Surgery

Below are four distinct clinical scenarios involving peripheral vascular compromise. Pair each patient presentation with its most characteristic diagnostic finding.

During morning rounds, a physician evaluates a 54-year-old female recovering on the surgical unit. It is her seventh day recovering from an open myomectomy for large symptomatic uterine leiomyomas. For the past 48 hours, she has been unable to pass flatus or stool and has experienced progressive, crampy abdominal pain. This morning, she had two episodes of dark green, bilious emesis. Vital signs reveal a temperature of $38.7^{\circ}\text{C}$ ($101.7^{\circ}\text{F}$), heart rate of $122/\text{min}$, respiratory rate of $20/\text{min}$, and blood pressure of $94/60\text{ mmHg}$. On physical examination, the abdomen is markedly distended. Auscultation reveals high-pitched, hyperactive bowel sounds. Palpation demonstrates significant guarding and rebound tenderness in all four quadrants. Laboratory evaluation shows a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate level of $4.2\text{ mmol/L}$ (normal: $0.5$-$1.0\text{ mmol/L}$). Which of the following is the most appropriate next step in management?

A healthy 41-year-old female arrives at the surgical assessment unit complaining of steady pain under her right rib cage that began shortly after eating a heavy meal. Examination reveals localized tenderness and inspiratory arrest upon deep palpation in the right upper quadrant. Her temperature is 38.2°C (100.8°F) and vital signs are otherwise stable. Arrange the following interventions in the most appropriate chronological sequence for her standard evaluation and definitive care.

A 58-year-old man is brought to the emergency department by ambulance due to the sudden onset of severe, tearing chest pain that radiates to his back. His blood pressure is 210/115 mmHg in the right arm and 170/90 mmHg in the left arm. His pulse is 112/min. Physical examination reveals a new diastolic decrescendo murmur at the right sternal border. An electrocardiogram shows sinus tachycardia with no ischemic changes, and a chest x-ray reveals a widened mediastinum. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 52-year-old male patient is transported to the emergency department by ambulance following the sudden onset of unrelenting abdominal pain 6 hours ago. He has had multiple episodes of bilious vomiting and is now unable to tolerate oral intake. His medical history is significant for a laparoscopic Roux-en-Y gastric bypass performed 4 years ago, which was complicated by a marginal ulcer that was successfully treated with proton pump inhibitors. His temperature is 38.6°C (101.5°F), pulse is 128/min, respirations are 24/min, and blood pressure is 82/50 mm Hg. Physical examination reveals an ill-appearing, diaphoretic man lying completely still on the stretcher. His abdomen is distended, rigid, and exhibits diffuse rebound tenderness and guarding. Bowel sounds are absent. Intravenous fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

A 61-year-old man is evaluated in the surgical ward for new-onset right-sided back pain. He is currently on postoperative day $7$ following an open radical retropubic prostatectomy for localized prostate adenocarcinoma. His early postoperative recovery was routine, and he is tolerating a regular diet. Over the past $12$ hours, he has developed a fever and constant, dull pain in his right flank. He has a suprapubic catheter in place that is draining clear yellow urine. His temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $130/82$ mmHg, pulse is $105$/min, and respiratory rate is $16$/min. Physical examination demonstrates a soft, non-tender abdomen and a clean lower midline incision. There is pronounced right-sided costovertebral angle tenderness. Laboratory evaluation reveals a leukocyte count of $14,800/\text{mm}^3$. Analysis of the urine from the suprapubic catheter is negative for leukocyte esterase and nitrites, and shows $1$-$2$ leukocytes/hpf. Which of the following is the most appropriate next step in management?

Match each clinical trauma presentation with the most appropriate immediate diagnostic modality or therapeutic intervention.

A 26-year-old man is hospitalized after sustaining a closed mid-shaft fracture of the right femur in a motor vehicle collision. Due to multiple life-threatening cases in the operating room, his fracture is temporarily managed with skeletal traction. On the second day of hospitalization, he becomes acutely confused and agitated. His temperature is 38.3°C (100.9°F), blood pressure is 118/76 mmHg, heart rate is 122/min, and respiratory rate is 28/min. Pulse oximetry shows an oxygen saturation of 86% on room air. Physical examination reveals a non-blanching petechial rash over the anterior chest, axillae, and conjunctivae. Lung auscultation demonstrates bilateral scattered crackles. Which of the following interventions during the initial 24 hours of admission would have most effectively decreased the risk of this patient's current complication?

A 52-year-old male is recovering in the intensive care unit on postoperative day 3 following an open pancreaticoduodenectomy. He has had an uneventful recovery thus far. The surgical team decides to discontinue his right internal jugular central venous catheter. The nurse removes the catheter while the patient is sitting upright in his bed. Immediately after the catheter is pulled, the patient gasps and becomes unresponsive. His blood pressure drops to $65/40 \text{ mmHg}$, heart rate increases to $138 \text{ /min}$, and oxygen saturation falls to $76\%$ on room air. Auscultation of the chest reveals a loud, churning, machinery-like murmur over the precordium. Arrange the following immediate management steps in the most appropriate chronological order.

A 27-year-old man is brought to the emergency department by paramedics after sustaining a single stab wound to the left anterior chest during a physical altercation. On arrival, he is restless, diaphoretic, and confused. His temperature is 36.6°C (97.9°F), blood pressure is 64/38 mmHg, pulse is 142/min, and respiratory rate is 28/min. Oxygen saturation is 93% on a non-rebreather mask. Physical examination reveals a 3-cm laceration at the left fourth intercostal space, directly adjacent to the sternal border. His jugular veins are markedly distended. Pulmonary auscultation reveals clear and symmetric breath sounds bilaterally. Cardiac auscultation demonstrates faint and muffled heart sounds. The trachea is midline. A bedside focused assessment with sonography for trauma (FAST) confirms a large anechoic space surrounding the heart with evidence of right ventricular collapse during diastole. Rapid intravenous infusion of 1 liter of warmed crystalloid solution does not improve his blood pressure. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old woman is evaluated during morning rounds on the surgical ward. She was admitted 48 hours ago for management of a small bowel obstruction secondary to adhesions from a prior total abdominal hysterectomy. Initial management included bowel rest, intravenous fluid resuscitation, and nasogastric tube decompression. Over the last few hours, she reports that her previously intermittent, crampy abdominal pain has become unremitting, constant, and more severe. She has not had any bowel movements or passed flatus since admission. Her temperature is 38.3°C (100.9°F), blood pressure is 112/74 mmHg, pulse is 116/min, and respirations are 20/min. Physical examination reveals a distended abdomen with hypoactive bowel sounds. There is focal, severe tenderness with involuntary muscle spasm in the periumbilical region. Laboratory studies show a leukocyte count of 15,400/mm³ and a serum bicarbonate level of 16 mEq/L. Which of the following is the most appropriate next step in management?

A 32-year-old man is evaluated by the surgical team for severe right lower extremity pain. Twelve hours ago, he underwent an uncomplicated open reduction and internal fixation of a comminuted right tibial shaft fracture sustained in a mountain biking accident. The patient reports that over the past two hours, the pain has become agonizing and is no longer relieved by his scheduled doses of intravenous morphine. His temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $138/86\text{ mmHg}$, and heart rate is $112\text{/min}$. On physical examination, the right anterolateral leg appears tense and significantly swollen compared to the contralateral limb. The overlying skin is shiny. Passive plantar flexion of the right ankle and toes elicits a dramatic increase in pain. Capillary refill time is 2 seconds, and the dorsalis pedis and posterior tibial pulses are palpable bilaterally. Which of the following is the most appropriate next step in management?

A $58$-year-old man presents to the emergency department with a $4$-day history of progressively worsening left lower quadrant abdominal pain, subjective fever, and decreased appetite. He has no prior history of similar episodes. His temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $130/80\text{ mmHg}$, and pulse is $98\text{/min}$. Physical examination demonstrates marked focal tenderness and voluntary guarding in the left lower quadrant, but no generalized rigidity. Laboratory evaluation reveals a leukocyte count of $16,500\text{/mm}^3$. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated.

Assume the patient's clinical course progresses appropriately through standard management. Arrange the following steps in the most appropriate chronological sequence for the optimal diagnosis and long-term management of this patient.

Match each classic radiographic finding with its most likely surgical gastrointestinal diagnosis.

Match each clinical presentation of a trauma patient with the most appropriate next step in definitive management or diagnostic workup.

A $28$-year-old man with no significant past medical history is undergoing an elective open reduction and internal fixation of a right femur fracture. Anesthesia is induced with propofol and succinylcholine, and maintained with sevoflurane. Approximately $45$ minutes into the surgery, the anesthesiologist notes a sudden, unexplained rise in end-tidal carbon dioxide (ETCO2) from $35$ mmHg to $68$ mmHg. The patient's heart rate increases to $142$/min, and generalized masseter muscle rigidity is observed. His core body temperature begins to rise rapidly and is currently $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$). Arrange the following steps in the most appropriate chronological sequence for the immediate management of this patient's suspected complication.

A $54$-year-old woman is brought to the emergency department due to severe, generalized abdominal pain and persistent bilious vomiting for the past $12$ hours. She has not passed flatus or stool since yesterday. Her surgical history is significant for a total abdominal hysterectomy $5$ years ago. Temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $90/60\text{ mmHg}$, and pulse is $122/\text{min}$. Physical examination reveals a markedly distended abdomen with diffuse guarding, severe rebound tenderness, and absent bowel sounds. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ and a serum lactate of $5.1\text{ mmol/L}$. An upright abdominal radiograph shows multiple dilated loops of small bowel with air-fluid levels and no free air under the diaphragm. Which of the following is the most appropriate next step in management?

An ambulance brings a 60-year-old female to the emergency department due to severe, unrelenting abdominal pain and repeated bilious vomiting that started 24 hours ago. Her past medical history is notable for an open appendectomy performed 15 years prior. She reports that the pain was initially colicky, but over the last 3 hours, it has become constant and generalized. Her temperature is 38.7°C (101.7°F), pulse is 125/min, respirations are 22/min, and blood pressure is 85/50 mm Hg. Physical evaluation reveals a distended and rigid abdomen with marked diffuse tenderness, involuntary guarding, and rebound tenderness. Bowel sounds are absent. Laboratory studies demonstrate a leukocyte count of 19,500/mm³ and a serum lactate of 5.1 mmol/L. A plain upright abdominal radiograph displays multiple distended small bowel loops with air-fluid levels and no free intraperitoneal gas. Which of the following is the most appropriate next step in the care of this patient?

A 45-year-old individual is evaluated in the emergency department for severe, progressive abdominal pain and persistent vomiting of greenish fluid over the past 24 hours. The patient reports an inability to pass flatus since the symptoms began. Past medical history is notable for a Roux-en-Y gastric bypass performed three years ago for severe obesity. Vital signs are temperature $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure $88/58\text{ mmHg}$, heart rate $122\text{ /min}$, and respiratory rate $22\text{ /min}$. The patient appears acutely ill and diaphoretic. Abdominal examination reveals significant distension, diffuse tenderness to palpation, and involuntary guarding. Bowel sounds are absent. Laboratory studies demonstrate a leukocyte count of $19,000/\text{mm}^3$ and a serum lactate level of $4.2\text{ mmol/L}$. Upright abdominal radiography shows multiple dilated loops of small bowel with prominent air-fluid levels and no gas in the rectum. Which of the following is the most appropriate next step in management?

A pediatric orthopedic clinic evaluates several patients with lower extremity complaints. Match each patient's clinical presentation with the most likely underlying diagnosis.