Surgery

A 72-year-old man is evaluated for severe shortness of breath on postoperative day 3 following an open left hemicolectomy for colon cancer. The patient has a history of hypertension, coronary artery disease, and chronic obstructive pulmonary disease. During the operation and the first 24 hours postoperatively, he received a total of 6 liters of isotonic crystalloid for resuscitation. He was recovering well until this morning when he developed worsening dyspnea, orthopnea, and a mild cough. His temperature is 37.8°C (100.0°F), blood pressure is 162/94 mmHg, pulse is 108/min, and respirations are 26/min. Oxygen saturation is 89% on room air. Physical examination reveals distended jugular veins when sitting at 45 degrees. Lung auscultation demonstrates bilateral crackles extending to the mid-lung fields and expiratory wheezing. Cardiac examination reveals a regular tachycardia with a prominent S3 gallop. The abdomen is soft and nondistended, and the surgical incision is intact. Which of the following is the most appropriate next step in the management of this patient?

Match each classic clinical presentation to the most likely surgical diagnosis.

A 62-year-old man is evaluated in the surgical ward on postoperative day 5 following an open anterior resection for severe rectal prolapse. Postoperative pain was managed with a lumbar epidural catheter, which was removed yesterday. He had been ambulating with assistance and tolerating a soft diet. Over the past 12 hours, he has developed a fever, chills, and increasing lower back pain. His temperature is 38.9°C (102.0°F), pulse is 110/min, respirations are 18/min, and blood pressure is 118/72 mm Hg. Physical examination reveals exquisite tenderness to palpation over the lower lumbar spine. Neurologic examination demonstrates 3/5 motor strength in the bilateral lower extremities and diminished sensation to pinprick below the L2 dermatome. A bedside bladder ultrasound reveals 600 mL of urine, despite the patient reporting no urge to void. The abdominal incision is clean, dry, and intact with no erythema or fluctuance. Which of the following is the most appropriate next step in management?

A 61-year-old male is currently hospitalized on the surgical ward undergoing treatment for a mechanical small bowel obstruction. He was admitted two days ago with colicky abdominal pain, significant abdominal distention, and obstipation. His past medical history is notable for an exploratory laparotomy for a ruptured appendix during childhood.

Initial management with strict nothing-by-mouth status, intravenous crystalloids, and nasogastric tube decompression resulted in moderate symptomatic relief and decreased abdominal distention. However, over the past three hours, the nursing staff urgently requests an evaluation due to a dramatic clinical change.

The patient now complains of excruciating, unrelenting, and constant abdominal pain. His temperature is 39.1°C (102.4°F), pulse is 128/min, blood pressure is 88/52 mmHg, and respirations are 24/min. Physical examination reveals a rigid, distended abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are entirely absent. A point-of-care venous blood gas shows a pH of 7.28 and a lactate level of 5.2 mmol/L.

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

A 24-year-old male with no significant past medical history is undergoing an elective open reduction and internal fixation of a right clavicle fracture. Induction of general anesthesia is achieved with propofol and succinylcholine, and anesthesia is maintained with sevoflurane. Thirty minutes into the procedure, the anesthesiologist notes a sudden and abrupt rise in the end-tidal carbon dioxide ($ETCO_2$) to $78\text{ mmHg}$. The patient develops generalized muscle rigidity, most notably in the masseter muscles. His core body temperature begins to rise rapidly and is currently $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$). His heart rate is $152\text{/min}$, and blood pressure is $155/95\text{ mmHg}$.

Arrange the following management steps in the most appropriate chronological priority order for this patient's acute perioperative complication.

Emergency medical services arrive at the hospital with a 42-year-old man who was rescued from a structural fire in an enclosed basement. The patient sustained full-thickness burns over his entire anterior torso, both upper extremities, and the anterior aspect of both thighs, yielding an estimated 45% total body surface area involvement. Although awake and agitated, he exhibits a noticeably hoarse voice, and inspection of the oropharynx reveals carbonaceous sputum and soot. Vital signs include a blood pressure of 110/70 mm Hg, heart rate of 118/min, and respiratory rate of 26/min. His oxygen saturation reads 94% while receiving high-flow oxygen. Arrange the following acute management interventions in the most appropriate chronological sequence.

Match each clinical presentation of acute abdominal pain to the most appropriate next step in management.

A 34-year-old female is brought to the emergency department via helicopter after being rescued from a residential house fire. The burn injury occurred at 14:00, and she arrives at the trauma bay at 17:00. Her weight is $90 \text{ kg}$. Physical examination reveals deep partial-thickness and full-thickness burns involving her entire anterior trunk (chest and abdomen), her entire right arm (circumferential), and the anterior surface of her left leg. The remainder of her skin is uninjured. En route to the hospital, paramedics successfully intubated her for airway protection and administered $740 \text{ mL}$ of lactated Ringer solution intravenously. According to current Advanced Trauma Life Support (ATLS) guidelines ($2 \text{ mL/kg/\%TBSA}$ for adult thermal burns), what should be the intravenous fluid infusion rate in $\text{mL/hr}$ for the remainder of the first 8-hour post-injury period?

A 52-year-old man is brought to the emergency department after experiencing the sudden onset of excruciating, diffuse abdominal pain that began 2 hours ago. He has a history of severe osteoarthritis and takes high doses of naproxen daily. His temperature is 38.3°C (100.9°F), blood pressure is 100/60 mmHg, and pulse is 115/min. On physical examination, he is diaphoretic and lying completely motionless on the stretcher. His abdomen is rigid and board-like, with diffuse rebound tenderness. Arrange the following critical management steps in the most appropriate chronological sequence for this patient.

Paramedics transport a 32-year-old man to the trauma resuscitation bay following an altercation outside a restaurant. The patient sustained a single stab wound to the left lower abdominal quadrant. He is awake, alert, and conversant. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate of $92/\text{min}$, respiratory rate of $16/\text{min}$, and blood pressure of $128/82 \text{ mm Hg}$. Physical examination reveals a $3\text{-cm}$ laceration in the left lower quadrant with a segment of omentum actively protruding through the defect. The remainder of the abdomen is soft and non-tender. Two large-bore intravenous lines are established. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old woman is evaluated in the surgical ward due to the sudden onset of shortness of breath and right-sided chest pain that exacerbates with deep inspiration. She is currently on postoperative day 6 following an open radical cystectomy and ileal conduit formation for bladder cancer. The patient has been mostly bedbound since the surgery due to inadequate pain control. Her temperature is 38.1°C (100.6°F), blood pressure is 108/68 mm Hg, pulse is 118/min, and respirations are 26/min. Pulse oximetry shows an oxygen saturation of 88% on room air. Physical examination reveals clear lungs bilaterally. The right calf appears mildly swollen and is tender to palpation. The surgical incision is clean, intact, and shows no erythema or drainage.

Which of the following are the most appropriate initial steps in the management of this patient? (Select 3)

A 7-year-old boy is brought to the emergency department by his parents 30 minutes after falling from a playground structure. He fell onto his outstretched left arm and immediately complained of severe elbow pain. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 105/65 mm Hg, heart rate of 112/min, and respiratory rate of 20/min. Physical examination reveals a distressed child holding his left arm. There is marked swelling and an "S-shaped" deformity at the left elbow. There are no open wounds or visible ecchymoses.

Neurovascular assessment demonstrates a palpable radial pulse and a capillary refill time of 1 second in the fingers. When asked to make an "OK" sign with his left hand, the patient is unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. Sensation to light touch is intact over the median, ulnar, and radial nerve distributions. Anteroposterior and lateral radiographs of the left elbow show a displaced extension-type supracondylar humerus fracture with posterior displacement of the distal fragment.

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

Emergency medical services arrive at the trauma bay with a 28-year-old roofing contractor who fell from a residential building. The fall distance was approximately $4.5$ meters ($15$ feet). The patient is fully conscious and reports agonizing pain in his left leg. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate of $105/\text{min}$, blood pressure of $130/80\text{ mm Hg}$, and a respiratory rate of $18/\text{min}$. The initial trauma assessment confirms a patent airway, normal breathing, and no clinical evidence of intra-abdominal hemorrhage. Attention to the left lower extremity reveals a visibly angulated mid-shaft tibia. A $5\text{-cm}$ skin tear is present over the medial aspect, oozing dark blood, with underlying bone fragments exposed. The distal foot is noticeably pale and cold compared to the contralateral limb. Palpation of the dorsalis pedis and posterior tibial arteries yields no pulse, and capillary refill in the toes is absent. Neurological evaluation of the foot is limited secondary to extreme pain. Which of the following is the most appropriate initial step in the management of this patient's left extremity?

A 22-year-old male is brought to the emergency department after a high-speed motorcycle collision. He complains of severe right leg pain. On physical examination, his right knee is grossly deformed with a prominent medial femoral condyle. The patient's right foot is cold and pale, and the dorsalis pedis and posterior tibial pulses are not palpable. Capillary refill is delayed. Arrange the following management steps in the most appropriate chronological order for this patient, assuming that an arterial injury is present and requires definitive treatment.

Match the following specific orthopedic injuries with their most commonly associated neurological deficit or physical examination finding.

A mother brings her 3-year-old son to an urgent care clinic because he has been crying inconsolably whenever she tries to change his diaper or move his right leg. Since yesterday morning, the child has refused to stand or walk. He had a runny nose and low-grade fever two weeks ago, which resolved without medication. Today, his temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), pulse is $110/\text{min}$, and blood pressure is $90/60\text{ mmHg}$. Physical examination reveals a distressed child who holds his right leg flexed, abducted, and externally rotated at the hip joint. Any attempt to internally rotate the right leg causes severe guarding and screaming. Laboratory analysis reveals a leukocyte count of $17,500/\text{mm}^3$ and an erythrocyte sedimentation rate of $52\text{ mm/h}$. Plain radiographs of the pelvis and bilateral lower extremities demonstrate no fracture, dislocation, or evidence of avascular necrosis. Which of the following is the most appropriate next step in the evaluation and management of this patient?

Match the following upper extremity musculoskeletal conditions with their classic physical examination findings or provocative test results.

During a night shift, a ward nurse urgently pages the orthopedic resident regarding a patient with uncontrolled pain. The patient is a $34$-year-old right-hand-dominant carpenter who sustained a closed, displaced fracture of the right distal radius $8$ hours ago. He was treated with closed reduction and application of a circumferential fiberglass cast. He has received $2$ doses of intravenous morphine over the past hour but continues to writhe in bed, describing a severe, burning pain in his forearm. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $142/88\text{ mmHg}$, and heart rate $112\text{/min}$. Examination of the right upper extremity shows a rigid, intact cast. The exposed digits are mildly swollen but pink, and capillary refill is $< 2\text{ seconds}$. The radial pulse is palpable. Passive extension of the digits by the examiner elicits agonizing pain that causes the patient to withdraw the arm immediately. Which of the following is the most appropriate next step in management?

A 15-year-old boy presents to the orthopedic clinic with a 3-month history of progressively worsening deep pain in his right distal thigh. The pain is persistent, often awakens him at night, and is not relieved by over-the-counter analgesics. Physical examination reveals a palpable, tender, and firm mass over the anterior distal femur. There is no history of preceding trauma, and the patient is afebrile. Arrange the following steps in the most appropriate chronological sequence for the evaluation and definitive management of this patient's suspected primary bone sarcoma.

A 24-year-old man presents to the urgent care clinic with right wrist pain. Two days ago, he fell forward onto his outstretched right hand while playing basketball. He notes focal swelling and pain that worsens when gripping objects. Vital signs are temperature 36.8°C (98.2°F), blood pressure 118/76 mm Hg, heart rate 72/min, and respiratory rate 14/min. Physical examination reveals localized tenderness over the dorsal radial aspect of the right wrist, specifically in the depression bounded by the extensor pollicis longus and extensor pollicis brevis tendons. Pain is reproduced with axial compression of the first metacarpal. Neurovascular assessment shows 2+ radial and ulnar pulses with brisk capillary refill and normal sensation to light touch in all digits. Initial anteroposterior, lateral, and scaphoid-view radiographs of the right wrist demonstrate no fracture lines, step-offs, or dislocations. Which of the following is the most appropriate next step in management?