Surgery

A 68-year-old female is evaluated on postoperative day 5 following a robotic-assisted hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. She reports a 2-hour history of sudden-onset shortness of breath and right-sided chest pain that worsens when she takes a deep breath. She has a history of type 2 diabetes mellitus, hypertension, and obesity. Her current medications include subcutaneous enoxaparin and oral oxycodone as needed. Temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is 118/76 mmHg, pulse is 114/min, and respirations are 24/min. Pulse oximetry shows 92% on room air. Physical examination reveals clear breath sounds bilaterally and a regular, rapid heart rhythm. The abdomen is soft and non-tender, and the surgical incisions are well-approximated with no erythema. There is no lower extremity edema or calf tenderness. Electrocardiogram shows sinus tachycardia. Which of the following is the most appropriate next step in management?

A 58-year-old woman is recovering on the surgical ward on postoperative day 7 following an open abdominal hysterectomy. She experiences a severe coughing fit, after which she reports a sudden 'giving way' sensation in her abdomen. Examination reveals complete separation of the surgical incision with loops of small bowel protruding through the wound. Arrange the following steps for the immediate management of this complication in the most appropriate chronological order.

A 35-year-old previously healthy gentleman arrives at the triage desk reporting severe, unremitting abdominal pain accompanied by multiple episodes of bilious vomiting over the past 12 hours. He has not had a bowel movement or passed flatus since the pain began. His temperature is 38.6°C (101.5°F), pulse is 118/min, and blood pressure is 98/60 mm Hg. Physical examination reveals a markedly distended abdomen with absent bowel sounds. Palpation of the groin demonstrates a 4-cm, firm, erythematous, and exquisitely tender bulge in the right inguinal region. Laboratory studies show a leukocyte count of 19,000/mm³ with 85% neutrophils and a serum lactate level of 4.2 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

A 48-year-old woman is assessed in the intensive care unit due to persistent hypotension. Five hours ago, she underwent an uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis. Her medical history includes severe rheumatoid arthritis, for which she has taken daily oral prednisone for the past three years. She reports that she abruptly stopped all her medications five days before the procedure to "clear her system for anesthesia."

Upon admission to the unit, her blood pressure was 82/44 mmHg and her pulse was 118/min. She was administered 3 L of intravenous normal saline, but her repeat blood pressure remains 78/42 mmHg. Current temperature is 38.1°C (100.6°F), pulse is 124/min, and respirations are 20/min. Physical examination shows a lethargic patient who arouses to voice. The abdomen is soft and mildly tender at the surgical port sites, with no guarding or rigidity.

Laboratory studies show:
- Sodium: 130 mEq/L
- Potassium: 4.1 mEq/L
- Chloride: 97 mEq/L
- Bicarbonate: 22 mEq/L
- Blood urea nitrogen: 18 mg/dL
- Serum creatinine: 0.9 mg/dL
- Glucose: 58 mg/dL
- Leukocyte count: 10,500/mm³

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

A 38-year-old female is evaluated in the emergency department after a low-speed collision in which her bicycle was struck by a turning vehicle. She was wearing a helmet and reports no loss of consciousness. She complains primarily of left-sided abdominal pain and left shoulder pain. Upon arrival, her blood pressure is 122/78 mm Hg, heart rate is 88/min, and respiratory rate is 16/min. Oxygen saturation is 99% on room air. The primary survey is unremarkable. Physical examination reveals bruising over the left lower ribs. Abdominal examination demonstrates mild left upper quadrant tenderness but no rebound or guarding. A bedside focused assessment with sonography for trauma (FAST) demonstrates a distinct rim of anechoic fluid surrounding the spleen. Which of the following is the most appropriate next step in management?

As a trauma and burn unit leader, you are tasked with managing multiple complex clinical scenarios simultaneously. Match each specific patient presentation to the most appropriate immediate diagnostic or therapeutic intervention.

A $48$-year-old man is brought to the emergency department by his wife due to sudden-onset, agonizing abdominal pain that began $2$ hours ago. He reports no prior episodes of similar pain but has a history of chronic knee osteoarthritis, for which he takes high-dose naproxen daily. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), pulse is $118/\text{min}$, blood pressure is $90/58\text{ mm Hg}$, and respirations are $22/\text{min}$. The patient appears distressed and lies completely still on the examination table, refusing to move. Physical examination reveals a rigid, board-like abdomen with diffuse guarding and rebound tenderness. Bowel sounds are absent. An upright chest radiograph demonstrates a crescent of free air under the right hemidiaphragm. Which of the following is the most appropriate next step in management?

Match each classic trauma or burn presentation to its most appropriate definitive intervention or next step in management.

During a trauma surgery conference, a team reviews the intraoperative management algorithms for retroperitoneal hematomas discovered during emergency exploratory laparotomies. The attending surgeon emphasizes that the decision to open and explore a hematoma depends critically on its anatomical zone and the mechanism of injury. Match each specific clinical scenario involving a retroperitoneal hematoma with the most appropriate intraoperative management strategy.

A thorough physical examination is critical in evaluating patients presenting with an acute abdomen or jaundice. Match each classic physical examination finding with the most likely associated abdominal pathology.

A $72$-year-old man is evaluated on the surgical floor due to fever and abdominal discomfort. He underwent an open partial colectomy for a large adenomatous polyp four days ago. His indwelling urinary catheter, which was placed during surgery, was removed yesterday morning. The patient now reports new-onset burning with urination and a feeling of incomplete bladder emptying. His temperature is $38.5^\circ\text{C}$ ($101.3^\circ\text{F}$), blood pressure is $128/78\text{ mmHg}$, pulse is $92/\text{min}$, and respiratory rate is $16/\text{min}$. Physical examination reveals a soft abdomen with mild suprapubic tenderness but no guarding or rebound. The surgical incision is clean, dry, and intact with no surrounding erythema or fluctuance. Lung auscultation is clear bilaterally. Examination of the lower extremities shows no edema or calf tenderness. Which of the following is the most appropriate next step in the management of this patient's fever?

Match each clinical presentation of gastrointestinal obstruction or distension with its most likely specific etiology or anatomical mechanism.

Match each patient's clinical presentation following trauma with the most appropriate next step in diagnosis or management.

A 55-year-old female patient with a body mass index of 34 kg/m² is evaluated during morning rounds on her second day recovering from an elective open abdominal hysterectomy. Her vital signs show a temperature of 38.2°C (100.8°F), blood pressure of 128/82 mmHg, heart rate of 88/min, and respiratory rate of 16/min. Physical examination reveals mildly decreased breath sounds at the lung bases bilaterally without wheezes or crackles. The surgical dressing is clean, and the wound edges are well-approximated with no surrounding warmth or induration. The patient is voiding spontaneously without dysuria, and her calves are soft and non-tender. Which of the following are the most appropriate management steps for this patient? (Select 2)

A 67-year-old woman is evaluated by the rapid response team on the medical-surgical floor due to sudden clinical deterioration. She was admitted 24 hours ago for a partial small bowel obstruction secondary to severe adhesive disease from a prior open colectomy. Initial conservative management included intravenous fluid resuscitation and nasogastric tube decompression, which yielded 800 mL of bilious output. Over the last hour, she developed severe, unrelenting, constant lower abdominal pain, which is a significant change from her previous intermittent, cramping pain. Her vital signs are temperature 38.6°C (101.5°F), blood pressure 92/58 mm Hg, pulse 122/min, and respirations 24/min. Physical examination now reveals a distended, exquisitely tender abdomen with marked rigidity and rebound tenderness in the lower quadrants. Laboratory studies demonstrate a leukocyte count of 18,400/mm³ with 12% bands, and a serum lactate of 4.1 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old woman is evaluated in the post-anesthesia care unit 4 hours after undergoing a total thyroidectomy for a toxic multinodular goiter. The nursing staff urgently requests assistance because the patient is highly agitated, reporting severe neck pressure, and having significant difficulty breathing. Vital signs show a temperature of 37.1°C, heart rate of 118/min, blood pressure of 152/94 mm Hg, respiratory rate of 28/min, and oxygen saturation of 88% on room air. Physical examination reveals audible inspiratory stridor. The anterior neck incision is intact, but the surrounding tissue is markedly swollen, tense, and ecchymotic. Arrange the following management steps in the correct chronological order.

Match each clinical presentation with the most appropriate definitive surgical intervention.

An ambulance brings a 68-year-old resident of an assisted living facility to the acute care clinic due to progressive confusion, rigors, and new-onset jaundice over the past day. Vital signs on arrival show a temperature of 39.5°C (103.1°F), a pulse of 118/min, and a blood pressure of 88/54 mmHg. Abdominal examination is notable for right upper quadrant guarding and tenderness on palpation. Blood tests demonstrate a leukocytosis of 18,500/mm³ and a total bilirubin of 5.8 mg/dL with a direct fraction of 4.2 mg/dL. Suspecting acute severe ascending cholangitis, arrange the following clinical interventions in the most appropriate chronological order.

A 28-year-old man is evaluated on the surgical floor for an elevated temperature. He is currently on his first postoperative day following an open reduction and internal fixation of a closed right femur fracture sustained in a motor vehicle collision. The patient reports expected mild pain at the surgical site but denies shortness of breath, cough, dysuria, or calf pain. His temperature is 38.3°C (100.9°F), blood pressure is 122/78 mmHg, heart rate is 88/min, and respiratory rate is 14/min. Pulse oximetry shows 98% on room air. Physical examination reveals a clean, dry, and intact surgical dressing with no surrounding erythema or excessive swelling. The lungs are clear to auscultation bilaterally. Which of the following is the most appropriate next step in the management of this patient?

A 29-year-old man is brought to the emergency department after a high-speed motorcycle collision. On presentation, he is lethargic and only opens his eyes to painful stimuli. Vital signs are temperature 36.2°C (97.2°F), blood pressure 78/45 mm Hg, heart rate 138/min, and respiratory rate 24/min. Oxygen saturation is 95% on a non-rebreather mask. The patient undergoes rapid sequence intubation for airway protection. Following intubation, a portable chest radiograph shows clear lung fields without pneumothorax or hemothorax. A pelvic radiograph reveals no fractures. Focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid in the hepatorenal and splenorenal recesses. The patient receives warmed intravenous crystalloid fluids and uncrossmatched type O-negative blood, but his blood pressure remains 80/48 mm Hg. Which of the following is the most appropriate next step in management?