Surgery

A 74-year-old retired teacher is evaluated in the emergency department for sudden, excruciating pain in his right lower extremity that began 3 hours ago. He reports that his foot feels cold and he cannot move his toes. His past medical history includes hypertension, osteoarthritis, and paroxysmal atrial fibrillation. He is not currently taking anticoagulation due to a history of peptic ulcer disease. His pulse is 112/min and irregularly irregular, and his blood pressure is 152/88 mm Hg. Physical examination reveals a pale, cold right leg from the mid-calf distally. The right femoral pulse is palpable, but the popliteal and pedal pulses are absent. There is profound sensory loss over the dorsum of the foot, and the patient is unable to actively dorsiflex his ankle. Continuous-wave Doppler ultrasound detects venous signals but no arterial signals over the dorsalis pedis artery. Which of the following is the most appropriate next step in management?

Following 8 hours of severe, crampy abdominal pain and repeated bilious vomiting, a 61-year-old man arrives at the emergency department. He reports absolute constipation and an inability to pass flatus since the symptoms commenced. His surgical history is notable for an open appendectomy performed 15 years ago. The patient takes lisinopril for hypertension. His temperature is 37.2°C (99.0°F), pulse is 78/min, respirations are 16/min, and blood pressure is 134/82 mm Hg. Cardiopulmonary examination is unremarkable. The abdomen is significantly distended and tympanic to percussion. Auscultation reveals high-pitched, tinkling bowel sounds. Palpation elicits mild, diffuse tenderness without guarding, rigidity, or rebound. Laboratory studies show a leukocyte count of 8,500/mm³ and a serum lactate level of 1.1 mmol/L. Intravenous fluid resuscitation is initiated. A contrast-enhanced CT scan of the abdomen and pelvis demonstrates multiple dilated loops of small bowel measuring up to 4.5 cm in diameter. There is a specific transition point in the right lower quadrant where a clustered, U-shaped configuration of fluid-filled bowel loops is seen, with engorged mesenteric vessels radiating toward a single central point. The large intestine is entirely decompressed. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation of acute genitourinary trauma with the most appropriate immediate diagnostic or therapeutic next step.

A 34-year-old woman is brought to the trauma bay via ambulance after being ejected from a rolling vehicle. Paramedics report she has been unresponsive since their arrival 20 minutes ago and intubated her at the scene. Current vital signs include a temperature of 36.2°C (97.2°F), blood pressure of 72/40 mm Hg, heart rate of 145/min, and respiratory rate of 28/min. Neurological evaluation reveals a Glasgow Coma Scale score of 3T. Her right pupil is 7 mm and unreactive to light; the left pupil is 3 mm and briskly reactive. Physical examination is notable for a large, actively bleeding laceration with a palpable step-off over the right temporal bone, as well as a tensely distended, rigid abdomen. Intravenous access is established, and a rapid infusion of 2 L of warmed crystalloid does not improve her blood pressure. Which of the following is the most appropriate next step in the management of this patient?

A $62$-year-old man comes to the urology clinic reporting a dull, aching heaviness in his left scrotum that has gradually worsened over the past $3$ months. He denies any dysuria, urethral discharge, fever, or history of sexually transmitted infections. His medical history includes hypertension and a $30$-pack-year history of smoking. Vital signs are within normal limits. Physical examination of the patient in the standing position reveals a palpable, non-tender, tortuous, "bag of worms" mass superior to the left testicle. When the patient is placed in the supine position, the scrotal mass does not decompress or reduce in size. Urinalysis shows $15$ red blood cells per high-power field, but is negative for leukocyte esterase and nitrites. Which of the following is the most appropriate next step in management?

A physician is evaluating a $68$-year-old man in the hospital who was admitted $36$ hours ago for crampy abdominal pain, obstipation, and vomiting. He has a history of an open appendectomy $20$ years ago. On admission, plain abdominal radiographs demonstrated dilated loops of small intestine with multiple air-fluid levels and a paucity of colonic gas. He was initially managed with intravenous fluid resuscitation, bowel rest, and nasogastric tube decompression. Over the last two hours, the patient reports that his abdominal pain has transitioned from intermittent cramping to a severe, constant ache. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $96/60\text{ mmHg}$, pulse is $118\text{/min}$, and respiratory rate is $22\text{/min}$. Physical examination reveals a markedly distended abdomen with involuntary guarding and rebound tenderness in the periumbilical region. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ with $12\%$ bands, and a serum lactate level of $4.2\text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

Match each postoperative clinical presentation with the most likely diagnosis and its appropriate initial management.

A 79-year-old man is brought to the emergency department by his daughter due to a 2-day history of worsening confusion and right-sided weakness. He had a mechanical fall approximately one month ago but did not seek medical attention at the time. His past medical history is significant for permanent atrial fibrillation, for which he takes warfarin and metoprolol. On examination, the patient is somnolent but arouses to verbal stimuli. His blood pressure is 155/90 mmHg, and heart rate is 78/min. Neurologic examination reveals a left-sided pupil that is sluggishly reactive to light and right-sided hemiparesis. Laboratory studies show an international normalized ratio (INR) of 2.8. A non-contrast computed tomography (CT) scan of the head demonstrates a large, crescent-shaped, hypodense extra-axial fluid collection over the left cerebral hemisphere with a 13-mm midline shift. Which of the following is the most appropriate next step in management?

Match each clinical and radiographic vignette with the most likely primary bone tumor diagnosis.

A $38$-year-old man presents to the clinic complaining of episodic headaches, excessive sweating, and a feeling of a rapid heart rate. His blood pressure in the clinic is $172/105 \text{ mmHg}$. He reports that these "spells" have been occurring once or twice a week for the past $3$ months. Physical examination is otherwise unremarkable. Laboratory evaluation reveals a serum potassium of $4.2 \text{ mEq/L}$ and fasting blood glucose of $115 \text{ mg/dL}$. A $24$-hour urine collection shows fractionated metanephrines that are $4$ times the upper limit of normal. Contrast-enhanced CT of the abdomen reveals a $4.5 \text{ cm}$ well-circumscribed, lipid-poor mass in the right adrenal gland. The patient is scheduled to undergo a laparoscopic right adrenalectomy in $3$ weeks. Which of the following is the most appropriate preoperative pharmacological sequence to prevent perioperative complications?

Match the following thyroid nodule presentations and cytology findings with the most appropriate initial surgical or medical management.

An urgent evaluation is requested for a 65-year-old male patient in the cardiovascular intensive care unit due to an acute decline in mental status and worsening dyspnea. The patient is currently on postoperative day 2 following a surgical aortic valve replacement and ascending aortic aneurysm repair. Until this morning, his recovery was progressing as expected. Current vital signs show a temperature of $37.5^\circ\text{C}$ ($99.5^\circ\text{F}$), heart rate of $128/\text{min}$, respiratory rate of $26/\text{min}$, and a blood pressure of $78/48\text{ mm Hg}$. When the patient takes a deep breath, his systolic blood pressure drops to $64\text{ mm Hg}$. Telemetry demonstrates marked sinus tachycardia accompanied by alternating heights of the QRS complexes. On physical assessment, the neck veins are severely distended despite the head of the bed being elevated. Auscultation reveals clear lung fields bilaterally, but the cardiac sounds are notably faint. The nursing staff reports that while the mediastinal drain produced $150\text{ mL}$ of bloody output yesterday, it has yielded only $5\text{ mL}$ over the last 4 hours. Which of the following is the most appropriate next step in management?

During a routine wellness examination, a $54$-year-old woman is found to have an asymmetric thyroid gland. She reports feeling generally well, though she notes a mild increase in anxiety and occasional loose stools over the past two months. Her heart rate is $92/min$ and blood pressure is $128/78$ $mmHg$. Physical examination reveals a non-tender, mobile, $2.8$ cm nodule in the right lobe of the thyroid gland. There is no palpable cervical lymphadenopathy. Laboratory testing reveals:

Thyroid-stimulating hormone (TSH): $0.04$ $\mu U/mL$ (normal: $0.4-4.0$ $\mu U/mL$)
Free thyroxine (T4): $2.1$ $ng/dL$ (normal: $0.9-1.7$ $ng/dL$)

A neck ultrasound confirms a $2.8$ cm solid, hypoechoic right-sided thyroid nodule with increased internal vascularity. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old man is brought to the emergency department via ambulance 45 minutes after being struck on the right side of his head with a baseball bat during an altercation. Witnesses report that he briefly lost consciousness for about one minute but then awoke and was conversing normally. During transport, he became increasingly somnolent and is now unarousable with a Glasgow Coma Scale (GCS) score of 5 (Eyes: 1, Verbal: 1, Motor: 3). His temperature is 37.0°C (98.6°F), blood pressure is 165/95 mm Hg, pulse is 52/min, and respirations are 10/min and irregular. Physical examination reveals a right-sided fixed and dilated pupil, and he exhibits decorticate posturing on the left side in response to painful stimuli. A non-contrast computed tomography (CT) scan of the head demonstrates a 3.5-cm biconvex, hyperdense collection in the right temporal region with 11 mm of midline shift. Which of the following is the next best step in management?

A 34-year-old female presents to the emergency department with a sudden onset of intense, unrelenting periumbilical pain that began 4 hours ago. The pain radiates to her mid-back and is accompanied by several episodes of nonbilious vomiting. Her past medical history is notable for a laparoscopic Roux-en-Y gastric bypass performed two years ago for morbid obesity, resulting in a 45-kg (99-lb) weight loss. Vital signs show a temperature of 37.2°C (99.0°F), a heart rate of 115/min, and a blood pressure of 108/65 mm Hg. On physical examination, the patient appears deeply uncomfortable and is constantly shifting positions in bed to find relief. Her abdomen is soft and non-distended; there is moderate periumbilical tenderness to deep palpation, but no guarding, rigidity, or rebound tenderness. Bowel sounds are hyperactive. Laboratory studies reveal a leukocyte count of 11,500/mm³ and a serum lactate of 1.4 mmol/L (normal: 0.5-2.2 mmol/L). A CT scan of the abdomen and pelvis with intravenous contrast reveals a cluster of dilated small bowel loops in the left upper quadrant, vascular engorgement of the mesentery, and a 'whirl' appearance of the mesenteric root. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old man is brought to the emergency department after a high-speed motorcycle collision. His airway is patent, breathing is unlabored, and he is hemodynamically stable. Examination reveals a grossly deformed right lower leg with a 4-cm anteromedial laceration through which fractured bone fragments are visible. The wound is oozing dark blood, but there is no pulsatile bleeding.

Arrange the following steps in the most appropriate sequential order for the acute management of this patient's orthopedic injury.

A 9-year-old boy is brought to the emergency department by his parents due to a 3-day history of worsening left leg pain and fever. The parents report that he initially started limping but now refuses to bear any weight on the left leg. There is no history of recent trauma, tick bites, or travel. His temperature is 38.8°C (101.8°F), blood pressure is 105/65 mmHg, heart rate is 115/min, and respiratory rate is 18/min. On physical examination, the child is ill-appearing. There is exquisite point tenderness, localized warmth, and mild swelling over the proximal anterior aspect of the left tibia. Range of motion of the left knee and ankle is fully preserved and does not elicit pain. Laboratory studies reveal a leukocyte count of 15,500/mm³ (85% neutrophils), an erythrocyte sedimentation rate (ESR) of 65 mm/hr, and a C-reactive protein (CRP) level of 82 mg/L. Plain radiographs of the left tibia and knee show no obvious abnormalities. Which of the following is the most appropriate next step in management?

Match each clinical vignette describing an orthopedic injury with the most appropriate definitive management step.

An $82$-year-old male is evaluated in the surgical ward on postoperative day $8$ following an open sigmoid colectomy for recurrent diverticulitis. Over the past $24$ hours, he has developed worsening, severe abdominal pain and multiple episodes of bilious emesis. He has not passed flatus or stool for two days. His temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, pulse is $132/\text{min}$, and respiratory rate is $26/\text{min}$. The patient is lethargic and diaphoretic. Abdominal examination reveals a markedly distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. The surgical incision is clean with no surrounding erythema or purulent drainage.

Laboratory studies show:
Leukocyte count: $24,000/\text{mm}^3$
Serum lactate: $6.2\text{ mmol/L}$
Bicarbonate: $12\text{ mEq/L}$

Arterial blood gas (room air):
pH: $7.21$
pCO $_2$: $29\text{ mm Hg}$
pO $_2$: $80\text{ mm Hg}$

Supine and upright abdominal radiographs display multiple dilated loops of small bowel with air-fluid levels and an absence of colonic gas. Aggressive intravenous fluid resuscitation is initiated.

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

While recovering in the surgical ward, a 65-year-old man develops acute-onset, severe abdominal pain. He is currently 8 days status post an open ventral hernia repair with mesh placement. His initial recovery was uncomplicated; he began passing flatus on the fourth day after surgery and was tolerating a regular diet. Over the past 24 hours, he has experienced progressive abdominal distension, nausea, and two episodes of bilious vomiting. He has not passed flatus since the pain began. His temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $88/50 \text{ mmHg}$, pulse is $122/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals a markedly distended abdomen. There is diffuse tenderness with involuntary guarding and rebound tenderness, most prominent in the periumbilical region. Bowel sounds are absent. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$, a serum bicarbonate level of $14 \text{ mEq/L}$, and a lactate level of $4.2 \text{ mmol/L}$. An upright abdominal radiograph demonstrates multiple dilated loops of small intestine with prominent air-fluid levels and a paucity of colonic gas. Which of the following is the most appropriate next step in management?