Surgery

Emergency medical services bring a 72-year-old female resident of a skilled nursing facility to the acute care clinic due to progressive abdominal swelling, intractable vomiting, and profound weakness over the past day. Her past medical history includes an open total abdominal hysterectomy five years ago. On initial assessment, her temperature is 39.1°C (102.4°F), pulse is 128/min, respirations are 26/min, and blood pressure is 78/45 mm Hg. The patient is poorly responsive. The abdominal examination demonstrates severe distension, generalized rigidity, and diffuse rebound tenderness with absent bowel sounds. Initial laboratory analysis shows a white blood cell count of 22,000/mm³ and a serum lactate concentration of 6.2 mmol/L. Which of the following is the most appropriate next step in management?

During routine evening rounds, a physician is asked to assess a patient who recently underwent abdominal surgery. The patient is a 54-year-old male who had an open partial colectomy for a large, benign colonic polyp 48 hours ago. The nursing staff reports that his temperature has increased to 38.5°C (101.3°F). Vital signs show a blood pressure of 130/80 mmHg, pulse of 96/min, and respirations of 20/min. Oxygen saturation is 96% on room air. The patient feels slightly fatigued but denies any chest pain, shortness of breath, or pain with urination. He is currently receiving patient-controlled intravenous morphine. On physical examination, the abdomen is mildly distended with hypoactive bowel sounds, and the surgical dressing is clean and dry. Auscultation of the chest reveals diminished breath sounds bilaterally at the lung bases without crackles or wheezes. There is no calf swelling or tenderness. Which of the following is the most appropriate initial intervention for this patient?

A $62$-year-old woman is evaluated in the emergency department for right-sided flank pain, nausea, and high fever that began $24$ hours ago. Her past medical history is significant for recurrent urinary tract infections. Temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $80/40\text{ mm Hg}$, pulse is $128/\text{min}$, and respirations are $26/\text{min}$. Right costovertebral angle tenderness is present. Laboratory tests show a leukocyte count of $24,000/\text{mm}^3$ with $15\%$ bands and a serum creatinine of $2.3\text{ mg/dL}$. Urinalysis reveals $4+$ leukocyte esterase, positive nitrites, and numerous bacteria. A noncontrast CT scan of the abdomen and pelvis shows a $12\text{-mm}$ calculus obstructing the right proximal ureter with associated severe hydronephrosis. Aggressive intravenous fluid resuscitation and broad-spectrum intravenous antibiotics are initiated, and a norepinephrine infusion is started to maintain mean arterial pressure. Which of the following is the most appropriate next step in management?

A $55$-year-old woman is brought to the emergency department due to severe right flank pain, fever, and chills for the past $24$ hours. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $88/55\text{ mm Hg}$, and pulse is $122/\text{min}$. Laboratory studies show a leukocyte count of $18,000/\text{mm}^3$. A noncontrast computed tomography scan of the abdomen and pelvis reveals a $9\text{-mm}$ obstructing calculus in the right proximal ureter with moderate hydronephrosis and perinephric stranding. Arrange the following management steps in the most appropriate chronological order.

A 42-year-old man is brought to the emergency department via helicopter following a structural fire. The injury occurred exactly 2 hours prior to arrival. He weighs $90 \text{ kg}$. Physical examination reveals deep partial-thickness and full-thickness burns involving his entire anterior trunk, his entire right arm, and the entire anterior surface of his right leg. The remainder of his skin is intact. During transport, paramedics administered $480 \text{ mL}$ of intravenous lactated Ringer solution. The trauma team initiates fluid resuscitation using the traditional Parkland formula ($4 \text{ mL} \times \text{weight in kg} \times \% \text{TBSA}$). At what rate (in $\text{mL/hr}$) should the lactated Ringer infusion be set for the remainder of the first 8-hour period following the injury?

A 48-year-old male construction worker is brought to the emergency department after being crushed between a concrete barrier and a moving vehicle at the level of his hips. On arrival, he is pale, diaphoretic, and confused. Vital signs are blood pressure 75/40 mm Hg, heart rate 138/min, and respiratory rate 24/min. The airway is patent, and breath sounds are clear and equal bilaterally. A portable chest radiograph shows no abnormalities. The abdomen is soft, non-distended, and mildly tender to deep palpation. Anteroposterior compression of the pelvis reveals severe mechanical instability, and a pelvic binder is immediately applied in the trauma bay. A focused assessment with sonography for trauma (FAST) exam demonstrates no anechoic free fluid in the pericardium, hepatorenal recess, splenorenal recess, or retrovesical space. The patient receives 2 units of uncrossmatched type O-negative packed red blood cells and 1 L of isotonic crystalloid. Reassessment reveals a blood pressure of 78/42 mm Hg and a heart rate of 135/min. Which of the following is the most appropriate next step in management?

A 42-year-old woman is brought to the emergency department complaining of sudden-onset, severe, colicky abdominal pain that has become constant over the past 6 hours. She has also experienced multiple episodes of bilious vomiting and has not passed flatus or stool since the pain began. Her medical history is unremarkable, and she has never undergone abdominal surgery. She is an avid long-distance runner. Her temperature is 38.6°C (101.5°F), pulse is 122/min, respirations are 22/min, and blood pressure is 92/58 mm Hg. Physical examination reveals an asymmetrically distended abdomen with a tympanitic mass palpable in the mid-abdomen. There is marked right-sided tenderness with involuntary guarding and rebound tenderness. Laboratory studies show a leukocyte count of $16,500/\mu L$ and a serum lactate of $4.2 \text{ mmol/L}$. An upright plain abdominal radiograph demonstrates a large, comma-shaped dilated bowel loop projecting from the right lower quadrant toward the left upper quadrant, with a paucity of gas in the distal colon. Which of the following is the most appropriate next step in management?

A 62-year-old man is assessed on the surgical ward 72 hours after undergoing an open sigmoid colectomy for complicated diverticulitis. He reports feeling fatigued but denies shortness of breath, chest pain, dysuria, or nausea. He is tolerating a clear liquid diet and passed flatus this morning. His medical history includes chronic obstructive pulmonary disease (COPD) and essential hypertension.

His vital signs are:
Temperature: 38.6°C (101.5°F)
Blood pressure: 132/84 mm Hg
Heart rate: 96/min
Respiratory rate: 18/min
Oxygen saturation: 94% on room air

Physical examination reveals a soft abdomen with mild, localized tenderness at the surgical incision site. There is no rebound tenderness or guarding. The midline incision is well-approximated, clean, and dry without erythema or discharge. Pulmonary auscultation reveals mild, scattered expiratory wheezes bilaterally that are unchanged from his preoperative baseline examination. There are no crackles, and jugular venous distension is absent. His indwelling urethral catheter was removed 24 hours ago, and he has voided spontaneously since then. Bilateral calf examination shows no edema or tenderness.

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

A 38-year-old man arrives at the emergency department accompanied by his spouse, reporting excruciating abdominal pain that began 6 hours ago. He states that he has had a painless "bulge" in his right groin for two years, which typically disappears when he lies down. Earlier today, the bulge became noticeably larger, highly painful, and could no longer be pushed back in. Over the past 3 hours, the pain has generalized across his entire abdomen, and he has vomited dark, bilious fluid three times. He has not passed flatus since yesterday. His temperature is 38.6°C (101.5°F), blood pressure is 98/60 mm Hg, pulse is 118/min, and respirations are 22/min. On physical examination, the patient is diaphoretic and lying completely still. Abdominal examination reveals board-like rigidity, diffuse involuntary guarding, and severe rebound tenderness in all quadrants. Examination of the right groin demonstrates a 6-cm, tense, erythematous mass protruding into the scrotum that is exquisitely tender to palpation. Laboratory results show a leukocyte count of 17,500/mm³ and a serum lactate of 4.1 mmol/L. Which of the following is the most appropriate next step in management?

Emergency medical services arrive at the trauma bay with a 22-year-old college student who crashed his mountain bike at high speed, striking his torso against the handlebars. He is awake but lethargic, complaining of severe pain in his left upper abdomen and left shoulder.

Vital signs include a heart rate of 135/min, blood pressure of 82/48 mm Hg, and respiratory rate of 22/min. Oxygen saturation is 96% on room air.

Physical examination reveals a large contusion over the left lower rib cage with marked tenderness and guarding in the left upper quadrant.

Intravenous access is established, and a bolus of warmed isotonic crystalloid is initiated. A focused assessment with sonography for trauma (FAST) demonstrates a large anechoic stripe between the spleen and the left kidney.

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

A respiratory therapy consult is requested for a 64-year-old woman who has developed mild shortness of breath on her second day of recovery following an open ventral hernia repair. She has a known history of chronic obstructive pulmonary disease and diet-controlled type 2 diabetes mellitus. Current vital signs reveal a temperature of 37.8°C (100°F), a heart rate of 102/min, a respiratory rate of 22/min, and blood pressure of 138/85 mmHg. Oxygen saturation is 92% on ambient air. When questioned, the patient states that taking large breaths causes significant discomfort at the incision site. Physical examination demonstrates shallow respirations with noticeably diminished breath sounds at both pulmonary bases. The lungs are otherwise clear, without wheezes, rhonchi, or crackles. The jugular veins are flat, and cardiac auscultation shows a regular rhythm with no gallops or murmurs. The surgical wound appears clean, dry, and intact. Which of the following is the most appropriate initial intervention to manage this patient's current respiratory presentation?

A 6-year-old girl is evaluated in the emergency department after falling from a trampoline onto her outstretched left arm. She is in significant distress and refuses to move her upper extremity. Vital signs are stable. Physical examination reveals a gross S-shaped deformity and severe swelling of the left elbow. The skin over the antecubital fossa is intact without puckering. Capillary refill in the left fingers is 1.5 seconds, and the hand is warm and pink. However, the left radial pulse is completely absent to palpation and cannot be detected with a hand-held Doppler device. Neurologic examination reveals an inability to actively flex the interphalangeal joint of the left thumb, but she is able to extend her wrist and fingers against resistance. Radiographs demonstrate a completely displaced, extension-type supracondylar fracture of the distal humerus. The patient is emergently taken to the operating room, where an anatomic closed reduction and percutaneous pinning are performed. Intraoperative fluoroscopy confirms perfect alignment and stable fixation. Immediate post-procedural evaluation reveals that the left hand remains warm and pink with a capillary refill of 1.5 seconds. However, the radial pulse remains undetectable by Doppler. Which of the following is the most appropriate next step in the management of this patient?

A 52-year-old woman is admitted to the hospital with a 2-day history of progressively worsening crampy abdominal pain, abdominal distension, and bilious vomiting. She has not passed flatus or stool for the past 24 hours. Her surgical history is significant for a total abdominal hysterectomy performed 5 years ago for uterine fibroids. Vital signs show a temperature of 37.1°C (98.8°F), pulse of 86/min, and blood pressure of 126/82 mm Hg. Physical examination reveals a distended and tympanic abdomen. There is diffuse mild tenderness to palpation, but no rebound tenderness, guarding, or rigidity. Laboratory studies show a normal leukocyte count and a serum potassium of 3.8 mEq/L. Computed tomography (CT) of the abdomen reveals multiple dilated loops of small bowel with air-fluid levels and a discrete transition point in the mid-ileum. There is no evidence of bowel wall thickening, pneumatosis intestinalis, or free intraperitoneal air. What is the most appropriate next step in the management of this patient?

A 58-year-old man is examined in the hospital one week after undergoing a laparoscopic-assisted right hemicolectomy for a ruptured appendix with a localized abscess. He was initially recovering well but has developed worsening right shoulder pain and a mild, persistent cough over the last two days. His temperature is 39.0°C (102.2°F), blood pressure is 128/82 mmHg, pulse is 112/min, and respirations are 20/min. Pulse oximetry is 96% on room air. Cardiopulmonary examination reveals diminished breath sounds over the right posterior lung base. The abdomen is soft, with moderate focal tenderness in the right upper quadrant. The surgical incisions are healing well without erythema, fluctuance, or discharge. His leukocyte count is 18,500/mm^3. A portable chest radiograph demonstrates a small right-sided pleural effusion with an elevated right hemidiaphragm.

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

A 27-year-old male is transported to the trauma bay after sustaining a knife wound to his right thigh during an altercation. On initial assessment, the patient is diaphoretic and confused. Vital signs show a heart rate of 134/min and a blood pressure of 80/42 mmHg. Examination of the right lower extremity reveals a 4-cm laceration over the anteromedial thigh with a rapidly expanding, pulsatile swelling beneath the skin. The right foot is markedly pale compared to the left, and no pulses are audible on Doppler ultrasound over the right dorsalis pedis or posterior tibial arteries. Intravenous access is established and rapid crystalloid infusion is started. Which of the following is the most appropriate next step in management?

Match each clinical presentation in a patient with a history of Roux-en-Y gastric bypass to the most likely postoperative complication.

While recovering on the surgical unit, a 68-year-old male is evaluated for new-onset respiratory distress and increased sputum production. The patient is currently on postoperative day 2 following an open partial colectomy for adenocarcinoma. His past medical history includes severe chronic obstructive pulmonary disease (COPD), osteoarthritis, and hypertension. He continues to smoke one pack of cigarettes daily.

Vital signs show a temperature of 38.7°C (101.6°F), pulse of 112/min, blood pressure of 138/82 mm Hg, and respirations of 26/min. Pulse oximetry reading is 88% on ambient air. Physical examination reveals a barrel-shaped chest with diffuse, bilateral expiratory wheezing and a prolonged expiratory phase. Jugular venous pressure is normal, and heart sounds are regular without any S3 gallop. The abdominal incision is clean, dry, and intact with no surrounding erythema. Both calves are soft, compressible, and nontender. A portable chest radiograph displays hyperinflated lung fields along with a newly developed dense consolidation in the left lower lobe.

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

Match each acute trauma clinical presentation with the most appropriate next step in management.

A 36-year-old woman arrives at the emergency department reporting three days of progressively worsening, colicky abdominal pain. She has not passed flatus or had a bowel movement during this period. The patient is an avid long-distance runner and has no history of prior abdominal surgeries or significant medical conditions. Her vital signs are temperature 37.3°C (99.1°F), pulse 102/min, respirations 18/min, and blood pressure 118/78 mm Hg. On physical examination, her abdomen is asymmetric, markedly distended, and tympanitic on percussion. Auscultation reveals high-pitched, metallic bowel sounds. Deep palpation elicits diffuse tenderness, but there is no rigidity or rebound tenderness. Laboratory tests demonstrate a leukocyte count of 9,500/mm³ and serum potassium of 3.8 mEq/L. A contrast-enhanced abdominal CT scan reveals a massively dilated, gas-filled cecum displaced into the left upper quadrant, accompanied by a twisting of the mesenteric vessels in the right mid-abdomen. The distal colon is entirely decompressed. Which of the following is the most appropriate next step in the management of this patient?

An 78-year-old female resident of an assisted living facility is evaluated in the emergency department for a 3-day history of progressively worsening, crampy abdominal pain and recurrent vomiting of dark green fluid. She has not passed flatus or had a bowel movement for the past 48 hours. Her past medical history includes hypertension, type 2 diabetes mellitus, and intermittent episodes of right upper quadrant postprandial pain for which she has repeatedly declined surgical intervention. Her temperature is 37.4°C (99.3°F), blood pressure is 112/68 mmHg, and pulse is 106/min. Physical examination demonstrates a distended, tympanic abdomen with high-pitched, "tinkling" bowel sounds. There is diffuse, mild abdominal tenderness but no guarding or rebound tenderness. Laboratory studies reveal a leukocyte count of 11,500/mm³ and normal serum lactate. An upright abdominal radiograph demonstrates multiple dilated loops of small intestine with prominent air-fluid levels and branching radiolucent lines overlying the liver shadow. Which of the following is the most appropriate next step in the management of this patient?