Surgery

A 36-year-old woman is brought to the emergency department due to a 6-hour history of sudden, severe, and relentless mid-abdominal pain that radiates to her back. The pain is accompanied by several episodes of retching and non-bilious vomiting. Her medical history is significant for a laparoscopic Roux-en-Y gastric bypass procedure performed three years ago for morbid obesity. She takes no daily medications. Upon arrival, her temperature is 38.4°C (101.1°F), pulse is 128/min, and blood pressure is 88/54 mm Hg after receiving 2 liters of intravenous crystalloids. Physical examination reveals an anxious, diaphoretic patient. The abdomen is slightly distended with marked periumbilical tenderness, striking involuntary guarding, and rebound tenderness. Bowel sounds are absent. Laboratory results demonstrate a leukocyte count of 17,200/mm³ and a serum lactate level of 4.1 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old man arrives at the emergency department following a violent collision during a rugby match. Paramedics report he was struck aggressively in the mid-abdomen by another player's helmet. Upon arrival, he appears pale and lethargic. His temperature is 36.6°C (97.9°F), pulse is 135/min, respirations are 24/min, and blood pressure is 78/45 mm Hg. Pulse oximetry is 95% on room air. The airway is clear, and breath sounds are symmetric bilaterally. Abdominal examination reveals severe distension, diffuse rigidity, and rebound tenderness. A bedside focused assessment with sonography for trauma (FAST) demonstrates a large volume of anechoic fluid in the hepatorenal recess. Which of the following is the most appropriate next step in management?

Emergency medical services transport a 39-year-old unrestrained driver to the trauma bay following a high-speed collision with a concrete barrier. Upon arrival, he is unresponsive and is immediately intubated for airway protection. His heart rate is 142/min and blood pressure is 74/40 mm Hg. Physical examination shows extensive bruising across the sternum. Breath sounds are diminished on the left side. A left-sided chest tube is inserted, yielding 250 mL of gross blood. Bedside ultrasonography (FAST) demonstrates normal cardiac motion without pericardial effusion and no free fluid in the peritoneal cavity. Anteroposterior radiographs of the chest and pelvis are obtained. The pelvic film is unremarkable. The chest radiograph demonstrates a widened mediastinum, obscured aortic contour, and a left apical pleural cap. The patient's hemodynamics do not improve despite the initiation of a massive transfusion protocol. Which of the following is the most appropriate next step in the evaluation of this patient?

A $34$-year-old man is brought to the emergency department after a severe industrial fire. He sustained deep, full-thickness circumferential burns to his anterior and posterior torso, as well as his bilateral lower extremities. The total body surface area burned is estimated at $55\%$. Due to marked oropharyngeal edema and carbonaceous sputum, he was intubated at the scene. Intravenous fluid resuscitation with lactated Ringer solution was initiated based on standard weight-based formulas.

Upon arrival, his temperature is $36.7^\circ\text{C}$ ($98.1^\circ\text{F}$), blood pressure is $112/68 \text{ mm Hg}$, and heart rate is $110/\text{min}$.

Four hours later, the patient's urine output has decreased to $10 \text{ mL/hr}$. Repeat vital signs show a blood pressure of $78/48 \text{ mm Hg}$ and a heart rate of $142/\text{min}$. The mechanical ventilator frequently alarms for high airway pressures.

Current ventilator parameters and central line measurements are as follows:
- Peak inspiratory pressure: $65 \text{ cm H}_2\text{O}$
- Plateau pressure: $55 \text{ cm H}_2\text{O}$
- Central venous pressure: $18 \text{ mm Hg}$

Bedside echocardiography demonstrates a small, underfilled, and hyperdynamic left ventricle. There is no evidence of pericardial effusion. An arterial blood gas analysis reveals a pH of $7.18$, $p\text{CO}_2$ of $72 \text{ mm Hg}$, and $p\text{O}_2$ of $62 \text{ mm Hg}$.

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

A 33-year-old male is transported to the trauma bay by paramedics after sustaining a gunshot wound to the left lower quadrant of his abdomen. On arrival, he appears pale and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 82/50 mm Hg, pulse is 135/min, and respirations are 24/min. Physical examination reveals a single penetrating wound just lateral to the umbilicus. The abdomen is distended, rigid, and diffusely tender to palpation with involuntary guarding. Intravenous access is established and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

Following a severe industrial accident where he fell approximately three stories, a 51-year-old male worker is evaluated in the trauma bay. He is deeply comatose, exhibiting a Glasgow Coma Scale score of 6. Initial vitals demonstrate a blood pressure of 72/38 mm Hg, a pulse of 142/min, and a respiratory rate of 36/min. During the primary evaluation, the clinician notes tracheal deviation toward the right side and a complete lack of breath sounds on the left. Furthermore, the patient's abdomen is markedly distended with guarding on palpation, and the pelvic ring demonstrates obvious mechanical instability.

Arrange the following interventions in the most appropriate chronological sequence for this patient's acute resuscitation, in accordance with standard trauma protocols.

A 74-year-old woman is brought to the emergency department due to the sudden onset of severe, unremitting abdominal pain that began 2 hours ago. She has a medical history of hypertension, hyperlipidemia, and atrial fibrillation, but has not been taking her prescribed anticoagulant medication. On physical examination, she appears distressed and diaphoretic. Her temperature is 37.1°C, blood pressure is 118/74 mmHg, and heart rate is 112/min and irregularly irregular. Abdominal examination reveals a soft, non-distended abdomen with mild diffuse tenderness but no guarding or rebound tenderness. Bowel sounds are hypoactive. Laboratory studies show a leukocyte count of 18,500/mm³ and a serum lactate of 3.8 mmol/L. Arrange the following management steps in the most appropriate sequential order for this patient.

On his sixth day of recovery following an open appendectomy for perforated appendicitis, a 65-year-old man reports progressive abdominal bloating and bilious vomiting. He has not passed flatus or stool for the past 48 hours. Vital signs show a heart rate of 110/min and blood pressure of 115/75 mmHg. Physical examination reveals a markedly distended, tympanitic abdomen with high-pitched 'tinkling' bowel sounds. There is diffuse mild tenderness but no rebound or guarding. Arrange the following management steps in the most appropriate chronological sequence for this patient's condition, progressing from initial intervention to definitive management.

A 60-year-old woman is evaluated on postoperative day 6 following a robotic-assisted total hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. Her recovery had been uncomplicated until this morning, when she developed a mild fever and sudden-onset shortness of breath. Her temperature is 38.2°C (100.8°F), blood pressure is 110/70 mm Hg, pulse is 112/min, and respirations are 24/min. Pulse oximetry shows an oxygen saturation of 92% on room air. Physical examination reveals clear breath sounds bilaterally. The abdominal surgical incisions are clean, dry, and intact with no surrounding erythema. Her right calf appears mildly swollen and is tender to palpation compared to the left. Which of the following are the most appropriate next steps in the management of this patient? (Select two)

A 38-year-old female is brought to the emergency department after a snowmobile collision in which she struck a tree at high speed. On arrival, she is lethargic and pale. Her temperature is 36.1°C (97.0°F), blood pressure is 74/42 mmHg, heart rate is 136/min, and respiratory rate is 24/min. Oxygen saturation is 96% on a non-rebreather mask. Two large-bore intravenous lines are established, and she receives 1 L of warmed lactated Ringer solution and 1 unit of uncrossmatched type O-negative packed red blood cells. Reassessment reveals a blood pressure of 76/40 mmHg and a heart rate of 132/min. Primary survey shows a patent airway and equal breath sounds bilaterally. A portable chest radiograph demonstrates a widened mediastinum and blurring of the aortic knob but no pneumothorax or hemothorax. A focused assessment with sonography for trauma (FAST) examination reveals a large amount of anechoic fluid in the hepatorenal recess (Morison pouch). An anteroposterior pelvic radiograph shows an intact pelvic ring with no fractures. Which of the following is the most appropriate next step in management?

A 72-year-old man is evaluated on postoperative day 4 following an elective right hemicolectomy for colon cancer. He has a history of chronic obstructive pulmonary disease (COPD). Yesterday, he developed a fever of 38.6°C (101.5°F). At that time, blood, urine, and sputum cultures were obtained, and empiric intravenous piperacillin-tazobactam was initiated. Today, his temperature is 38.2°C (100.8°F), blood pressure is 120/78 mmHg, and heart rate is 88/min. Lung auscultation reveals mild expiratory wheezing consistent with his baseline COPD, but no crackles or signs of respiratory distress. His surgical incision is clean, dry, and intact with no erythema. The indwelling urinary catheter, placed just before surgery, is still present. Urine culture results have just returned, showing greater than $10^5$ CFU/mL of Escherichia coli. The isolate is susceptible to ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole, but resistant to ampicillin. Blood and sputum cultures show no growth so far. Which of the following are appropriate next steps in the management of this patient? (Select all that apply.)

A 34-year-old woman is evaluated on the surgical ward 30 hours after undergoing an elective laparoscopic myomectomy for symptomatic uterine fibroids. The nursing staff notifies the physician because the patient's temperature has increased to 38.4°C (101.1°F). She is resting comfortably in bed and reports mild soreness at the surgical port sites. Her blood pressure is 118/76 mm Hg, pulse is 82/min, and respirations are 16/min. Pulse oximetry shows 98% on room air. Physical examination reveals clear lungs bilaterally, normal active bowel sounds, and non-erythematous incisions without any discharge or induration. Which of the following are the most appropriate next steps in managing this patient? (Select exactly 2 options)

A 24-year-old male is brought to the emergency department via ambulance following a high-speed motorcycle collision. He was found approximately 30 feet from his motorcycle. On arrival, he is moaning but not following commands. His blood pressure is 80/40 mmHg, and his heart rate is 132/min. Arrange the following steps of his initial trauma evaluation and management in the most appropriate chronological order.

A 35-year-old woman presents to the clinic after noticing a lump in her neck while applying lotion. She denies weight changes, palpitations, heat or cold intolerance, or changes in bowel habits. She has no family history of thyroid disease or head and neck irradiation. Vital signs are within normal limits. Physical examination reveals a 1.5-cm, firm, mobile nodule in the left lobe of the thyroid gland. There is no cervical lymphadenopathy. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 2.8 µU/mL (normal: 0.4–4.0 µU/mL) and a free T4 of 1.2 ng/dL (normal: 0.9–2.4 ng/dL). An ultrasound of the neck demonstrates a 1.6-cm solid, hypoechoic nodule with irregular margins and microcalcifications in the left thyroid lobe. Which of the following is the most appropriate next step in management?

A 72-year-old woman is brought to the emergency department due to severe, worsening abdominal pain, nausea, and bilious vomiting for the past 2 days. She has not had a bowel movement or passed flatus for 48 hours. Her medical history is significant for an open total abdominal hysterectomy 15 years ago. Her temperature is 38.6°C (101.5°F), pulse is 118/min, respirations are 22/min, and blood pressure is 96/60 mm Hg. Physical examination reveals a distended abdomen with absent bowel sounds. There is severe, diffuse abdominal tenderness with guarding and rebound tenderness. Laboratory studies show:

Leukocyte count: 18,500/mm³
Lactate: 4.2 mmol/L
Bicarbonate: 14 mEq/L

An upright abdominal radiograph reveals multiple dilated loops of small bowel with air-fluid levels and a paucity of gas in the colon. No pneumoperitoneum is observed. Which of the following is the most appropriate next step in the management of this patient?

A neurosurgical team is evaluating several patients with elevated intracranial pressure and deteriorating neurologic status following severe traumatic brain injury. Match each specific brain herniation syndrome with its corresponding characteristic neuroimaging findings and clinical signs.

An emergency medical crew brings a 61-year-old woman to the hospital after she developed severe left flank pain, nausea, and acute confusion over the past 48 hours. Her medical history is notable for type 2 diabetes mellitus and recurrent cystitis. Vital signs include a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of $84/52 \text{ mmHg}$, pulse of $122/\text{min}$, and respirations of $24/\text{min}$. Physical examination reveals marked left costovertebral angle tenderness and a lethargic affect. Laboratory testing demonstrates a leukocyte count of $22,000/\text{mm}^3$. An unenhanced computed tomography (CT) scan of the abdomen and pelvis reveals a $9\text{-mm}$ calculus lodged in the left proximal ureter, accompanied by severe hydroureteronephrosis and perinephric fat stranding. She is immediately given aggressive intravenous fluid resuscitation and broad-spectrum antibiotics (piperacillin-tazobactam). Two hours later, her blood pressure remains $86/54 \text{ mmHg}$ and her urine output is only $10 \text{ mL/hr}$. Which of the following is the most appropriate next step in management?

Nine days after undergoing an open right partial nephrectomy for localized renal cell carcinoma, a 58-year-old man is assessed by the surgical team prior to planned discharge. His postoperative course was notable for a urinary tract infection diagnosed on postoperative day 2, which was effectively treated with oral trimethoprim-sulfamethoxazole based on susceptibility testing. Today, the patient reports that he feels completely well, has a robust appetite, and is eager to return home. However, his vital signs show a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of $128/82\text{ mm Hg}$, pulse of $82\text{/min}$, and respirations of $14\text{/min}$. Oxygen saturation is $98\%$ on room air. Physical examination reveals a clean, well-approximated flank incision with no erythema, induration, or drainage. The lungs are clear to auscultation bilaterally. There is no costovertebral angle tenderness. The lower extremities show no edema or calf tenderness.

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

A 52-year-old man is evaluated in the surgical ward on postoperative day 6 following an open ventral hernia repair. He complains of worsening pain at the surgical site and feeling warm since this morning. His temperature is 38.9°C (102.0°F), heart rate is 104/min, blood pressure is 130/85 mm Hg, and respiratory rate is 16/min. Physical examination of the abdomen reveals a localized 5-cm area of marked erythema, induration, and tenderness surrounding the lower half of the surgical incision. There is visible spontaneous drainage of thick, yellowish fluid from the wound edges. The patient's lungs are clear to auscultation bilaterally, and his calves are soft and non-tender. Which of the following are the most appropriate initial steps in the management of this patient?

A $62$-year-old man is evaluated in the surgical intensive care unit for sudden clinical deterioration. Three days ago, he was admitted with septic shock secondary to an obstructing $12$-mm proximal left ureteral calculus. A left percutaneous nephrostomy tube was placed for urgent decompression, and empiric intravenous piperacillin-tazobactam was initiated. The patient initially stabilized and his leukocytosis improved. However, over the past $2$ hours, the nephrostomy tube has stopped draining, and the patient has become confused and diaphoretic. His temperature is $39.4^\circ C$ ($102.9^\circ F$), blood pressure is $78/45$ mmHg, and pulse is $132$/min. Physical examination reveals a new, exquisitely tender and fluctuant swelling in the left flank. Blood and urine cultures from admission are currently growing *Escherichia coli* that is susceptible to ceftriaxone, trimethoprim-sulfamethoxazole, and ciprofloxacin. Which of the following is the most appropriate next step in the management of this patient?