Surgery

1344 questions

All types1,344 Multiple choice692 Multiple select59 Numeric38 Matching264 Ordering291

A 58-year-old woman is evaluated in the hospital for a fever of 39.2°C (102.6°F), scleral icterus, and severe right upper quadrant abdominal pain. Her blood pressure is 100/60 mmHg and her heart rate is 110/min. Laboratory studies demonstrate a significant leukocytosis, conjugated hyperbilirubinemia, and markedly elevated alkaline phosphatase. Arrange the following steps in the most appropriate chronological sequence for the management of this patient's condition.

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Answer

The correct sequence is: initial medical stabilization with intravenous fluids and broad-spectrum antibiotics, followed by non-invasive imaging with an abdominal ultrasound, then urgent biliary decompression via ERCP, and finally definitive surgical management with a laparoscopic cholecystectomy.

The patient presents with the classic Charcot triad (fever, jaundice, and right upper quadrant abdominal pain), which is highly suspicious for acute ascending cholangitis. Given her tachycardia and borderline hypotension, she is at high risk for progressing to septic shock (Reynolds pentad). The universally accepted, evidence-based sequence of management begins with immediate hemodynamic stabilization, including the administration of intravenous crystalloids and broad-spectrum antibiotics (after drawing blood cultures). Once medical resuscitation is underway, an abdominal ultrasound is the fastest, safest, and most appropriate initial imaging modality to confirm common bile duct dilation. Following diagnostic confirmation, the source of the infection must be controlled via urgent biliary decompression, which is most safely and effectively achieved with an ERCP. Finally, once the patient has clinically recovered from the acute illness, an elective laparoscopic cholecystectomy is performed during the same admission or shortly thereafter to definitively remove the source of the gallstones and prevent future attacks.

Step-by-Step Solution

Stabilize the patient hemodynamically and treat the infection systemically.

Intravenous fluids and broad-spectrum antibiotics are administered.

The patient presents with Charcot triad and signs of systemic toxicity, requiring immediate resuscitation prior to any imaging or intervention.

Confirm the diagnosis using the most appropriate initial imaging modality.

An abdominal ultrasound is performed.

Ultrasound is the best initial test to quickly and safely identify biliary dilation and gallstones at the bedside.

Decompress the obstructed and infected biliary system.

An ERCP with sphincterotomy is performed.

Purulent material must be drained from the common bile duct to adequately control the source of the infection.

Prevent future occurrences of gallstone-related complications.

A laparoscopic cholecystectomy is performed.

Removing the gallbladder eliminates the source of the gallstones, but this should only be done after the acute cholangitis has resolved.

Key Concept

Management sequence for acute ascending cholangitis

Question 822Question →

A 35-year-old man is brought to the emergency department after being rescued from a closed-space house fire. On arrival, he is agitated and in respiratory distress. His vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mmHg, heart rate 115/min, and respiratory rate 26/min. Physical examination reveals full-thickness burns involving his anterior trunk and both upper extremities. He has soot in his oropharynx, singed nasal vibrissae, and a hoarse voice. Arrange the following steps in the most appropriate chronological order for the acute management of this patient.

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Answer

The correct sequence is endotracheal intubation, followed by establishing intravenous access, initiating fluid resuscitation, inserting a Foley catheter, and finally performing local wound care.

The sequence of interventions in trauma and severe burn patients strictly follows the Advanced Trauma Life Support (ATLS) protocol: Airway, Breathing, Circulation, Disability, and Exposure (ABCDE). This patient presents with clinical signs of inhalation injury (hoarseness, singed vibrissae, soot), which carries a high risk of rapid, irreversible airway edema. Therefore, early endotracheal intubation (Airway) is the first and most critical step. Once the airway is protected, focus shifts to Circulation. Severe burns cause massive capillary leak and hypovolemia, requiring establishing large-bore IV access followed immediately by crystalloid resuscitation (e.g., Parkland formula). To evaluate the adequacy of this resuscitation, a Foley catheter is inserted to measure hourly urine output. Finally, once life-threatening systemic issues are managed, attention turns to Exposure/Environment, which includes debridement and application of topical antimicrobials to the burn wounds.

Step-by-Step Solution

Assess the airway for impending obstruction.

Endotracheal intubation is selected as the first step.

Hoarseness, singed vibrissae, soot, and a closed-space fire indicate inhalation injury. Early intubation is required before progressive edema makes the airway completely inaccessible.

Address circulation by obtaining vascular access.

Large-bore IV access is established.

With the airway secured, the next ATLS priority is Circulation, which requires robust venous access for fluid administration.

Initiate calculated fluid resuscitation.

Lactated Ringer's infusion is started.

Extensive burns lead to massive fluid shifts and hypovolemic shock. Immediate crystalloid resuscitation is necessary to maintain end-organ perfusion.

Establish a method to monitor resuscitation efficacy.

A Foley catheter is inserted.

Urine output must be monitored closely to titrate the IV fluid rate up or down, ensuring adequate tissue perfusion without causing fluid overload.

Address the burn wounds.

Topical antimicrobials and dressings are applied.

Local wound care prevents infection and fluid loss but is a secondary priority compared to stabilizing the patient's airway and hemodynamics.

Key Concept

Acute burn management follows the ATLS ABCDE algorithm, requiring early intubation for inhalation injury before progressing to fluid resuscitation and lastly wound care.

Question 823Question →

A 35-year-old male is brought to the emergency department after a high-speed motorcycle collision. He complains of severe lower abdominal and pelvic pain.

Vital signs on arrival are:
Temperature: $36.5^\circ\text{C}$ ( $97.7^\circ\text{F}$ )
Blood pressure: $76/40\text{ mmHg}$
Heart rate: $135/\text{min}$
Respiratory rate: $24/\text{min}$
Oxygen saturation: $96\%$ on room air

The primary survey reveals a clear airway and bilaterally equal breath sounds. The abdomen is soft and non-distended without guarding or rebound tenderness. Emergency medical services placed a commercial pelvic binder prior to arrival. A portable anteroposterior pelvic radiograph reveals an "open-book" pelvic fracture with a $4\text{ cm}$ diastasis of the pubic symphysis.

A FAST (Focused Assessment with Sonography for Trauma) examination demonstrates no free fluid in the pericardial, perisplenic, perihepatic, or pelvic views.

Two large-bore intravenous lines are established, and he receives $1\text{ L}$ of warmed lactated Ringer solution and $1\text{ unit}$ of uncrossmatched type O-negative blood. A repeat blood pressure is $82/45\text{ mmHg}$ with a heart rate of $128/\text{min}$ .

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

Computed tomography of the abdomen and pelvis

Exploratory laparotomy

Pelvic angiography

Diagnostic peritoneal lavage

Retrograde cystourethrography

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Answer: Pelvic angiography

Answer

Pelvic angiography

This patient is in hemorrhagic shock following blunt trauma, with an 'open-book' pelvic fracture. The initial management for a hemodynamically unstable patient with a mechanically unstable pelvic fracture is the application of a pelvic binder to reduce pelvic volume and promote tamponade of venous bleeding. Despite the binder and initial fluid and blood resuscitation, the patient remains hypotensive. The FAST exam is negative, which essentially rules out massive intra-abdominal hemorrhage as the primary cause of shock. Therefore, the ongoing hemorrhage is originating from the retroperitoneal pelvic venous plexus or pelvic arterial branches. The most appropriate next step in management for a hemodynamically unstable patient with a pelvic fracture and a negative FAST is pelvic angiography with embolization (or preperitoneal pelvic packing) to definitively control the retroperitoneal hemorrhage.

Step-by-Step Solution

Assess hemodynamic status and primary survey findings.

The patient is in persistent hemorrhagic shock (hypotension, tachycardia) following blunt trauma despite initial fluid and blood resuscitation.

Determines the urgency of intervention and categorizes the patient into the unstable trauma treatment algorithm.

Evaluate the results of the FAST examination in the context of known injuries.

The FAST is negative, effectively ruling out massive intraperitoneal or pericardial hemorrhage as the cause of shock.

Differentiates between intra-abdominal bleeding (which would require laparotomy) and retroperitoneal bleeding (which requires angiography or packing).

Identify the remaining source of hemorrhage and select the definitive intervention.

With a negative FAST and an unstable pelvic fracture despite a previously applied binder, the bleeding is retroperitoneal. Pelvic angiography is selected.

Angiography allows for the rapid identification and embolization of actively bleeding pelvic arterial branches, achieving definitive hemorrhage control.

Key Concept

In hemodynamically unstable patients with pelvic fractures and a negative FAST exam, the source of bleeding is retroperitoneal; the appropriate next step is pelvic angiography with embolization or preperitoneal pelvic packing.

Estimated Time:1m 30s

Question 824Question →

Pair the following clinical presentations of acute trauma patients with the corresponding immediate management step.

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Answer

Cardiac tamponade requires pericardial drainage; tension pneumothorax requires needle or tube decompression; massive hemothorax requires a large-bore chest tube; and an unstable pelvic fracture without intraperitoneal fluid requires mechanical pelvic binding.

According to standardized trauma management algorithms, immediate life threats identified on the primary survey require rapid procedural intervention. Beck's triad indicates cardiac tamponade requiring drainage. Hyperresonance with absent breath sounds and shock indicates a tension pneumothorax requiring decompression. Dullness with absent breath sounds and shock indicates a massive hemothorax requiring tube thoracostomy. Finally, a disruptive pelvic fracture with a negative FAST indicates retroperitoneal bleeding, requiring a reduction in pelvic volume via a binder to promote tamponade.

Step-by-Step Solution

Analyze the physical examination findings for each patient to identify the specific life-threatening injury.

Identified cardiac tamponade, tension pneumothorax, massive hemothorax, and retroperitoneal bleeding from a pelvic fracture.

Accurate identification of the underlying pathology during the primary survey is required to direct appropriate intervention.

Match the identified pathology with the initial life-saving procedure dictated by trauma protocols.

Paired each presentation with its respective targeted intervention.

Immediate life threats must be treated instantaneously as they are recognized, prior to obtaining further imaging.

Key Concept

Advanced Trauma Life Support (ATLS) Primary Survey Interventions

Question 825Question →

A 71-year-old man is evaluated on the surgical ward immediately after experiencing a sudden "tearing" sensation in his abdomen during a severe bout of coughing. He is on postoperative day 6 following an open sigmoid resection for complicated diverticulitis. His temperature is $37.2^\circ\text{C}$ ( $99.0^\circ\text{F}$ ), blood pressure is $112/74\text{ mmHg}$ , and pulse is $102/\text{min}$ . When the abdominal binder and surgical dressings are removed, a large volume of serosanguineous fluid is noted, and loops of small intestine are visibly protruding through the separated midline fascial defect.

Arrange the following next steps in the most appropriate chronological sequence for managing this patient's acute complication.

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Answer

The correct sequence for managing abdominal evisceration is to first reduce abdominal tension by positioning the patient supine with flexed knees, followed by protecting the exposed bowel with moist sterile dressings, then initiating medical preparation with intravenous fluids and antibiotics, and finally transporting the patient to the operating room for definitive surgical closure.

Abdominal evisceration is a surgical emergency characterized by disruption of all layers of the abdominal wall with protrusion of intra-abdominal organs, often triggered by a sudden increase in intra-abdominal pressure (e.g., severe coughing). The most critical immediate goal is to prevent further evisceration and bowel ischemia. Positioning the patient supine with hips and knees flexed relaxes the abdominal musculature and reduces intra-abdominal pressure. Next, the exposed bowel must be covered with sterile, warm, saline-moistened dressings to prevent tissue desiccation and necrosis. Once the bowel is protected, the patient is hemodynamically stabilized and prepped with intravenous fluids and broad-spectrum antibiotics. Finally, the patient must be urgently transported to the operating room for formal surgical exploration, peritoneal washout, and fascial closure.

Step-by-Step Solution

Relieve abdominal tension

Patient positioned supine with hips and knees flexed

Relaxes the rectus abdominis muscles and decreases intra-abdominal pressure, preventing further evisceration.

Protect exposed viscera

Bowel covered with sterile, warm saline-soaked dressings

Prevents severe tissue desiccation, limits contamination, and maintains bowel viability while awaiting surgery.

Medical optimization

Intravenous fluids and broad-spectrum antibiotics administered

Prepares the patient hemodynamically for emergency surgery and provides necessary infection prophylaxis.

Definitive management

Patient transferred to the operating room

Allows for safe exploration, abdominal washout, and secure fascial closure under controlled conditions.

Key Concept

Acute management of postoperative abdominal evisceration

Question 826Question →

A $65$ -year-old man is evaluated in the surgical intensive care unit for sudden-onset severe dyspnea, diaphoresis, and right-sided chest pain. He is currently on postoperative day $3$ following an open radical retropubic prostatectomy for localized prostate cancer. His temperature is $37.2^\circ\text{C}$ ( $99.0^\circ\text{F}$ ), blood pressure is $76/45\text{ mm Hg}$ , pulse is $132/\text{min}$ , and respiratory rate is $28/\text{min}$ . Pulse oximetry shows an oxygen saturation of $82\%$ on room air. Physical examination reveals prominent jugular venous distention and a loud pulmonary component of the second heart sound ( $P_2$ ). Bilateral breath sounds are clear to auscultation. An electrocardiogram shows sinus tachycardia with a new-onset right bundle branch block. The patient remains persistently hypotensive despite the rapid administration of $1\text{ L}$ of intravenous normal saline.

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

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Answer

The correct sequence is: 1) Administer high-flow supplemental oxygen, 2) Perform bedside transthoracic echocardiography, 3) Initiate intravenous unfractionated heparin, 4) Arrange for catheter-directed mechanical thrombectomy.

The correct chronological management of massive pulmonary embolism in a high-bleeding-risk postoperative patient requires step-wise stabilization, bedside diagnosis, and contraindication-aware therapy. First, high-flow oxygen is provided immediately to address hypoxia. Second, because the patient is too unstable for a CT scan, bedside echocardiography is used to visualize right ventricular strain. Third, upon presumptive confirmation, intravenous unfractionated heparin is started to halt thrombus propagation; UFH is chosen for its rapid reversibility. Finally, because the recent major surgery is an absolute contraindication to systemic thrombolysis, mechanical thrombectomy is arranged for definitive treatment.

Step-by-Step Solution

Administer high-flow supplemental oxygen

Improves hypoxemia and provides initial stabilization.

Airway and breathing management (ABCs) is the universal first step in any hemodynamically unstable patient with acute respiratory distress.

Perform bedside transthoracic echocardiography

Identifies right ventricular dilation, septal flattening, or McConnell's sign, establishing a presumptive diagnosis of massive PE.

The patient is too unstable for a CT pulmonary angiogram. Bedside echo is the most appropriate diagnostic test to confirm RV strain before committing a high-bleeding-risk patient to anticoagulation.

Initiate continuous intravenous infusion of unfractionated heparin

Prevents further thrombus propagation.

Once the diagnosis is presumptively confirmed by echo, anticoagulation must begin immediately. UFH is preferred in post-operative patients due to its rapid onset, short half-life, and reversibility with protamine.

Arrange for emergency catheter-directed mechanical thrombectomy

Physically removes the thrombus to relieve right ventricular outflow obstruction and restore cardiac output.

Systemic thrombolysis (e.g., tPA) is the standard treatment for massive PE, but recent major surgery (within 3 weeks) is an absolute contraindication. Mechanical extraction is required.

Key Concept

Algorithm for Massive Pulmonary Embolism in the Postoperative Setting

Alternative Method

Surgical pulmonary embolectomy via median sternotomy is an equally valid alternative to catheter-directed mechanical thrombectomy in this scenario, depending on institutional availability and surgical expertise.

Estimated Time:1m 30s

Question 827Question →

The rapid response team is called to the surgical ward to assess a patient experiencing sudden respiratory distress. The patient is $48$ hours status-post an elective open ventral hernia repair. His past medical history is significant for severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a baseline left ventricular ejection fraction of $35\%$ . He complains of shortness of breath and a cough producing clear sputum. Vital signs reveal a temperature of $38.1^\circ\text{C}$ ( $100.6^\circ\text{F}$ ), blood pressure of $135/85\text{ mm Hg}$ , heart rate of $108\text{/min}$ , and respiratory rate of $26\text{/min}$ . Pulse oximetry shows an oxygen saturation of $87\%$ on room air. Physical examination demonstrates a prolonged expiratory phase with diffuse bilateral wheezing. Jugular venous pressure is normal, crackles are absent, and there is no lower extremity edema. A bedside lung ultrasound reveals diffuse bilateral A-lines. A portable chest radiograph shows hyperinflated lung fields without focal consolidation or pleural effusion. A sputum culture obtained on the first postoperative day for a mild baseline cough is finalized today and reveals only normal respiratory flora. Based on this clinical presentation, which of the following are the most appropriate next steps in management? (Select all that apply)

Select all that apply

Administration of systemic methylprednisolone

Administration of nebulized ipratropium and albuterol

Administration of intravenous furosemide

Initiation of intravenous piperacillin-tazobactam

Lower extremity venous duplex ultrasonography

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Answer: Administration of systemic methylprednisolone; Administration of nebulized ipratropium and albuterol

Answer

The correct next steps in management are the administration of systemic methylprednisolone and nebulized ipratropium and albuterol.

The patient is experiencing a postoperative acute exacerbation of COPD, likely triggered by surgical stress and anesthesia. The classic presentation includes dyspnea, diffuse wheezing, and hypoxemia. Crucially, the bedside lung ultrasound showing A-lines confirms the absence of pulmonary edema, ruling out an acute heart failure decompensation despite his low ejection fraction. The standard of care for an acute COPD exacerbation requires short-acting bronchodilators (such as albuterol and ipratropium) to relieve bronchospasm, and systemic glucocorticoids (such as methylprednisolone) to reduce airway inflammation.

Step-by-Step Solution

Analyze the clinical syndrome and vital signs.

The patient has acute dyspnea, hypoxemia, wheezing, and hyperinflated lungs occurring

48

hours after surgery, superimposed on a history of both COPD and heart failure.

Identifying the primary cause of respiratory distress is critical for directing immediate postoperative therapy.

Differentiate between COPD exacerbation and acute decompensated heart failure.

The physical examination shows no signs of fluid overload, and the bedside ultrasound demonstrates A-lines (dry lungs) rather than B-lines (pulmonary edema).

Patients with multiple cardiopulmonary comorbidities require objective data (like POCUS) to distinguish the exact etiology of an exacerbation.

Evaluate the fever and infectious risk.

The low-grade fever fits the timeline for early postoperative inflammation or atelectasis. The clear sputum and normal flora on culture rule out a severe bacterial pneumonia.

This prevents the inappropriate administration of broad-spectrum antibiotics and unnecessary diagnostic workups for deep vein thrombosis.

Select the appropriate targeted interventions.

The diagnosis is an acute COPD exacerbation triggered by surgical stress, requiring short-acting bronchodilators and systemic steroids.

These medications directly address the acute bronchospasm and airway inflammation causing the hypoxemia.

Key Concept

Differentiation of postoperative respiratory distress using bedside ultrasound and clinical timelines to target appropriate therapy for COPD exacerbations.

Question 828Question →

During a routine sports physical, a 16-year-old adolescent female complains of persistent right lower thigh pain that has progressively worsened over the last two months. She states the pain initially occurred only after running but now throbs at night and regularly disrupts her sleep. She has experienced no fevers, chills, or unintentional weight loss. On examination, the physician palpates a firm, exquisitely tender mass fixed to the underlying bone near the distal right femur. The overlying skin is slightly warm but not erythematous. Plain radiographs of the right lower extremity exhibit a poorly marginated, destructive lytic lesion in the distal femoral metaphysis accompanied by a sunburst pattern of periosteal reaction and a Codman triangle. Which of the following is the most appropriate next step in the management of this patient?

Open incisional biopsy of the femoral mass

Computed tomography scan of the chest

Magnetic resonance imaging of the right femur

Intravenous administration of broad-spectrum antibiotics

Immobilization in a long-leg cast and non-weight bearing

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Answer: Magnetic resonance imaging of the right femur

Answer

The correct answer is magnetic resonance imaging of the right femur.

Magnetic resonance imaging (MRI) of the entire affected bone is the most appropriate next step in the management of a suspected primary bone malignancy. MRI provides the most detailed soft-tissue contrast, allowing accurate assessment of the intraosseous and extraosseous tumor extent, involvement of the adjacent neurovascular structures, and the presence of 'skip' metastases within the same bone. This imaging must be completed before any biopsy is attempted so that the biopsy tract can be carefully planned by the orthopedic oncologist to ensure it can be entirely excised during the definitive tumor resection.

Step-by-Step Solution

Analyze the clinical presentation.

A 16-year-old female presents with chronic, worsening bone pain, night pain, and a palpable mass, which strongly suggests a primary malignant bone tumor rather than a benign or infectious process.

Identifying the red flag symptoms (night pain, palpable firm mass) narrows the differential diagnosis to oncologic etiologies.

Interpret the radiographic findings.

The presence of a destructive lytic lesion with a 'sunburst' periosteal reaction and a Codman triangle is classically pathognomonic for osteosarcoma.

Radiographic patterns dictate the urgency and type of the subsequent diagnostic algorithm.

Determine the proper sequence for oncologic staging and diagnosis.

Before any tissue biopsy is performed, local staging must be completed with an MRI of the entire affected extremity.

An MRI defines the precise anatomic extent of the tumor, assesses for neurovascular bundle involvement, checks for skip lesions within the same bone, and safely guides the surgical approach for the eventual biopsy.

Key Concept

In patients with suspected primary malignant bone tumors (e.g., osteosarcoma), MRI of the entire affected bone is required for local staging prior to performing a biopsy.

Estimated Time:1m 15s

Question 829Question →

A 31-year-old woman is brought to the trauma center by emergency medical services after a high-speed head-on motor vehicle collision. At the scene, she was unresponsive and intubated for airway protection. Upon arrival, her temperature is 36.1°C (97.0°F), blood pressure is 76/40 mmHg, and heart rate is 142/min. She is receiving mechanical ventilation. Glasgow Coma Scale score is 3T. Pupillary examination reveals a 7-mm nonreactive right pupil and a 3-mm reactive left pupil. Breath sounds are equal bilaterally. The pelvis is mechanically stable on anteroposterior compression. There are no obvious external sources of bleeding. A focused assessment with sonography for trauma (FAST) examination reveals a large anechoic stripe in the hepatorenal recess. Which of the following is the most appropriate next step in the management of this patient?

Immediate exploratory laparotomy

Emergent computed tomography of the head and cervical spine

Emergent computed tomography of the abdomen and pelvis

Intravenous administration of mannitol

Await telephone consent from next-of-kin prior to surgical intervention

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Answer: Immediate exploratory laparotomy

Answer

Immediate exploratory laparotomy is the most appropriate next step to achieve hemorrhage control in this hemodynamically unstable patient.

The correct action is immediate exploratory laparotomy. This patient has two immediate life threats: profound hemorrhagic shock from intra-abdominal bleeding (confirmed by a positive FAST) and severe traumatic brain injury with signs of uncal herniation (blown pupil, GCS 3). According to ATLS principles, circulation and hemorrhage control take absolute precedence. A patient cannot survive a craniotomy, nor tolerate a trip to the CT scanner, if they exsanguinate. The priority is to establish source control in the operating room. Often in such extreme cases, a simultaneous laparotomy and craniotomy may be performed, but the laparotomy cannot be delayed for neurologic diagnostics.

Step-by-Step Solution

Assess the patient's hemodynamic status.

The patient is in Class III/IV hemorrhagic shock, evidenced by a blood pressure of 76/40 mmHg and a heart rate of 142/min.

Hemodynamic instability dictates the entire trauma algorithm, shifting focus from comprehensive diagnostics to immediate life-saving interventions.

Interpret the diagnostic adjuncts.

The FAST examination is positive for free fluid in Morison's pouch (hepatorenal recess).

In the setting of blunt trauma and shock, a positive FAST confirms that intra-abdominal hemorrhage is the primary cause of the hemodynamic instability.

Evaluate competing clinical priorities (Traumatic Brain Injury vs. Hemorrhagic Shock).

The patient has signs of uncal herniation (GCS 3T, asymmetric blown pupil) alongside exsanguinating intra-abdominal hemorrhage.

Complex trauma often presents with competing life-threatening injuries requiring prioritization.

Determine the definitive next step based on Advanced Trauma Life Support (ATLS) principles.

The patient must be taken directly to the operating room for an exploratory laparotomy.

Restoration of circulating blood volume and source control of hemorrhage takes absolute precedence. Neurologic interventions (CT scan, craniotomy) cannot be prioritized over restoring perfusion, as the ischemic brain will not survive ongoing catastrophic hemorrhagic shock.

Key Concept

In patients with multiple severe injuries, hemodynamic stabilization and control of massive hemorrhage (via exploratory laparotomy for a positive FAST) take precedence over diagnostic imaging or intervention for traumatic brain injury.

Question 830Question →

An urgent surgical consultation is requested for a $67$ -year-old male who was admitted three days ago with a partial small bowel obstruction. He has a history of an exploratory laparotomy for a perforated appendix in his twenties. For the first two days of his current admission, he was managed with intravenous fluids, bowel rest, and nasogastric tube decompression. Over the past six hours, his abdominal pain transitioned from intermittent and crampy to severe and unremitting. Current vital signs include a temperature of $38.9^\circ\text{C}$ ( $102.0^\circ\text{F}$ ), a pulse of $124/\text{min}$ , a blood pressure of $88/52 \text{ mm Hg}$ , and respirations of $24/\text{min}$ . On physical examination, the patient lies completely still in bed. His abdomen is tightly distended with diffuse rigidity, involuntary guarding, and marked rebound tenderness. Laboratory analysis demonstrates a leukocyte count of $19,500/\text{mm}^3$ and an arterial lactate concentration of $4.6 \text{ mmol/L}$ . Which of the following represents the most appropriate next step in the care of this patient?

Immediate exploratory laparotomy

Continued nasogastric tube decompression and serial abdominal examinations

Computed tomography of the abdomen and pelvis with intravenous contrast

Initiation of broad-spectrum antibiotics and intensive care unit observation

Diagnostic laparoscopy

Show answer & explanation

Answer: Immediate exploratory laparotomy

Answer

Immediate exploratory laparotomy is the most appropriate next step in management.

The correct action is immediate open surgical exploration. This patient exhibits classic signs of a complicated (strangulated or perforated) small bowel obstruction. The transition from crampy pain to severe, constant pain, accompanied by fever, hypotension, marked leukocytosis, and an elevated lactate level, points to mesenteric ischemia secondary to a closed-loop obstruction or adhesive band. Furthermore, the physical examination reveals frank peritonitis (rigidity, involuntary guarding, rebound tenderness). In any patient presenting with an acute surgical abdomen and hemodynamic instability, emergent exploratory laparotomy is the gold standard for both definitive diagnosis and life-saving therapeutic intervention (e.g., resection of necrotic bowel).

Step-by-Step Solution

Analyze the patient's initial presentation and current clinical trajectory.

The patient initially had a partial small bowel obstruction managed conservatively, but has acutely decompensated with severe, unremitting pain.

Tracking the progression of symptoms distinguishes between a resolving obstruction and one complicated by ischemia or perforation.

Evaluate the vital signs and physical examination findings.

The patient exhibits fever (

38.9^\circ\text{C}

), tachycardia (

124/\text{min}

), hypotension (

88/52 \text{ mm Hg}

), and frank peritonitis (rigidity, guarding, rebound tenderness).

These findings are cardinal signs of a surgical emergency, specifically an acute abdomen with systemic inflammatory response syndrome (SIRS)/sepsis.

Interpret the laboratory results.

Leukocytosis (

19,500/\text{mm}^3

) and elevated lactate (

4.6 \text{ mmol/L}

) are present.

Elevated lactate in the setting of obstruction strongly suggests bowel ischemia (strangulation).

Determine the definitive management strategy based on the diagnosis of a strangulated small bowel obstruction.

The patient requires immediate exploratory laparotomy.

Hemodynamic instability combined with peritonitis necessitates emergent open surgical exploration for source control; conservative measures or further imaging will fatally delay care.

Key Concept

Management of complicated (strangulated) small bowel obstruction

Question 831Question →

A 28-year-old pregnant woman at 34 weeks gestation is evaluated in the trauma center following a high-velocity motor vehicle collision. First responders noted substantial vehicular damage. On arrival, she is alert but anxious. Her airway is patent and breathing is unlabored. Vital signs show a temperature of $36.7^\circ\text{C}$ ( $98.1^\circ\text{F}$ ), blood pressure of $78/48\text{ mm Hg}$ , pulse of $134/\text{min}$ , and respiratory rate of $24/\text{min}$ . The trachea is midline, and breath sounds are symmetric. Her abdomen is distended, gravid, and diffusely tender with rebound. Manual compression of the iliac crests reveals a stable pelvis. Two large-bore peripheral intravenous catheters are placed, and warmed crystalloid infusion is started. A bedside ultrasonographic assessment demonstrates an anechoic fluid collection in the hepatorenal space. Which of the following is the most appropriate next step in the management of this patient?

Transport the patient for cross-sectional radiographic imaging of the torso

Delay any invasive intervention until her spouse arrives to provide informed consent

Transfer the patient to the surgical suite for an operative exploration

Perform an emergent bedside cesarean delivery to salvage the fetus

Initiate continuous electronic fetal monitoring to assess for decelerations prior to any surgery

Show answer & explanation

Answer: Transfer the patient to the surgical suite for an operative exploration

Answer

Transfer the patient to the surgical suite for an operative exploration

This patient presents with hemorrhagic shock following blunt trauma, evidenced by severe hypotension and tachycardia. The positive focused assessment with sonography for trauma (FAST) confirms the presence of intraperitoneal hemorrhage. In any hemodynamically unstable patient with a positive FAST, the immediate next step is urgent transfer to the operating room for an exploratory laparotomy to control the bleeding. Although this patient is pregnant, the core algorithms of trauma resuscitation remain identical to those for non-pregnant patients. Maternal stabilization and survival are the absolute highest priorities, as they are the most crucial determinants of fetal survival.

Step-by-Step Solution

Assess hemodynamic stability

The patient is hypotensive (

78/48\text{ mm Hg}

) and tachycardic (

134/\text{min}

), indicating hemorrhagic shock.

Determines the appropriate algorithmic pathway for blunt trauma management.

Interpret the FAST examination

The ultrasound shows free fluid in the hepatorenal space (Morison's pouch), confirming intraperitoneal hemorrhage.

Identifies the anatomic source of bleeding in an unstable patient.

Determine the definitive management

The patient requires immediate surgical exploration (laparotomy).

An unstable patient with confirmed intraperitoneal bleeding needs immediate operative hemorrhage control; other concerns (such as pregnancy or surrogate consent) must not delay life-saving maternal resuscitation.

Key Concept

Hemodynamically unstable patients with blunt abdominal trauma and a positive FAST examination require immediate exploratory laparotomy, regardless of pregnancy status. Maternal stabilization is the primary priority in pregnant trauma patients.

Question 832Question →

During afternoon rounds, a physician evaluates a 54-year-old female patient due to an episode of elevated temperature. The patient underwent an uncomplicated laparoscopic cholecystectomy three days ago for recurrent biliary colic. She has been tolerating a regular diet and her pain is well controlled with oral medications. Her current vital signs show a temperature of 38.3°C (100.9°F), heart rate of 92/min, blood pressure of 128/82 mmHg, and respiratory rate of 14/min. Auscultation of the lungs reveals clear breath sounds bilaterally. Her abdomen is soft and non-tender, and the surgical port sites are healing appropriately without signs of infection. Inspection of the right distal forearm, where a peripheral venous catheter has been in place since admission, demonstrates localized tenderness, induration, and a 3-centimeter streak of erythema tracing the course of the vein. There is no fluctuance or purulent discharge. Which of the following is the most appropriate next step in management?

Remove the peripheral venous catheter

Initiate empiric intravenous vancomycin therapy

Obtain a lower extremity venous duplex ultrasound

Administer a therapeutic dose of enoxaparin

Perform a computed tomography scan of the abdomen and pelvis

Show answer & explanation

Answer: Remove the peripheral venous catheter

Answer

The most appropriate next step is to remove the peripheral venous catheter.

The correct answer is to remove the peripheral venous catheter. This patient is presenting with a low-grade fever and localized signs of inflammation (erythema, induration, tenderness) along the course of a vein hosting a peripheral IV catheter. This is the classic presentation of superficial infusion thrombophlebitis, a frequent cause of fever in hospitalized surgical patients (often categorized under 'Wires' or 'Wonder drugs/Wounds' in postoperative fever mnemonics). The initial and most definitive management is the prompt removal of the offending catheter. Warm compresses and nonsteroidal anti-inflammatory drugs (NSAIDs) can be added for symptomatic relief. Systemic antibiotics are not required unless there is evidence of frank purulence (suppurative phlebitis) or signs of systemic sepsis.

Step-by-Step Solution

Evaluate the timeline and clinical signs of the postoperative fever.

The patient developed a fever on postoperative day 3 with an identified local inflammatory reaction (erythema, induration, tenderness) at the site of an existing peripheral IV line.

Identifying the '5 Ws' of postoperative fever (Wind, Water, Wound, Walking, Wires) helps isolate the etiology. Here, the 'Wires' (IV catheter) is the likely culprit.

Diagnose the specific condition based on physical findings.

The 3-centimeter linear streak of erythema and induration indicates superficial infusion thrombophlebitis.

Phlebitis is a common complication of indwelling peripheral venous catheters left in place for multiple days.

Determine the standard of care for superficial infusion thrombophlebitis.

The definitive management is immediate removal of the catheter.

Source control is the primary intervention. Antibiotics are generally reserved for cases with suspected systemic bloodstream infection or frank purulence.

Key Concept

Superficial infusion thrombophlebitis is a common cause of postoperative fever that presents with erythema, tenderness, and a palpable cord at an IV site. The primary treatment is removal of the catheter.

Question 833Question →

A 47-year-old woman is evaluated in the hospital during the evening shift for a sudden change in her clinical status. She was admitted 48 hours ago for a partial small bowel obstruction, attributed to adhesions from a previous total abdominal hysterectomy. Initial therapy with intravenous fluids and bowel rest resulted in a decrease in her abdominal distention. Over the past 3 hours, however, she reports a sudden onset of excruciating, unremitting abdominal pain. Her temperature is 39.1°C (102.4°F), blood pressure is 88/54 mm Hg, pulse is 122/min, and respirations are 22/min. Physical examination reveals a rigid abdomen with severe diffuse rebound tenderness and involuntary guarding. Laboratory studies show a leukocyte count of 21,000/mm³ with 15% band forms. Arterial blood gas analysis reveals a pH of 7.28, $pCO_2$ of 32 mm Hg, and a bicarbonate ( $HCO_3^-$ ) of 15 mEq/L. Serum lactate is 5.8 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

Emergent exploratory laparotomy

Urgent contrast-enhanced abdominal computed tomography

Continuation of nasogastric suction and intravenous fluid resuscitation

Transfer to the intensive care unit for initiation of vasopressor therapy and observation

Initiation of broad-spectrum intravenous antibiotics and surgical reassessment in 12 hours

Show answer & explanation

Answer: Emergent exploratory laparotomy

Answer

Emergent exploratory laparotomy

The correct answer is emergent exploratory laparotomy. This patient initially presented with an uncomplicated small bowel obstruction (SBO) and was appropriately managed conservatively. However, she has now developed classic signs of strangulation and bowel ischemia. These signs include a sudden change to continuous and excruciating abdominal pain, hemodynamic instability (hypotension, tachycardia), fever, overt peritonitis (rigid abdomen, rebound tenderness), marked leukocytosis with a left shift, and lactic acidosis. When an SBO is complicated by bowel ischemia, necrosis, or perforation, conservative management must be abandoned immediately in favor of emergent surgical exploration to resect the nonviable bowel and achieve source control.

Step-by-Step Solution

Analyze the patient's change in clinical presentation from admission to current status.

The patient transitioned from an uncomplicated partial bowel obstruction to having severe, unremitting pain, fever, hypotension, tachycardia, and a rigid abdomen with rebound tenderness.

These are classic signs of peritonitis and systemic inflammatory response syndrome (SIRS), indicating clinical deterioration.

Evaluate the significance of the laboratory findings.

The patient has marked leukocytosis with a left shift and high anion gap metabolic acidosis (elevated lactate of 5.8 mmol/L, pH 7.28).

Lactic acidosis in the context of an existing bowel obstruction strongly points to bowel strangulation, tissue hypoperfusion, and necrosis.

Determine the optimal management step based on the clinical and laboratory assessment.

The patient requires immediate surgical exploration.

In a patient with an established small bowel obstruction who develops peritonitis or hemodynamic instability, immediate operative intervention is mandated to resect ischemic bowel and prevent death.

Key Concept

Indications for emergent surgical exploration in small bowel obstruction

Alternative Method

Recognizing the triad of fever, tachycardia, and localized tenderness in any patient with a known SBO should immediately trigger a surgical consult for operative management, even before labs return.

Estimated Time:1m 15s

Question 834Question →

A male patient, aged 54, is brought to the surgical evaluation unit due to intense, unremitting abdominal pain and bilious vomiting that started 12 hours prior. His past medical history is notable for an open appendectomy performed two decades ago. Current vital signs include a temperature of 39.1°C (102.4°F), heart rate of 124/min, and blood pressure of 92/58 mm Hg. The abdominal examination reveals marked distension, absent bowel sounds, involuntary guarding, and diffuse rebound tenderness. Laboratory assessment is significant for a leukocyte count of 19,500/mm³ and a serum lactate of 4.5 mmol/L. Upright radiographic imaging of the abdomen demonstrates multiple dilated small intestinal loops with air-fluid levels and an absence of distal colonic gas. Which of the following is the most appropriate next step in management?

Exploratory laparotomy

Nasogastric intubation and intravenous fluid resuscitation

Abdominal computed tomography with intravenous contrast

Intravenous antibiotics and ward observation

Barium enema examination

Show answer & explanation

Answer: Exploratory laparotomy

Answer

The most appropriate next step in management is to perform an exploratory laparotomy.

The correct response is exploratory laparotomy. This patient presents with classic signs of a small bowel obstruction (SBO) complicated by bowel ischemia and peritonitis, often referred to as a strangulated SBO. The diagnosis of an SBO is established by the history of prior abdominal surgery, colicky-to-unremitting pain, bilious emesis, and abdominal X-ray findings. The crucial clinical determination is whether the obstruction is uncomplicated or strangulated. The presence of high fever, tachycardia, hypotension, a rigid abdomen with rebound tenderness, significant leukocytosis, and elevated serum lactate all point to compromised intestinal blood flow, ischemia, and impending or actual perforation. The definitive and life-saving treatment for a strangulated small bowel obstruction is immediate operative exploration to resect any necrotic bowel and relieve the source of the obstruction. Delaying surgery for further imaging or prolonged observation significantly increases mortality.

Step-by-Step Solution

Identify the primary diagnosis based on the history and initial imaging.

The patient has a small bowel obstruction (SBO), supported by prior abdominal surgery, bilious vomiting, distension, and radiographs showing dilated small bowel loops with air-fluid levels.

Recognizing the underlying mechanical issue is the first step in abdominal pain evaluation.

Assess for complications indicating ischemia, necrosis, or perforation.

The patient exhibits severe unremitting pain, high fever (39.1°C), tachycardia, hypotension, involuntary guarding, rebound tenderness, significant leukocytosis, and lactic acidosis.

These findings reliably distinguish an uncomplicated obstruction from a strangulated obstruction with bowel ischemia.

Determine the definitive treatment based on the presence of these complications.

Because signs of strangulation and peritonitis are present, conservative management must be bypassed in favor of emergent surgical intervention.

Delaying surgery in a strangulated bowel obstruction significantly increases morbidity and mortality due to spreading necrosis and sepsis.

Key Concept

Patients with a small bowel obstruction who develop signs of strangulation or bowel ischemia (e.g., fever, tachycardia, hemodynamic instability, severe localized pain, peritonitis, leukocytosis, metabolic acidosis) require emergent surgical exploration.

Question 835Question →

During surgical rounds, the attending physician discusses the classic timeline of postoperative complications with the medical team. Arrange the following common etiologies of postoperative fever in the chronological order they typically present, from earliest (postoperative day 1) to latest (postoperative day 7).

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The chronological sequence for classic postoperative fever etiologies is: Atelectasis (earliest), followed by Catheter-associated urinary tract infection, Deep vein thrombosis, and finally Surgical site infection (latest).

The correct chronological order follows the classic timeline framework for postoperative fever etiologies. 'Wind' (atelectasis and generalized inflammation) occurs on Postoperative Days 1-2. 'Water' (urinary tract infections) occurs on Postoperative Days 3-5. 'Walking' (venous thromboembolism such as deep vein thrombosis) presents on Postoperative Days 4-6. Finally, 'Wound' (surgical site infections) presents on Postoperative Days 5-7. Recognizing this timeline is fundamental for directing the initial diagnostic workup in a postoperative patient with new-onset fever.

Step-by-Step Solution

Identify the earliest cause of postoperative fever (Postoperative Days 1-2).

Atelectasis and inflammatory cytokine release.

The physiologic stress of surgery and early hypoventilation cause cytokine release and atelectasis almost immediately after surgery.

Identify the next complication in the timeline (Postoperative Days 3-5).

Catheter-associated urinary tract infection.

Urinary stasis and colonization associated with indwelling urinary catheters take a few days to develop into a symptomatic infection.

Identify the third complication in the sequence (Postoperative Days 4-6).

Deep vein thrombosis.

Immobilization leads to venous stasis, taking several days to form a clinically significant venous thromboembolism.

Identify the latest complication in this sequence (Postoperative Days 5-7).

Surgical site infection.

Surgical site infections require sufficient time for bacterial inoculation to replicate and produce clinical signs such as purulence and erythema.

Key Concept

The classic chronological presentation of postoperative fever, commonly remembered by the mnemonic 'Wind, Water, Walking, Wound'.

Question 836Question →

A 28-year-old construction worker is brought to the emergency department after a heavy concrete beam fell on his pelvis. His blood pressure is 118/76 mmHg and heart rate is 92/min. Primary survey reveals a patent airway and clear lungs. A pelvic binder is applied. Physical examination reveals a scrotal hematoma and blood at the urethral meatus. Arrange the following diagnostic and therapeutic steps in the correct chronological sequence to appropriately evaluate and manage this patient, assuming findings lead to the diagnosis and treatment of an intraperitoneal bladder rupture.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence is: 1) Perform a FAST examination, 2) Obtain a retrograde urethrogram, 3) Insert a transurethral Foley catheter, 4) Perform a CT cystogram, 5) Perform an exploratory laparotomy.

The algorithm for pelvic trauma with suspected urologic injury follows ATLS priorities. The FAST exam is an initial primary survey adjunct. Following this, the sequence of urologic evaluation is strictly dictated by anatomic progression and safety: the urethra must be evaluated (retrograde urethrogram) before a catheter can be placed. Once the catheter is placed, the bladder can be evaluated with contrast (CT cystogram). Finally, the diagnosis of an intraperitoneal rupture dictates operative management (exploratory laparotomy).

Step-by-Step Solution

Perform a FAST examination

Assesses for hemoperitoneum.

According to ATLS protocols, ruling out massive intra-abdominal hemorrhage is part of the initial primary survey adjuncts, prior to focused urologic workup.

Obtain a retrograde urethrogram

Evaluates the integrity of the urethra.

Blood at the urethral meatus is an absolute contraindication to blind urethral catheterization. The urethra must be visualized first to avoid converting a partial tear into a complete transection.

Insert a transurethral Foley catheter

Allows for bladder decompression and evaluation of urine.

After the urethra is cleared by the retrograde urethrogram, a catheter is necessary to monitor urine output and identify gross hematuria, which indicates potential bladder injury.

Perform a computed tomography (CT) cystogram

Identifies the presence and location of a bladder rupture.

Gross hematuria in the setting of a pelvic fracture mandates imaging of the bladder to differentiate between extraperitoneal and intraperitoneal ruptures.

Perform an exploratory laparotomy

Surgically repairs the bladder defect.

Unlike extraperitoneal ruptures which can often be managed with catheter drainage alone, intraperitoneal bladder ruptures leak urine into the peritoneal cavity and require urgent operative repair.

Key Concept

Sequential ATLS management of pelvic trauma complicated by suspected urologic injury.

Estimated Time:1m 30s

Question 837Question →

A 54-year-old man arrives at the trauma center via ambulance after falling approximately 20 feet from a roof. En route, emergency medical services placed a cervical collar and secured him to a backboard. Upon arrival, the patient is agitated, pale, and diaphoretic. His temperature is $36.8^\circ\text{C}$ ( $98.2^\circ\text{F}$ ), blood pressure is $78/48\text{ mmHg}$ , pulse is $132\text{/min}$ , and respiratory rate is $22\text{/min}$ . Oxygen saturation is $98\%$ on a non-rebreather mask. The airway is patent, and breath sounds are clear and equal bilaterally. The abdomen is notably distended and diffusely tender to palpation, with significant involuntary guarding. The pelvis is mechanically stable to manual compression. Two large-bore intravenous lines are established, and rapid resuscitation with warmed isotonic crystalloids is initiated. Which of the following is the most appropriate next step in the management of this patient?

Transfer the patient for cross-sectional imaging of the torso

Admit to the intensive care unit for serial physical examinations

Administer intravenous broad-spectrum antimicrobial therapy

Perform bedside ultrasonography of the peritoneal cavity

Proceed directly to the operating theater for abdominal exploration

Show answer & explanation

Answer: Perform bedside ultrasonography of the peritoneal cavity

Answer

Perform bedside ultrasonography of the peritoneal cavity

This patient is exhibiting signs of severe hemorrhagic shock (tachycardia, hypotension, diaphoresis) following blunt trauma. In the initial evaluation of an unstable trauma patient, the source of bleeding must be identified rapidly without leaving the resuscitation bay. Bedside ultrasonography (FAST exam) is the standard next step to quickly evaluate for intraperitoneal free fluid (blood) or pericardial effusion. If the FAST exam is positive in this unstable patient, it will immediately dictate the need for emergency surgical intervention.

Step-by-Step Solution

Analyze the patient's vital signs and clinical presentation.

The patient has a blood pressure of 78/48 mmHg and a heart rate of 132/min, indicating Class III/IV hemorrhagic shock.

Recognizing hemodynamic instability is the critical first step in trauma triage.

Evaluate the primary survey findings.

The airway is patent and breath sounds are equal bilaterally, ruling out tension pneumothorax or massive hemothorax as the primary cause of shock. The abdomen is distended with peritonitis.

This localizes the likely source of hemorrhage to the intra-abdominal cavity.

Determine the appropriate diagnostic pathway based on hemodynamic status.

Because the patient is unstable, advanced imaging that requires transport must be avoided. A rapid bedside evaluation is required.

The Advanced Trauma Life Support (ATLS) protocol dictates using a Focused Assessment with Sonography for Trauma (FAST) to confirm intraperitoneal free fluid before surgical exploration.

Key Concept

Management algorithm for hemodynamically unstable blunt abdominal trauma

Question 838Question →

A 64-year-old woman is evaluated in the emergency department 12 days after undergoing a coronary artery bypass grafting (CABG) procedure. She reports a 2-day history of increasing retrosternal pain, fever, and profound fatigue. Her temperature is 38.8°C (101.8°F), heart rate is 112/min, blood pressure is 105/65 mmHg, and respiratory rate is 18/min. Physical examination reveals erythema, induration, and a small amount of purulent drainage from the inferior aspect of the sternotomy incision. A palpable 'click' and abnormal movement are felt over the sternum during respiration. Arrange the following management steps in the most appropriate chronological order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct chronological sequence for managing acute postoperative mediastinitis is to first obtain microbiological cultures, immediately follow with empiric broad-spectrum intravenous antibiotics, then obtain a computed tomography (CT) scan of the chest to delineate the infection, and finally proceed with definitive surgical exploration and debridement.

The presentation of fever, purulent wound drainage, and a 'clicking' sternum 12 days post-CABG is highly suspicious for acute postoperative mediastinitis complicated by sternal dehiscence. The standard of care mandates a strict chronological sequence to optimize patient outcomes. First, blood and deep wound cultures must be collected to ensure the causative organism (typically Gram-positive cocci such as Staphylococcus aureus or epidermidis) can be identified. Second, empiric broad-spectrum intravenous antibiotics are administered immediately after cultures to treat the severe systemic infection. Third, a CT scan of the chest is performed to evaluate the mediastinum for fluid collections and the extent of bone involvement, which directly guides the operative plan. Finally, urgent surgical exploration is performed to achieve definitive source control through rigorous debridement of necrotic bone and tissue, followed by stabilization or vascularized muscle flap reconstruction.

Step-by-Step Solution

Identify acute postoperative mediastinitis with sternal dehiscence.

Recognize the clinical triad of fever, purulent sternal drainage, and sternal instability (clicking) in a post-cardiac surgery patient.

This is a life-threatening complication that requires immediate, protocolized medical and surgical intervention.

Prioritize microbiological yield before medical therapy.

Obtain blood and deep wound cultures.

Pathogen identification is required for targeted therapy and must be completed before antibiotics obscure the microbiological results.

Initiate acute systemic sepsis treatment.

Administer empiric broad-spectrum intravenous antibiotics.

To rapidly control the systemic infection and prevent clinical deterioration into hemodynamic instability.

Define the anatomical involvement of the infection.

Obtain a chest CT scan.

Imaging is necessary to guide the surgical approach by identifying retrosternal abscesses or undrained fluid collections.

Perform definitive source control.

Proceed to the operating room for surgical exploration.

Surgical source control via extensive debridement of necrotic bone and tissue, followed by sternal rewiring or flap closure, is the only curative intervention for deep sternal wound infections.

Key Concept

The management of acute postoperative mediastinitis requires a rapid, standardized sequence: obtain cultures, initiate broad-spectrum antibiotics, obtain cross-sectional imaging for operative planning, and perform definitive surgical debridement.

Question 839Question →

Match each patient's clinical and radiographic presentation with the most likely orthopedic diagnosis.

Click a left item, then click its matching right item

Show answer & explanation

Answer

Presentation 1 matches with Osteoid osteoma; Presentation 2 matches with Osteosarcoma; Presentation 3 matches with Ewing sarcoma; Presentation 4 matches with Giant cell tumor of bone; Presentation 5 matches with Osteochondroma.

Each primary bone tumor has a characteristic profile. Osteoid osteoma presents with NSAID-responsive pain and a sclerotic nidus. Osteosarcoma involves the metaphysis with a sunburst pattern. Ewing sarcoma involves the diaphysis with an onion-skin pattern and can cause systemic symptoms. Giant cell tumor involves the epiphysis in adults with a soap-bubble appearance. Osteochondroma is a benign stalk pointing away from the joint.

Step-by-Step Solution

Analyze presentation 1

Night pain relieved by NSAIDs with a small radiolucent nidus and surrounding sclerosis.

These are the pathognomonic clinical and imaging features of an osteoid osteoma.

Analyze presentation 2

Metaphyseal destructive lesion with 'sunburst' pattern and Codman triangle in a teenager.

These aggressive radiographic signs indicate a malignant primary bone tumor, characteristic of osteosarcoma.

Analyze presentation 3

Diaphyseal permeative lesion with 'onion skin' periosteal reaction in a child with systemic symptoms.

The diaphyseal location and lamellated reaction are classic for Ewing sarcoma, which can present similarly to osteomyelitis.

Analyze presentation 4

Epiphyseal 'soap bubble' lytic lesion in a young adult.

An epiphyseal location in a patient with closed growth plates strongly points to a giant cell tumor of bone.

Analyze presentation 5

Painless bony outgrowth from the metaphysis pointing away from the joint.

This benign morphology describes an osteochondroma, the most common benign bone tumor.

Key Concept

Differentiation of primary bone tumors based on patient age, tumor location (epiphysis vs. metaphysis vs. diaphysis), and characteristic radiographic patterns.

Estimated Time:1m 30s

Question 840Question →

A 72-year-old man is evaluated on postoperative day 3 following an open partial gastrectomy for a perforated peptic ulcer. Over the last several hours, he has developed progressive dyspnea, a nonproductive cough, and a sense of chest tightness. His medical history is significant for severe chronic obstructive pulmonary disease and ischemic cardiomyopathy with a baseline left ventricular ejection fraction of 40%. During his surgery, he received 4 liters of isotonic crystalloid resuscitation. His temperature is 37.8°C (100.0°F), blood pressure is 158/92 mmHg, pulse is 112/min, and respirations are 24/min. Pulse oximetry shows 88% on room air. Physical examination reveals elevated jugular venous pressure to 10 cm H2O. Lung auscultation demonstrates bilateral coarse crackles at the bases and scattered expiratory wheezes. The surgical incision is clean, dry, and intact. There is bilateral trace lower extremity edema, which is unchanged from baseline. A chest radiograph demonstrates bilateral perihilar opacities and prominent pulmonary vasculature, with no focal consolidation. Which of the following is the most appropriate next step in management?

Intravenous loop diuretic therapy

Inhaled short-acting bronchodilators and systemic glucocorticoids

Empiric broad-spectrum antibiotic therapy

Computed tomography angiography of the chest

Flexible fiberoptic bronchoscopy

Show answer & explanation

Answer: Intravenous loop diuretic therapy

Answer

Intravenous loop diuretic therapy

The patient's clinical presentation is highly consistent with acute decompensated heart failure (ADHF) secondary to volume overload. During major abdominal surgery, patients routinely receive large volumes of intravenous crystalloid resuscitation, much of which shifts into the interstitial ('third') space. Typically, around postoperative day 3, this fluid begins to rapidly mobilize back into the intravascular space. In patients with underlying ventricular dysfunction (e.g., ischemic cardiomyopathy), this sudden increase in intravascular volume can overwhelm the heart, leading to ADHF. Key indicators in this patient include elevated jugular venous pressure, bilateral basilar crackles, and a chest radiograph demonstrating perihilar opacities and prominent pulmonary vasculature. Although the patient has a history of COPD and presents with wheezing, this represents 'cardiac asthma'—bronchospasm triggered by pulmonary edema. The most appropriate initial management is diuresis with an intravenous loop diuretic to quickly reduce intravascular volume and alleviate pulmonary congestion.

Step-by-Step Solution

Analyze the timing and context of the patient's respiratory distress.

The patient developed symptoms on postoperative day 3 after receiving significant intraoperative fluid resuscitation.

Postoperative day 3 is the classic timeframe for third-space fluid mobilization, which shifts fluids back into the intravascular space.

Evaluate the clinical signs and symptoms.

The patient exhibits progressive dyspnea, hypoxemia, elevated jugular venous pressure, crackles, and wheezing.

These findings point toward a cardiac etiology for the respiratory distress, specifically acute decompensated heart failure exacerbating pulmonary congestion.

Interpret the chest radiograph findings.

The radiograph shows bilateral perihilar opacities and prominent pulmonary vasculature without focal consolidation.

These findings are highly characteristic of pulmonary edema, confirming the diagnosis of acute decompensated heart failure rather than an infectious pneumonia or a primary COPD exacerbation.

Determine the most appropriate next step in management.

The patient should receive intravenous loop diuretic therapy.

Intravenous diuresis is the first-line treatment to rapidly reduce intravascular volume and alleviate pulmonary edema in acute decompensated heart failure.

Key Concept

Acute decompensated heart failure frequently occurs around postoperative day 3 due to the mobilization of third-space fluids back into the intravascular space; it presents with volume overload signs (elevated JVP, pulmonary edema) and is managed with intravenous loop diuretics.

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