Surgery

Match each clinical presentation of lower extremity pain with its most likely orthopedic diagnosis.

A 34-year-old female presents to the triage desk with a 6-hour history of sudden-onset, severe, and unrelenting periumbilical pain. She reports multiple episodes of bilious vomiting and an inability to keep any oral intake down since the pain began. Her surgical history is notable for a laparoscopic Roux-en-Y gastric bypass performed two years ago for severe obesity, resulting in a 45-kg (99-lb) weight loss. Her temperature is 38.6°C (101.5°F), blood pressure is 92/58 mmHg, pulse is 128/min, and respirations are 24/min. Physical examination reveals a markedly distended abdomen. There is diffuse tenderness to palpation, most prominent in the periumbilical region, with severe involuntary guarding and rebound tenderness. Bowel sounds are absent. Laboratory studies show a leukocyte count of 18,000/mm³ and a serum lactate level of 5.1 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

A 54-year-old woman is evaluated in the hospital due to a rapid change in her clinical status. She was admitted 24 hours ago for nausea, bilious emesis, an inability to pass flatus, and crampy abdominal pain. Her surgical history is notable for an open myomectomy five years ago. On admission, she was afebrile with normal vital signs, and an abdominal radiograph revealed multiple dilated loops of small intestine with air-fluid levels but no free intraperitoneal air. She was appropriately started on intravenous fluids, bowel rest, and nasogastric tube decompression. Over the past two hours, the patient reports that her abdominal pain has shifted from an intermittent, crampy character to a severe, constant ache. Current vital signs show a temperature of 38.8 C (101.8 F), heart rate of 118/min, blood pressure of 100/60 mm Hg, and respiratory rate of 22/min. Physical examination now reveals a significantly distended abdomen with localized rigidity, guarding, and rebound tenderness in the right lower quadrant. Laboratory studies demonstrate a leukocyte count of 16,500/mm³ with 15% band forms, and a serum lactate level of 3.8 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

Match the following acute upper extremity orthopedic injuries with their most characteristic physical examination findings and anatomical disruptions.

Match each patient's pancreatic cystic lesion presentation with the most appropriate definitive management strategy.

Match each clinical presentation to the most appropriate cardiothoracic surgical diagnosis or traumatic injury.

A 28-year-old man comes to the emergency department due to a 24-hour history of progressively worsening crampy abdominal pain, intractable vomiting, and an inability to pass flatus or stool. He states that over the last 2 hours, his pain has transitioned from crampy to constant and severe. His medical history is significant for medically refractory ulcerative colitis, for which he underwent a total proctocolectomy with ileal pouch-anal anastomosis 3 years ago. His temperature is 39.1°C (102.4°F), blood pressure is 96/58 mmHg, pulse is 128/min, and respirations are 22/min. Physical examination reveals a markedly distended abdomen with absent bowel sounds. There is severe, diffuse abdominal tenderness with involuntary guarding and rebound tenderness. Laboratory studies show a leukocyte count of 19,500/mm³ and a serum lactate level of 4.8 mmol/L. An upright abdominal radiograph demonstrates multiple dilated loops of small bowel with prominent air-fluid levels, but no free intraperitoneal air. Which of the following is the most appropriate next step in management?

Match each of the following specific orthopedic injuries with its most commonly associated acute neurovascular deficit as assessed on physical examination.

A 34-year-old man is brought to the emergency department for severe right shoulder pain. Thirty minutes ago, he experienced a witnessed generalized tonic-clonic seizure that lasted 2 minutes. On physical examination, the right arm is held firmly in adduction and internal rotation. The patient actively resists any attempt at passive external rotation due to severe pain. The radial pulse is 2+ and sensation is intact to light touch over the deltoid and distal fingers. An initial anteroposterior (AP) radiograph of the right shoulder reveals a symmetric, rounded appearance of the humeral head with no obvious fracture lines. Which of the following is the most appropriate next step in the management of this patient?

A 34-year-old male construction worker is brought to the emergency department via ambulance after being crushed by a heavy concrete pipe. On arrival, he is confused and agitated. His temperature is 36.5°C (97.7°F), blood pressure is 78/40 mm Hg, pulse is 135/min, and respirations are 24/min. Pulse oximetry shows 96% on room air. Primary survey reveals a patent airway and equal breath sounds bilaterally. Heart sounds are rapid but normal in intensity. The abdomen is soft, nondistended, and without guarding. The pelvis is mechanically unstable to gentle lateral compression. A prominent scrotal hematoma and blood at the urethral meatus are noted. Intravenous access is established, a pelvic binder is applied, and a massive transfusion protocol with uncrossmatched blood products in a $1:1:1$ ratio is initiated. Ten minutes later, his blood pressure is 80/42 mm Hg and pulse is 132/min. A focused assessment with sonography for trauma (FAST) exam demonstrates no fluid in the pericardial sac, hepatorenal recess, splenorenal recess, or rectovesical pouch. Anteroposterior chest radiograph is unremarkable. Which of the following is the most appropriate next step in management?

A 78-year-old woman is brought to the emergency department due to the sudden onset of excruciating abdominal pain that began 2 hours ago. She has a history of congestive heart failure and atrial fibrillation, for which she has not been taking her prescribed anticoagulant medication. She is writhing in pain. Vital signs show a temperature of 37.1°C (98.8°F), pulse of 122/min and irregularly irregular, blood pressure of 135/85 mm Hg, and respiratory rate of 22/min. Physical examination reveals a soft abdomen with mild, diffuse tenderness to deep palpation, without any guarding, rigidity, or rebound tenderness. Bowel sounds are diminished. An electrocardiogram confirms atrial fibrillation with a rapid ventricular response. Arrange the following steps in the most appropriate chronological order for diagnosing and managing this patient's condition.

A 45-year-old woman is evaluated in the emergency department for severe, unremitting abdominal pain and bilious vomiting that started 8 hours ago. She has a history of an open hysterectomy 5 years ago. Her temperature is 39.1°C (102.4°F), pulse is 124/min, and blood pressure is 88/55 mm Hg. Physical examination reveals a markedly distended abdomen. There is diffuse rigidity, guarding, and severe rebound tenderness. Bowel sounds are absent. Laboratory studies show a leukocyte count of 19,000/mm³ and an elevated serum lactate level. An upright plain radiograph of the abdomen demonstrates dilated small bowel loops with multiple air-fluid levels and no free intraperitoneal air. Which of the following is the most appropriate next step in management?

Match each clinical presentation of an acute abdominal condition with its most appropriate initial definitive management step.

A $42$-year-old man is evaluated in the surgical step-down unit due to a sudden deterioration in his clinical status. He was admitted $48$ hours ago for management of an adhesive small bowel obstruction. Initial treatment with intravenous fluids, bowel rest, and nasogastric tube decompression led to mild improvement during the first day. However, over the past $3$ hours, his previously intermittent, crampy periumbilical pain has transitioned to severe, constant, and diffuse abdominal pain. Temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), pulse is $128/\text{min}$, respirations are $24/\text{min}$, and blood pressure is $86/50\text{ mm Hg}$. Physical examination reveals a rigid, distended abdomen with marked rebound tenderness and involuntary guarding in all quadrants. Bowel sounds are absent. Laboratory evaluation demonstrates a leukocyte count of $18,500/\text{mm}^3$ with $15\%$ band forms, and a serum lactate of $4.8\text{ mmol/L}$. Which of the following is the most appropriate next step in management?

A 35-year-old male is transported to the emergency department after his motorcycle struck a concrete barrier at high speed. Upon arrival, he is lethargic and visibly pale. Vital signs show a heart rate of 142/min, a blood pressure of 76/40 mm Hg, and a respiratory rate of 24/min. Oxygen saturation is 96% on a non-rebreather mask. The airway is patent, and breath sounds are crisp and equal bilaterally. The abdomen is tense, distended, and dull to percussion. The pelvis is stable to manual compression. Focused assessment with sonography for trauma demonstrates significant free anechoic fluid in the splenorenal and hepatorenal recesses. Two large-bore intravenous lines are established, and resuscitation with balanced crystalloids and uncrossmatched blood is initiated. Which of the following is the most appropriate next step in management?

During routine morning rounds on postoperative day 3, a 51-year-old man is evaluated after an elective open reduction and internal fixation of a right tibial fracture. He reports feeling mildly fatigued but is participating in early physical therapy. An indwelling urinary catheter was placed intraoperatively and removed on postoperative day 1. His temperature is 38.6°C (101.5°F), blood pressure is 125/80 mmHg, heart rate is 88/min, and respiratory rate is 16/min. Oxygen saturation is 98% on room air. Physical examination reveals clear breath sounds bilaterally. The right lower extremity surgical dressings are intact, with no surrounding erythema, induration, or unusual swelling. Palpation of the left calf is non-tender. When questioned further, he notes increased urinary frequency and mild suprapubic discomfort since the previous evening. Which of the following is the most appropriate next step in management?

Match the following thoracic trauma clinical presentations to their most appropriate immediate next step in management or diagnostic evaluation.

Following a fall from a second-story residential roof, a 54-year-old male is evaluated in the trauma center. He was reportedly cleaning gutters when he lost his balance and fell approximately 20 feet (6 meters) onto the grass below. The patient is awake, alert, and secured to a rigid backboard with a cervical collar.

Vital signs are:
Temperature: 36.6°C (97.9°F)
Heart rate: 122/min
Blood pressure: 80/50 mm Hg
Respiratory rate: 22/min
Oxygen saturation: 96% on room air

Physical examination reveals a patent airway with midline trachea. Breath sounds are clear and equal bilaterally. Heart sounds are normal without murmurs, rubs, or gallops. His abdomen is soft, non-distended, and non-tender to deep palpation, though he notes he cannot feel the examiner's hands well. The pelvis is stable to anterior-posterior and lateral compression. Neurologic examination reveals flaccid paralysis and areflexia of both lower extremities, with a complete loss of pain, temperature, and light touch sensation below the level of the umbilicus. Upper extremity strength and sensation are intact. Two large-bore peripheral intravenous lines are established, and a bolus of warm isotonic crystalloid is initiated.

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

A 62-year-old male presents to the emergency department six days after undergoing an elective open umbilical hernia repair with mesh. He reports a new onset of severe, throbbing pain at the surgical site that began yesterday, accompanied by subjective chills. His medical history includes type 2 diabetes mellitus, obesity, and chronic venous insufficiency characterized by long-standing, stable bilateral ankle edema. Vital signs upon triage are temperature 38.8°C (101.8°F), blood pressure 130/82 mm Hg, pulse 102/min, and respirations 16/min. Oxygen saturation is 98% on room air. Cardiopulmonary auscultation reveals clear breath sounds bilaterally without crackles or wheezes. Abdominal examination demonstrates a 5-cm area of marked erythema and induration surrounding the incision, along with a palpable fluctuant mass deep to the suture line. Purulent fluid is actively weeping from the central portion of the wound. Which of the following are the most appropriate immediate next steps in the management of this patient? (Select exactly 2)

A 68-year-old man is evaluated on the surgical ward due to worsening respiratory distress. He is currently on his third postoperative day following a partial colectomy with primary anastomosis for a localized colon adenocarcinoma. His medical history is significant for hypertension, type 2 diabetes mellitus, a 35-pack-year smoking history, and an anterior wall myocardial infarction three years ago. Since the operation, he has been receiving intravenous lactated Ringer solution at a continuous rate of 125 mL/h.

His temperature is 37.7°C (99.9°F), blood pressure is 156/92 mm Hg, pulse is 114/min and regular, and respirations are 26/min. Pulse oximetry reveals an oxygen saturation of 88% while breathing ambient air.

Physical examination shows a distressed patient sitting on the edge of the bed and using accessory muscles of respiration. Inspection of the neck reveals distension of the jugular veins when the patient is reclined at a 45-degree angle. Pulmonary auscultation demonstrates bilateral coarse crackles in the lower two-thirds of the lung fields, accompanied by scattered expiratory wheezes. Cardiac auscultation reveals a regular tachycardia, normal S1 and S2, and a low-frequency diastolic sound heard best at the cardiac apex. The surgical incision is clean, dry, and intact with no surrounding erythema. The bilateral lower extremities exhibit 1+ pitting edema.

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