Surgery

During the overnight shift in the intensive care unit, a nurse urgently pages the surgical resident to evaluate a patient admitted earlier that evening. The patient, a 59-year-old male with a history of poorly controlled essential hypertension, was recently diagnosed with an acute descending thoracic aortic dissection. Initial management with an esmolol infusion successfully reduced his blood pressure to 112/74 mmHg and heart rate to 62/min.

Upon arrival at the bedside, the resident finds the patient writhing in agony, complaining of severe, diffuse abdominal pain that began abruptly 30 minutes ago. Physical examination reveals a soft, non-distended abdomen with vague, mild tenderness to deep palpation and absent peritoneal signs. Bowel sounds are hypoactive. The lower extremities are warm with symmetric, easily palpable pedal pulses. Laboratory studies drawn stat reveal a serum lactate level of 6.3 mmol/L and a leukocyte count of 18,500/mm³.

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

A 47-year-old man is reassessed by the surgical team 18 hours after admission for abdominal distension, obstipation, and bilious emesis. He has a history of an open appendectomy for perforated appendicitis three weeks ago. Upon admission, abdominal radiography revealed dilated small bowel loops with multiple air-fluid levels, and he was managed with intravenous hydration and placement of a nasogastric tube. He now reports that his abdominal pain, which was previously intermittent and cramping, has become a continuous, severe ache over the past three hours. Vital signs show a temperature of 38.1°C (100.6°F), blood pressure of 115/75 mmHg, and heart rate of 114/min. Physical examination demonstrates a distended abdomen with localized guarding and focal tenderness in the left lower quadrant. Laboratory studies show a leukocyte count of 14,800/mm³ and a serum bicarbonate level of 16 mEq/L, compared to 9,500/mm³ and 24 mEq/L on admission, respectively. Which of the following is the most appropriate next step in the management of this patient?

Match the following specific clinical presentations and physical exam findings with their most likely cardiothoracic or vascular surgical diagnosis.

A 74-year-old female is transported to the acute care unit from a skilled nursing facility after staff noted her vomiting dark, foul-smelling fluid for the last day. The patient has advanced Alzheimer disease and cannot provide a meaningful history. Her past medical records indicate no prior intra-abdominal procedures. Vital signs show a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse of $118$/min, and blood pressure of $92/54$ mmHg. Abdominal assessment demonstrates marked distension with generalized tenderness to palpation. A prominent, firm, $4$-cm swelling is identified in the right groin, situated medial to the femoral vein and inferior to the inguinal ligament. The skin over this area appears dusky and is warm to the touch. Complete blood count reveals a leukocyte level of $19,200$/mm $^3$ with a left shift. Serum lactate is $4.8$ mmol/L. Supine and upright plain films reveal centrally located, dilated loops of small intestine with prominent air-fluid levels and absent gas in the rectum. Which of the following is the most appropriate next step in management?

A 58-year-old man is evaluated on postoperative day 1 following an elective open right hemicolectomy for early-stage colon cancer. He reports mild to moderate pain at the surgical site, which is adequately controlled with intravenous analgesics. His temperature is 38.3°C (101°F), blood pressure is 128/78 mmHg, pulse is 88/min, and respirations are 16/min. Pulse oximetry shows 95% on room air. Physical examination reveals decreased breath sounds at both lung bases. The surgical incision is clean, dry, and intact with no erythema or induration. The urinary catheter was removed earlier today, and he has voided spontaneously. Which of the following is the most appropriate next step in management?

A 68-year-old man is evaluated in the surgical intensive care unit due to sudden clinical deterioration. He is currently on postoperative day 1 following an emergent open repair of a ruptured abdominal aortic aneurysm. During the surgery, he experienced significant hemorrhage and received 10 liters of crystalloid and 8 units of packed red blood cells. The patient remains mechanically ventilated and sedated. Over the past 4 hours, his total urine output has decreased to 15 mL. His temperature is 38.2°C (100.8°F), blood pressure is 86/50 mmHg, and heart rate is 118/min. Central venous pressure is measured at 22 mm Hg. The ventilator monitor reveals a sudden increase in peak inspiratory pressures from 24 cm H2O to 48 cm H2O, with a corresponding increase in plateau pressures from 20 cm H2O to 44 cm H2O. Physical examination shows a tense and massively distended abdomen. The surgical incision is dry and intact. Which of the following is the most appropriate next step in the management of this patient?

During morning rounds, the surgical team assesses a $48$-year-old man who is recovering from an elective open ventral hernia repair performed yesterday (postoperative day $1$). He notes some mild incisional discomfort but denies shortness of breath, dysuria, or calf pain. Vital signs show a temperature of $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), a pulse of $88/\text{min}$, a blood pressure of $128/82\text{ mm Hg}$, and a respiratory rate of $18/\text{min}$. Oxygen saturation is $96\%$ on room air. Auscultation of the chest demonstrates diminished breath sounds at the bilateral bases, but no crackles are heard. The abdominal incision is well-approximated, dry, and lacks any surrounding redness. Which of the following are the most appropriate management steps for this patient's current condition? (Select two)

A 71-year-old man is evaluated on postoperative day 4 following an open sigmoid colectomy for recurrent diverticulitis. Over the last several hours, he has developed worsening shortness of breath and a cough productive of pink, frothy sputum. His medical history is significant for ischemic cardiomyopathy with an ejection fraction of $35\%$ and severe chronic obstructive pulmonary disease. Since the operation, he has been receiving continuous $0.9\%$ normal saline at a rate of $150\text{ mL/hr}$ and scheduled intravenous piperacillin-tazobactam.

Temperature is $38.2^\circ \text{C}$ ($100.8^\circ \text{F}$), blood pressure is $168/94\text{ mmHg}$, pulse is $112/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $86\%$ on room air. Physical examination reveals elevated jugular venous pressure, an $S_3$ gallop, and coarse crackles over the bilateral lower and mid lung fields. Expiratory wheezing is absent. The surgical incision is clean, dry, and intact with no surrounding erythema or induration. The abdomen is soft, mildly tender near the incision, but not distended.

Laboratory studies show a leukocyte count of $12,500/\mu\text{L}$. A portable chest radiograph reveals cardiomegaly, bilateral fluffy alveolar opacities, and small bilateral pleural effusions.

Which of the following are the most appropriate next steps in management? (Select 2)

A 30-year-old male is evaluated in the trauma center shortly after sustaining a stab wound to the left anterior abdomen during an altercation. On arrival, he is lethargic and diaphoretic. Vital signs are temperature 36.7°C (98.1°F), pulse 142/min, and blood pressure 72/40 mmHg. His airway is secure, and breath sounds are present and equal bilaterally. The abdomen is rigid with severe, diffuse guarding and rebound tenderness. Intravenous access is rapidly obtained and isotonic fluid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old woman is evaluated on the surgical ward due to increasing restlessness and new-onset left shoulder pain. She underwent an uncomplicated laparoscopic Roux-en-Y gastric bypass for severe obesity two days ago. Her medical history is significant for obstructive sleep apnea and type 2 diabetes mellitus. She is currently receiving intravenous fluids, prophylactic subcutaneous enoxaparin, and patient-controlled analgesia with hydromorphone. Her temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), pulse is $134/\text{min}$, blood pressure is $122/78\text{ mmHg}$, and respirations are $22/\text{min}$. Pulse oximetry shows $95\%$ on room air. The patient appears extremely anxious. Physical examination reveals an obese abdomen with mild, diffuse tenderness but no rebound or guarding. The surgical incisions are clean, dry, and intact. Breath sounds are slightly decreased at the left lung base. The Jackson-Pratt drain in the left upper quadrant has accumulated $30\text{ mL}$ of serosanguinous fluid over the past 24 hours. Which of the following is the most appropriate next step in the management of this patient?

A $74$-year-old woman is brought to the emergency department via ambulance after her daughter found her unresponsive at home. The daughter mentions that the patient slipped and struck the right side of her head against a doorframe two weeks prior, but did not seek medical care at the time. Her medical history includes paroxysmal atrial fibrillation, for which she is prescribed apixaban. On arrival, her blood pressure is $185/105$ mmHg, heart rate is $52$/min, and respiratory rate is $10$/min with an irregular pattern. Her Glasgow Coma Scale score is $6$ (eye opening $1$, verbal response $1$, motor response $4$). Neurological examination is notable for a right pupil that measures $7$ mm and does not react to light, while the left pupil is $3$ mm and briskly reactive. Painful stimuli elicit decerebrate posturing of the left upper and lower extremities. She is immediately intubated for airway protection. Which of the following is the most appropriate next step to acutely manage her neurological deterioration prior to surgical intervention?

A 68-year-old man is evaluated in the emergency department for a 2-day history of escalating lower abdominal pain, nausea, and fever. Seven days ago, he underwent a transurethral resection of the prostate (TURP) and cystolitholapaxy for severe benign prostatic hyperplasia and concurrent bladder stones. His urethral catheter was removed on postoperative day 2 prior to an uncomplicated discharge. Today, his temperature is 38.9°C (102.0°F), blood pressure is 105/65 mm Hg, and pulse is 112/min. Physical examination reveals marked suprapubic tenderness with voluntary guarding. Laboratory studies show a leukocyte count of 18,500/mm³. A CT scan of the abdomen and pelvis with intravenous contrast reveals a 5-cm rim-enhancing fluid collection in the prevesical space (space of Retzius) with adjacent fat stranding. The intraperitoneal cavity has no free fluid. Which of the following is the most appropriate next step in management?

A 24-year-old male presents to the emergency department supporting his right arm after an awkward fall during a recreational rugby match. He is in significant pain, and his right shoulder has a visibly 'squared-off' appearance. He complains of numbness over the lateral aspect of his shoulder. Arrange the following steps in the most appropriate chronological sequence for the acute management of this patient's presentation.

A 68-year-old man with a history of poorly controlled hypertension is brought to the emergency department due to sudden-onset, severe, tearing interscapular back pain. On arrival, his blood pressure is 215/115 mmHg, and his heart rate is 118/min. He appears diaphoretic and in severe distress. An electrocardiogram shows sinus tachycardia with no ischemic changes. A portable chest radiograph demonstrates a widened mediastinum. The physician strongly suspects an acute aortic dissection. Arrange the following evaluation and management steps in the most appropriate chronological sequence for this patient.

A 29-year-old male with a history of sickle cell trait presents to the emergency department with a painful, rigid erection that has persisted for 8 hours. He denies any trauma or use of erectile dysfunction medications. On physical examination, the corpora cavernosa are tense and tender, while the glans penis and corpus spongiosum remain flaccid. A dorsal penile nerve block is performed for local anesthesia. Cavernosal blood gas analysis reveals a $\text{pO}_2$ of $18\text{ mmHg}$, $\text{pCO}_2$ of $88\text{ mmHg}$, and $\text{pH}$ of $7.05$. Assuming the patient's condition remains refractory to each successive intervention, arrange the following management steps in the correct standard-of-care escalation sequence.

During morning rounds on the surgical step-down unit, a $57$-year-old male patient is evaluated for worsening shortness of breath and severe anterior chest pain. He is currently on postoperative day $7$ following an open mitral valve replacement and single-vessel coronary artery bypass graft. His medical history includes type 2 diabetes mellitus, medically managed obesity, and a $35$-pack-year smoking habit. The pain is described as deep and sharp, exacerbating significantly when he coughs.

Vital signs show a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse of $118/\text{min}$, respirations of $24/\text{min}$, and blood pressure of $92/64 \text{ mm Hg}$. Physical examination reveals a diaphoretic, ill-appearing man. Inspection of the midline sternotomy incision demonstrates marked surrounding erythema and a $2\text{-cm}$ separation of the proximal wound edges. A moderate amount of cloudy, malodorous exudate is draining from the defect. Upon palpation of the chest wall during respiration, the two halves of the sternum shift independently of one another. Laboratory studies are significant for a leukocyte count of $19,500/\text{mm}^3$.

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

A $49$-year-old man arrives at the emergency department due to a $24$-hour history of unremitting, severe abdominal pain. He reports multiple episodes of dark green vomiting and an inability to pass flatus since the onset of his symptoms. His surgical history is notable for a ruptured appendix requiring an open midline laparotomy at age $20$. His temperature is $38.5^\circ\text{C}$ ($101.3^\circ\text{F}$), blood pressure is $96/55\text{ mm Hg}$, pulse is $124/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals a visibly distended abdomen that is diffusely tender. There is pronounced involuntary guarding and board-like rigidity. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ with $15\%$ bandemia and a serum lactate of $4.2\text{ mmol/L}$. An upright abdominal radiograph demonstrates multiple dilated loops of small bowel with air-fluid levels, and no free air under the diaphragm. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old man is brought to the emergency department via ambulance with a sudden onset of severe, tearing chest pain that radiates to his interscapular region. His medical history is significant for poorly controlled hypertension. On presentation, he is diaphoretic and in severe distress. Blood pressure is 215/115 mm Hg in the right arm and 180/95 mm Hg in the left arm. Heart rate is 112/min. A new early diastolic decrescendo murmur is heard at the right upper sternal border. Electrocardiogram shows sinus tachycardia and left ventricular hypertrophy without acute ischemic changes. Chest x-ray reveals a widened mediastinum. A diagnosis of acute aortic dissection is suspected. Arrange the following steps in the most appropriate sequential order for the management of this patient.

A $62$-year-old man presents to the emergency department with a $4$-hour history of severe, unrelenting abdominal pain and nonbilious vomiting. He has a history of an open cholecystectomy $12$ years ago. His temperature is $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), blood pressure is $135/85\text{ mmHg}$, pulse is $88/\text{min}$, and respirations are $16/\text{min}$. Physical examination reveals a moderately distended abdomen. There is diffuse tenderness to deep palpation, but no involuntary guarding, rigidity, or rebound tenderness is present. Laboratory studies show a leukocyte count of $9,800/\text{mm}^3$ and a serum lactate level of $1.1\text{ mmol/L}$. Computed tomography of the abdomen and pelvis with intravenous contrast reveals a high-grade mechanical small bowel obstruction. A transition point is identified in the mid-ileum, accompanied by a cluster of dilated, fluid-filled bowel loops arranged in a U-shaped configuration. The mesenteric vessels supplying this segment demonstrate a "whirl" pattern. The bowel wall shows normal contrast enhancement, and there is no pneumatosis intestinalis or free intraperitoneal air.

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

A 74-year-old man requires evaluation in the orthopedic ward four days after undergoing a right hip hemiarthroplasty for a femoral neck fracture. Over the last 12 hours, he has experienced progressively worsening shortness of breath, chest tightness, and a new-onset cough producing small amounts of clear sputum. His past medical history is significant for hypertension and moderate chronic obstructive pulmonary disease. His home medications, which include a daily fluticasone-salmeterol inhaler, were inadvertently not restarted after the procedure. His temperature is 38.1°C (100.6°F), blood pressure is 138/86 mmHg, pulse is 108/min, and respiratory rate is 22/min. Pulse oximetry shows 91% on room air. Physical examination reveals a prolonged expiratory phase and diffuse expiratory wheezing over all lung fields. There is no jugular venous distention, and heart sounds are normal without gallops or murmurs. The surgical incision is clean, dry, and intact with no surrounding erythema. There is no unilateral lower extremity edema. A chest radiograph demonstrates hyperinflated lung fields and flattened hemidiaphragms, without focal consolidation, pleural effusion, or pulmonary vascular congestion. An electrocardiogram shows sinus tachycardia without right heart strain. Which of the following is the most appropriate next step in the management of this patient?