Surgery

A 55-year-old woman arrives at the emergency department reporting a two-day history of progressively worsening, crampy periumbilical pain accompanied by bilious vomiting. She reports an inability to pass flatus or stool for the past 18 hours. Her past medical history is notable for a total abdominal hysterectomy performed eight years ago. Current vital signs are temperature $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure $92/58\text{ mm Hg}$, heart rate $115\text{/min}$, and respiratory rate $20\text{/min}$. Physical examination reveals a significantly distended abdomen with high-pitched bowel sounds. There is marked focal tenderness with voluntary guarding and rebound localized to the left lower quadrant. Laboratory evaluation shows a leukocyte count of $16,800/\mu\text{L}$ and a serum lactate level of $4.1\text{ mmol/L}$. Upright abdominal plain films demonstrate multiple dilated small intestinal loops with prominent air-fluid levels and a paucity of colonic gas. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old woman is evaluated in the post-anesthesia care unit 3 hours after undergoing a total thyroidectomy for a multinodular goiter. The nurse calls for assistance because the patient has developed sudden, progressive difficulty breathing. On physical examination, the patient is agitated and diaphoretic. Her blood pressure is 145/90 mm Hg, pulse is 115/min, and respiratory rate is 26/min. Oxygen saturation is 88% on room air. High-pitched inspiratory stridor is audible. The anterior neck reveals a tense, rapidly expanding, firm swelling beneath the surgical incision. Arrange the following steps in the most appropriate chronological order for managing this patient's condition.

Following a high-speed collision with a commercial vehicle, a 29-year-old male cyclist is evaluated in the emergency department. He reports severe pain on the left side of his chest and abdomen. Vital signs show a blood pressure of 82/48 mm Hg, a heart rate of 132/min, and a respiratory rate of 24/min. Oxygen saturation is 98% on supplemental oxygen. The airway is secure, and the trachea is midline. Auscultation reveals clear and equal breath sounds bilaterally. There is a prominent transverse contusion across the left upper quadrant of the abdomen, consistent with a handlebar impact. The abdomen is tender to deep palpation in this region, but there is no involuntary guarding or rebound tenderness. The pelvis is mechanically stable to compression. Intravenous access is established, and a bolus of warmed isotonic crystalloid is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 61-year-old woman is seen on the surgical ward due to a new-onset fever. She is currently on postoperative day 4 following an elective open total abdominal hysterectomy and bilateral salpingo-oophorectomy for complex atypical endometrial hyperplasia. The nursing staff notes that her temperature spiked to 38.8°C (101.8°F) two hours ago. The patient reports experiencing generalized fatigue, urinary urgency, and mild suprapubic discomfort, but she denies having a cough, dyspnea, or calf pain. Her indwelling urinary catheter, placed during the surgery, was removed 48 hours ago. Her temperature is 38.8°C (101.8°F), blood pressure is 126/82 mm Hg, pulse is 98/min, and respirations are 16/min. Pulse oximetry is 98% on room air. Physical examination reveals clear lung fields bilaterally. The abdomen is soft, with mild tenderness noted in the suprapubic region but no rebound or guarding. The surgical midline incision is well-approximated with intact staples; there is a 2-mm margin of light erythema along the wound edges, but no fluctuance, induration, or purulent exudate is present. Bilateral lower extremities show no edema or tenderness. Which of the following is the most appropriate next step in the management of this patient?

During morning rounds in the surgical intensive care unit, a physician evaluates a $53$-year-old man. The patient underwent an open sigmoid colectomy for complicated diverticulitis $5$ days ago. Over the past $24$ hours, he has not passed flatus or stool and has developed worsening abdominal bloating. Overnight, his clinical status declined significantly, and he now reports severe, unremitting, generalized abdominal pain. His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $82/50 \text{ mm Hg}$, pulse is $128 \text{ beats/min}$, and respirations are $24 \text{ breaths/min}$. Physical examination of the abdomen demonstrates marked distension, diffuse rigidity, and involuntary guarding. A nasogastric tube placed previously is draining dark, foul-smelling material. Laboratory evaluation is significant for a leukocyte count of $19,500/\text{mm}^3$ and a serum lactate level of $6.2 \text{ mmol/L}$. Bedside plain abdominal radiography shows multiple dilated small bowel loops with prominent air-fluid levels and no pneumoperitoneum. Which of the following is the most appropriate next step in the management of this patient?

A 30-year-old woman, gravida 2, para 1, at 33 weeks gestation, is brought to the emergency department via ambulance after her vehicle struck a concrete barrier at highway speeds. Upon arrival, she is lethargic, pale, and diaphoretic. She localizes to painful stimuli and moans incomprehensibly. Her temperature is 36.4°C (97.5°F), blood pressure is 76/40 mmHg, heart rate is 135/min, and respiratory rate is 26/min. Physical examination reveals a seatbelt sign across her lower abdomen. The abdomen is distended and exhibits diffuse rebound tenderness. A focused assessment with sonography for trauma (FAST) demonstrates significant free fluid in the hepatorenal and splenorenal recesses. Continuous fetal monitoring shows a baseline heart rate of 100/min with minimal variability. Which of the following is the most appropriate next step in management?

An $18$-year-old male is brought to the emergency department $30$ minutes after falling from a $15$-foot scaffolding. He is groggy and responsive only to painful stimuli. Vital signs show a temperature of $36.5^\circ$ C, a heart rate of $142$/min, a blood pressure of $78/45$ mmHg, and a respiratory rate of $24$/min. An intravenous line is established, and $1$ L of warm crystalloid fluid is rapidly administered. Following resuscitation, his blood pressure remains $82/50$ mmHg. Primary survey reveals equal breath sounds bilaterally and a stable pelvis. There is extensive bruising over the left upper quadrant of the abdomen. Point-of-care abdominal ultrasonography reveals a significant amount of anechoic fluid in the hepatorenal and splenorenal spaces. Which of the following is the most appropriate next step in management?

A 74-year-old man is assessed on the surgical ward 48 hours after undergoing an uncomplicated right hemicolectomy for adenocarcinoma. His past medical history is significant for chronic obstructive pulmonary disease and ischemic cardiomyopathy. Since the operation, he has been receiving continuous intravenous lactated Ringer's at 125 mL/hr. Current vital signs show a temperature of 38.1°C (100.6°F), heart rate of 105/min, blood pressure of 142/86 mmHg, and a respiratory rate of 24/min. Pulse oximetry reveals an oxygen saturation of 91% on room air. Physical examination demonstrates distended neck veins up to 9 cm H2O and scattered fine crackles at the bases of both lungs. There is no wheezing or rhonchi. The surgical incision is clean, dry, and intact without surrounding erythema. Which of the following are appropriate management steps for this patient? (Select exactly two options)

Match each clinical presentation following severe thoracic trauma to its most likely diagnosis.

For each patient presentation described in the surgical emergency and critical care setting below, select the most appropriate primary intervention from the available list.

A 64-year-old man presents to the emergency department with a 4-day history of worsening left lower quadrant abdominal pain, fever, and chills. His temperature is 38.6°C (101.5°F), blood pressure is 128/82 mmHg, and pulse is 98/min. Physical examination demonstrates a tender, palpable mass in the left lower quadrant. There is no diffuse rigidity or rebound tenderness. Laboratory tests show a leukocyte count of $17,500/\text{mm}^3$. Arrange the following management steps in the most appropriate chronological sequence for this patient's condition.

Sixteen hours after undergoing a scheduled laparoscopic cholecystectomy for symptomatic cholelithiasis, a 34-year-old female patient is evaluated due to an elevated temperature. Her vitals indicate a core body temperature of 38.5°C (101.3°F), a blood pressure of 118/76 mmHg, a heart rate of 88/min, and a respiratory rate of 16/min. Pulse oximetry demonstrates 98% oxygen saturation on ambient air. The patient reports mild discomfort around the umbilical port site, for which she is receiving oral acetaminophen. She is tolerating a clear liquid diet and has ambulated to the bathroom independently. Physical examination demonstrates an abdomen that is soft and non-tender, with dry, intact surgical incisions. Cardiopulmonary auscultation reveals clear breath sounds bilaterally without crackles or wheezes, and regular heart sounds. There is no calf swelling or tenderness. Which of the following is the most appropriate next step in the management of this patient?

Review the clinical scenarios described below. Match each clinical presentation of a gastrointestinal or abdominal pathology with its most appropriate primary surgical or procedural intervention.

A 68-year-old male is evaluated on postoperative day 6 following an emergent exploratory laparotomy and bowel resection for perforated diverticulitis. He has a history of poorly controlled diabetes mellitus and chronic obstructive pulmonary disease. While coughing forcefully, he feels a sudden "giving way" sensation in his abdomen. The nurse reports a large amount of salmon-colored fluid draining from the surgical site. Physical examination reveals a separation of the midline fascial closure with a segment of small intestine protruding through the defect. His blood pressure is 130/80 mm Hg and pulse is 95/min. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 24-year-old male is brought to the emergency department by helicopter after colliding with a tree while skiing at high speed. On arrival, his blood pressure is $76/40$ mmHg, heart rate is $138$/min, and respiratory rate is $26$/min. The patient is confused, pale, and diaphoretic. The trachea is midline, and breath sounds are equal bilaterally without chest wall crepitus. The abdomen is distended with diffuse tenderness and involuntary guarding. The pelvis is mechanically stable to gentle anteroposterior and lateral compression. Bilateral large-bore peripheral intravenous lines are placed, and resuscitation with type O negative packed red blood cells is initiated. A bedside Focused Assessment with Sonography for Trauma (FAST) reveals a large anechoic collection in the splenorenal recess and the rectovesical pouch. Which of the following is the most appropriate next step in management?

An orthopedic surgery team is consulted regarding a post-operative complication in an 82-year-old male patient. The patient underwent an uncomplicated left hemiarthroplasty three days ago following a femoral neck fracture. His past medical history is significant for Parkinson disease, essential hypertension, and chronic kidney disease. Over the last 24 hours, the nursing staff reports that he has developed progressive, marked abdominal swelling and has not passed any flatus or stool. He complains of mild, generalized abdominal discomfort and nausea but has not vomited. His current pain management regimen includes scheduled acetaminophen and as-needed intravenous hydromorphone.

His temperature is 37.1°C (98.8°F), pulse is 92/min, blood pressure is 135/85 mm Hg, and respiratory rate is 16/min. Physical examination reveals a profoundly distended and tympanitic abdomen. Bowel sounds are diminished. There is mild, diffuse palpation tenderness, but no guarding, rigidity, or rebound tenderness is elicited. An upright plain radiograph of the abdomen demonstrates marked gaseous distension of the ascending colon and cecum, with the cecal diameter measuring 10.5 cm. The distal colon contains scattered air, and there is no evidence of pneumoperitoneum.

Which of the following represents the most appropriate initial intervention for this patient's current gastrointestinal presentation?

A 32-year-old male is brought to the emergency department after being rescued from a structure fire. He sustained deep partial-thickness and full-thickness thermal burns involving his entire anterior chest and abdomen, his entire right lower extremity, and his entire right upper extremity. The patient currently weighs $80\text{ kg}$. The injury occurred exactly $2\text{ hours}$ prior to his arrival at the emergency department. Two large-bore peripheral intravenous lines are placed. Following current Advanced Trauma Life Support (ATLS) guidelines for adult thermal burns (which recommend $2\text{ mL/kg/\%TBSA}$), what should be the initial continuous intravenous infusion rate of lactated Ringer solution in $\text{mL/hr}$?

A 64-year-old woman is evaluated on postoperative day 6 following an open partial gastrectomy for a refractory peptic ulcer. She complains of increasing pain at her surgical incision site and feeling feverish since yesterday. Her medical history includes type 2 diabetes mellitus and hypertension. Her temperature is 38.5°C (101.3°F), blood pressure is 135/85 mmHg, pulse is 98/min, and respiratory rate is 18/min. Oxygen saturation is 96% on room air. Lung auscultation reveals mild, scattered bibasilar crackles that clear with coughing. Cardiac examination is unremarkable. The abdomen is soft and non-distended, with normal active bowel sounds. Examination of the midline surgical incision reveals a 5-cm area at the inferior aspect that is exquisitely tender, erythematous, indurated, and fluctuant. There is no spontaneous drainage. Which of the following is the most appropriate next step in management?

A 19-year-old female university student is rushed to the trauma center by helicopter after a high-speed collision while riding an electric scooter. She was not wearing a helmet and struck a concrete barrier. Upon arrival, her airway is clear, and breath sounds are present bilaterally. Vital signs show a blood pressure of 72/40 mm Hg, a heart rate of 144/min, and a respiratory rate of 22/min. Her abdomen is bruised across the lower quadrants, distended, and rigid to palpation. Bedside ultrasonography (FAST) demonstrates a significant accumulation of anechoic fluid in the hepatorenal recess and the rectouterine pouch. A pelvic binder is placed by emergency medical services, and a portable chest radiograph is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of blunt pelvic and genitourinary trauma with the most appropriate next step in management or diagnosis.