-year smoking history. Physical examination reveals a soft, non-tender, tortuous mass superior to the left testis. The mass does not decompress when the patient assumes a supine position. His abdomen is soft and non-tender. Urinalysis demonstrates 4-5 red blood cells per high-power field. Which of the following is the most appropriate next step in management?

A 72-year-old male with a history of poorly controlled type 2 diabetes mellitus and tobacco use disorder is evaluated in the outpatient vascular surgery clinic for worsening right foot pain. Over the past month, he has experienced a continuous, burning ache in his right toes that frequently awakens him from sleep. He notes that the pain is somewhat alleviated by sitting up and dangling his foot over the edge of the bed. Physical examination of the right lower extremity demonstrates cool, shiny, and hairless skin. There is a 1.5-cm, well-demarcated, dry ulcer with a pale base located on the tip of the great toe. Palpation of the right femoral pulse is normal, but the popliteal, dorsalis pedis, and posterior tibial pulses are absent. Capillary refill time in the toes is 5 seconds. The ankle-brachial index is 0.35 on the right. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation or anatomical description of a specific abdominal or pelvic hernia with its correct diagnostic eponym.

An $82$-year-old woman is brought to the emergency department after a mechanical fall at home. She tripped over a rug and landed directly on her right side. She complains of severe right groin pain and is completely unable to bear weight. Her past medical history is significant for osteoporosis, hypertension, and mild chronic obstructive pulmonary disease. Her current medications include amlodipine, alendronate, and an albuterol inhaler.

Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $138/82\text{ mm Hg}$, pulse $88/\text{min}$, and respiratory rate $16/\text{min}$. On physical examination, her right lower extremity is visibly shortened and externally rotated. Palpation over the greater trochanter elicits significant tenderness. Distal pulses are intact, and there are no sensory deficits.

Anteroposterior radiographs of the right hip reveal a completely displaced fracture line extending transversely across the anatomical neck of the right femur, entirely proximal to the intertrochanteric line. There is no evidence of underlying osteolytic lesions.

Which of the following is the most appropriate definitive management for this patient's injury?

A young adult is transported to the trauma center via helicopter after a high-speed motorcycle crash. Following completion of the primary trauma survey and hemodynamic stabilization, evaluation reveals an isolated, severe left lower extremity injury. Examination shows a highly comminuted, open mid-shaft tibia fracture with a 12-cm soft tissue defect, extensive contamination, and exposed bone. The ipsilateral foot is pale and cold. Doppler ultrasonography demonstrates absent signals over the dorsalis pedis and posterior tibial arteries. Immediate operative intervention is planned. Arrange the following surgical management steps in the most appropriate chronological order for this patient.

Match each clinical presentation of a urologic condition with its most appropriate definitive surgical or procedural management.

A 22-year-old man is evaluated in the hospital for severe right leg pain. Ten hours ago, he underwent closed reduction and placement of a circumferential long-leg cast for a closed, displaced midshaft tibia fracture sustained during a soccer match. He states that the pain is agonizing, describes it as a deep 'burning' sensation, and reports that it has progressively worsened over the last three hours despite receiving scheduled doses of intravenous hydromorphone. On physical examination, the right foot is warm and pink. Capillary refill is 2 seconds, and the dorsalis pedis and posterior tibial pulses are palpable. He holds his ankle in slight plantar flexion. Passive dorsiflexion of the right toes elicits excruciating pain. Sensation to light touch is decreased over the first dorsal web space. Which of the following is the most appropriate initial step in the management of this patient?

A 52-year-old woman is evaluated in the emergency department for a 2-day history of severe left-sided flank pain, nausea, and chills. Her temperature is 39.4°C (102.9°F), pulse is 118/min, and blood pressure is 88/56 mm Hg. Physical examination reveals marked left costovertebral angle tenderness and voluntary guarding. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum creatinine of $1.9 \text{ mg/dL}$ (baseline $0.9 \text{ mg/dL}$). A non-contrast computed tomography scan of the abdomen and pelvis demonstrates an 8-mm calculus in the proximal left ureter with ipsilateral hydronephrosis and prominent perinephric fat stranding. Intravenous fluid resuscitation and empiric broad-spectrum antibiotics are immediately initiated. Which of the following is the most appropriate next step in management?

Match each clinical presentation and physical examination finding to the most appropriate surgical vascular pathology.

A 32-year-old man is evaluated in the orthopedic ward for severe left leg pain. Twelve hours ago, he underwent closed reduction and placement of a long-leg cast for a closed midshaft tibial fracture. He now reports excruciating, throbbing pain in his calf that is worsening and no longer relieved by intravenous morphine. Physical examination reveals a tense, 'tight' feeling in the calf musculature and profound pain with passive dorsiflexion of the toes. He also reports new-onset tingling in the first web space of his foot. Distal pulses remain palpable. Arrange the following steps in the most appropriate chronological order for the acute evaluation and management of this patient's condition.