Surgery

A 52-year-old man is assessed on the surgical ward for an elevated temperature 24 hours after undergoing an elective open left hemicolectomy for recurrent, medically refractory diverticulitis. The patient reports expected, mild incisional pain and a dry throat from the endotracheal tube, but he specifically denies chills, chest pain, shortness of breath, dysuria, or productive cough. His medical history includes hypertension and hyperlipidemia. His temperature is 38.5°C (101.3°F), pulse is 94/min, respirations are 15/min, and blood pressure is 128/82 mmHg. Oxygen saturation is 98% on ambient air. The lungs are clear to auscultation bilaterally. Cardiac examination shows a regular rate and rhythm. The abdomen is soft but appropriately tender around the midline surgical incision. The surgical dressing is clean, dry, and intact with no surrounding erythema or drainage. A urinary catheter, placed preoperatively, is in place and draining clear, light-yellow urine. The lower extremities show no edema or calf tenderness. Which of the following is the most appropriate next step in management?

A 65-year-old man is evaluated for severe, worsening abdominal pain and persistent bilious emesis. He is currently on postoperative day 6 following a robotic-assisted prostatectomy for localized prostate cancer. The patient reports passing no flatus or stool for the past 24 hours. His temperature is 38.6°C (101.5°F), pulse is 118/min, and blood pressure is 98/60 mmHg. Physical examination reveals a markedly distended and tympanic abdomen. There is significant periumbilical tenderness with involuntary guarding and rebound tenderness. Bowel sounds are absent. Laboratory studies demonstrate a leukocyte count of 18,500/mm³ and a serum lactate level of 4.1 mmol/L. A portable abdominal radiograph shows multiple dilated loops of small intestine with prominent air-fluid levels and a complete absence of colonic gas. Which of the following is the most appropriate next step in patient management?

A 42-year-old woman is evaluated in the post-anesthesia care unit 90 minutes after undergoing an uncomplicated total thyroidectomy for a large multinodular goiter. The nurse urgently requests an evaluation because the patient has developed acute-onset stridor, agitation, and severe shortness of breath. On physical examination, her blood pressure is 145/85 mm Hg, pulse is 112/min, and oxygen saturation is 86% on room air. There is a tense, rapidly expanding, firm swelling directly beneath the cervical incision. Arrange the following management steps for this patient in the most appropriate chronological order.

A $33$-year-old construction worker is brought to the emergency department after a $20$-foot fall from a scaffold. On arrival, he is lethargic and diaphoretic. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $78/45\text{ mm Hg}$, and pulse is $132\text{/min}$. Oxygen saturation is $96\%$ on room air. Primary survey reveals a patent airway and bilaterally equal breath sounds. The abdomen is soft, non-distended, and without guarding. Inspection of the pelvis shows a scrotal hematoma and blood at the urethral meatus. Gentle lateral compression of the iliac crests elicits crepitus and abnormal mobility. A bedside focused assessment with sonography for trauma (FAST) shows no free fluid in the peritoneal cavity or pericardial sac. An anteroposterior pelvic radiograph reveals a $4.5\text{-cm}$ pubic symphysis diastasis and widening of the left sacroiliac joint. Intravenous access is established, and aggressive crystalloid resuscitation is initiated. Which of the following is the most appropriate next step in management?

A 62-year-old woman presents to the emergency department with a 4-day history of progressively worsening left lower quadrant abdominal pain, fever, and chills. Her temperature is 38.9°C (102.0°F), blood pressure is 105/65 mm Hg, and pulse is 112/min. Physical examination reveals focal tenderness, erythema, and localized guarding in the left lower quadrant, but no diffuse abdominal rigidity. Bowel sounds are hypoactive. Laboratory studies show a leukocyte count of 17,500/mm³. Arrange the following management steps in the most appropriate chronological order for this patient.

A 29-year-old man arrives at the trauma center via ambulance following an altercation where he sustained a stab wound to the periumbilical region. En route, he received $1$ L of intravenous crystalloid. Upon arrival, he appears pale and confused. Vital signs show a temperature of $36.6^\circ\text{C}$ ($97.9^\circ\text{F}$), blood pressure of $78/45\text{ mm Hg}$, heart rate of $138\text{/min}$, and respiratory rate of $28\text{/min}$. The airway is clear, and bilateral breath sounds are normal. Examination of the abdomen reveals a $4$-cm transverse laceration $2\text{ cm}$ to the left of the umbilicus. The abdomen is rigid with severe diffuse tenderness and rebound. Intravenous access is secured with two large-bore peripheral catheters, and uncrossmatched blood transfusions are initiated. Which of the following is the most appropriate next step in management?

A surgical consult is requested for a 67-year-old woman who has been hospitalized for the past 3 days due to an acute exacerbation of chronic obstructive pulmonary disease. Since yesterday evening, she has been experiencing worsening, diffuse abdominal cramps and has had three episodes of bilious vomiting. Her last bowel movement was 48 hours ago, and she reports an inability to pass flatus. Her past medical history is significant for an open appendectomy in her twenties and a total abdominal hysterectomy a decade ago. Vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 90/56 mmHg, and a heart rate of 122 beats/minute. On physical examination, her abdomen is distended, tympanitic, and diffusely tender. There is marked guarding and rebound tenderness in all four quadrants. Laboratory studies reveal a leukocyte count of 18,500/mm³ with a 15% bandemia, and a serum lactate level of 4.2 mmol/L. An upright abdominal radiograph displays multiple dilated loops of small intestine with prominent air-fluid levels, and no air is seen in the colon or rectum. Which of the following is the most appropriate next step in the management of this patient?

An emergency medical crew transports a 35-year-old female equestrian to the trauma bay after she was violently thrown from her horse and trampled. She arrives fully immobilized on a backboard with a cervical collar. Her airway is patent and self-maintained. Initial vital signs demonstrate a heart rate of 142/min, blood pressure of 72/38 mm Hg, and a respiratory rate of 26/min. Both lungs are clear to auscultation bilaterally, and heart sounds are crisp and normal. There is extensive ecchymosis across her anterior chest wall and lower abdomen. Pelvic compression elicits no crepitus or mechanical instability. A portable supine anteroposterior chest radiograph reveals a widened mediastinal silhouette and deviation of the trachea to the right, with no evidence of hemothorax or pneumothorax. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal space (Morison pouch) and the rectouterine pouch. Which of the following is the most appropriate next step in the management of this patient?

An emergency medical team is evaluating a 58-year-old male who developed excruciating, unremitting abdominal pain 6 hours ago. He reports no bowel movements or flatus for the past 48 hours. Ten years ago, he underwent an open appendectomy. His temperature is 38.6°C (101.5°F), blood pressure is 94/60 mmHg, pulse is 118/min, and respiratory rate is 22/min. On physical examination, the abdomen is markedly distended and tympanitic. Palpation elicits diffuse tenderness, which is most prominent in the periumbilical region, accompanied by involuntary guarding and rebound tenderness. Auscultation reveals absent bowel sounds. Laboratory analysis demonstrates a leukocyte count of 18,500/mm³ with 15% bands and a serum lactate level of 4.8 mmol/L. An upright abdominal radiograph displays multiple dilated loops of small intestine with air-fluid levels, and no free air under the diaphragm. Which of the following is the most appropriate next step in management?

A $45$-year-old man is brought to the burn center via helicopter after an industrial explosion. The incident occurred exactly $3$ hours prior to his arrival. He weighs $100$ kg. Physical examination reveals deep partial-thickness burns over his entire anterior trunk, entire right arm, and entire left arm. His airway is secure, and he is hemodynamically stable. Two large-bore intravenous lines are placed. Based on current Advanced Trauma Life Support (ATLS) guidelines (using $2 \text{ mL/kg} \times \%\text{TBSA}$ for adult thermal burns), at what rate (in $\text{mL/hr}$) should the intravenous lactated Ringer's solution be administered for the remainder of the first $8$-hour post-injury period?

A 65-year-old man is evaluated in the surgical unit for rapidly escalating abdominal pain on postoperative day 2 following an open umbilical hernia repair with mesh. His medical history includes obesity and poorly controlled type 2 diabetes mellitus. His temperature is 39.2°C (102.6°F), blood pressure is 86/50 mmHg, heart rate is 122/min, and respiratory rate is 24/min. He appears diaphoretic, anxious, and lethargic. Physical examination reveals an abdomen that is exquisitely tender out of proportion to the visible surface findings. The skin surrounding the surgical incision is erythematous, markedly edematous, and indurated. Palpation of the periwound area elicits a faint crackling sensation in the subcutaneous tissue. Removal of the surgical dressing reveals a small amount of cloudy, grayish exudate seeping from the wound edges. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's post-operative clinical presentation following gastric or bariatric surgery with the most likely diagnosis.

An 81-year-old male resident of a skilled nursing facility is assessed on postoperative day $2$ after undergoing an open cholecystectomy for acute gangrenous cholecystitis. The patient has become increasingly short of breath over the last $4$ hours. His medical history is significant for chronic obstructive pulmonary disease, hypertension, and ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$. The operative report notes that he received $4.5$ liters of crystalloid resuscitation due to transient intraoperative hypotension. His temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure is $152/90$ mmHg, pulse is $114/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry shows $88\%$ on room air. Physical examination reveals jugular venous distention to $11 \text{ cm } H_2O$. Cardiac auscultation reveals a regular tachycardia and a prominent S3 gallop. Pulmonary examination demonstrates bibasilar crackles extending to the mid-lung fields without wheezing. The surgical incision is clean, dry, and intact. Which of the following is the most appropriate next step in management?

A 26-year-old man weighing 90 kg is brought to the emergency department 2 hours after being rescued from a house fire. On primary survey, his airway is patent, and he is breathing spontaneously on supplemental oxygen without evidence of inhalation injury. Vital signs include a blood pressure of 110/70 mm Hg, heart rate of 115/min, and respiratory rate of 18/min. Physical examination reveals deep partial-thickness burns with blistering over his entire anterior trunk, entire left arm, and the anterior surface of his left leg. The skin on his face is erythematous and highly sensitive to touch, but no blisters are present. Two large-bore intravenous catheters were placed at the scene, but no intravenous fluids have been administered yet.

Based on current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns, what is the appropriate targeted intravenous fluid administration rate (in mL/hour) for the remainder of the first 8-hour period following the burn?

During morning rounds, a 74-year-old male patient is assessed for mild respiratory distress and a low-grade fever. He underwent a primary right total hip arthroplasty 48 hours ago. The patient has a medical history significant for hypertension, diet-controlled type 2 diabetes mellitus, and mild chronic obstructive pulmonary disease. He reports a new, mild cough producing scant white sputum, but denies chest pain, calf pain, or dysuria.

His temperature is 38.2°C (100.8°F), blood pressure is 146/84 mmHg, pulse is 94/min, and respiratory rate is 20/min. Pulse oximetry shows 93% on room air. Cardiac auscultation is unremarkable with no murmurs or gallops. Pulmonary examination reveals decreased breath sounds and fine crackles at both lung bases. The surgical incision is intact without drainage, and there is no lower extremity edema. A portable chest radiograph displays bilateral basilar linear opacities consistent with subsegmental atelectasis, without any focal consolidation or pleural effusion.

Which of the following are the most appropriate initial steps in the management of this patient? (Select 2)

During the evening shift, a physician is called to review the status of a $45$-year-old female admitted two days ago with a partial small bowel obstruction following a recent laparoscopic hysterectomy. Her initial management included intravenous fluids and continuous nasogastric suction. Recently, she reports a rapid exacerbation of her abdominal pain, which has become unremitting and localized. Vital signs indicate a temperature of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure of $85/50 \text{ mmHg}$, heart rate of $130/\text{min}$, and respiratory rate of $28/\text{min}$. Physical examination reveals a markedly distended abdomen with diffuse rigidity and severe rebound tenderness. Recent laboratory analysis displays a leukocyte count of $21,000/\text{mm}^3$ and a serum lactate of $6.2 \text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

A 52-year-old man presents to the emergency department with a 48-hour history of severe, colicky abdominal pain accompanied by nausea and multiple episodes of bilious vomiting. He reports no passage of flatus or stool for the past 24 hours. His surgical history is significant for an open appendectomy performed 15 years ago. On initial evaluation, his temperature is 37.1°C (98.8°F), heart rate is 88/min, blood pressure is 130/80 mm Hg, and respiratory rate is 16/min. The abdomen is markedly distended and tympanic, with high-pitched, tinkling bowel sounds and mild diffuse tenderness, but no rebound tenderness or guarding.

Arrange the following interventions in the correct sequential order for the management of this patient, from initial presentation to ultimate definitive care.

Determine the most appropriate immediate surgical or procedural intervention for each of the following critically injured trauma patients.

A 59-year-old man presents to the emergency department with a two-day history of fever, left-sided chest pain, and persistent hiccups. Ten days ago, he underwent an emergent laparotomy with splenectomy following a motor vehicle collision. His temperature is 39.1°C (102.4°F), blood pressure is 118/76 mmHg, pulse is 112/min, and respirations are 22/min. Pulse oximetry shows 94% on room air. Physical examination reveals decreased breath sounds at the left lung base. The abdomen is soft but tender to deep palpation in the left upper quadrant. The surgical incision is well-healed without erythema or discharge. Laboratory studies show a leukocyte count of 18,500/mm³. A chest radiograph demonstrates a left-sided pleural effusion with basilar atelectasis. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation with the most appropriate definitive management or next step in intervention.