Surgery

Match each vascular condition with its most characteristic clinical presentation.

Match the following classic clinical presentations and neuroanatomical findings with their corresponding brain herniation syndrome.

Match each clinical presentation of a large bowel emergency with its most appropriate next step in management.

Match each clinical presentation of an acute surgical abdomen to the most appropriate next step in management.

A $42$-year-old man comes to the emergency department due to sudden-onset, severe left-sided flank pain that radiates to his left groin. He has no significant past medical history. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $140/90\text{ mmHg}$, pulse is $98\text{/min}$, and respirations are $16\text{/min}$. Physical examination reveals left costovertebral angle tenderness but a soft, non-tender abdomen. Laboratory studies show a normal leukocyte count and urinalysis is positive for microscopic hematuria but negative for leukocyte esterase and nitrites. A noncontrast CT scan of the abdomen and pelvis reveals a $4\text{-mm}$ stone in the left distal ureter with mild hydroureter. His pain improves significantly after receiving intravenous ketorolac. Which of the following is the most appropriate next step in management?

Match the following clinical presentations of patients with adrenal masses or adrenal dysfunction to the most appropriate next step in management or surgical intervention.

A $38$-year-old man presents to the office to evaluate a newly discovered mass in his neck. He first noticed it while shaving two weeks ago. The patient reports no dysphagia, hoarseness, palpitations, headaches, or diaphoresis. He was adopted as a child and his family medical history is unknown. He takes no medications. Vital signs include a blood pressure of $152/94$ mm Hg and a heart rate of $88$/min. Physical examination reveals a $2.7$-cm, firm, non-tender nodule in the right lobe of the thyroid gland. No cervical lymphadenopathy is appreciated. Laboratory testing shows a serum thyroid-stimulating hormone level of $1.8$ $\mu\text{U}/\text{mL}$ (normal: $0.4$-$4.0$ $\mu\text{U}/\text{mL}$). An ultrasound of the neck confirms a solid, hypoechoic right thyroid nodule with irregular margins. A subsequent fine-needle aspiration biopsy of the nodule yields cytology consistent with medullary thyroid carcinoma. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man is evaluated on the surgical ward due to a sudden deterioration in his clinical status. He was admitted 24 hours ago for a mechanical small bowel obstruction secondary to adhesions from an appendectomy performed 15 years ago. Initial management included bowel rest, intravenous fluid resuscitation, and nasogastric tube decompression, which produced 800 mL of bilious output. During the last two hours, his previously intermittent, crampy abdominal pain has transitioned into constant, excruciating pain that is unresponsive to intravenous analgesics.

Vital signs currently show a temperature of 38.7°C (101.7°F), blood pressure of 102/64 mm Hg, pulse of 122/min, and respirations of 22/min. Physical examination demonstrates a markedly distended abdomen with diffuse rigidity, involuntary guarding, and severe rebound tenderness. Bowel sounds, which were previously high-pitched, are now absent. A repeat basic metabolic panel reveals a serum bicarbonate of 15 mEq/L, decreased from 24 mEq/L on admission.

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

A 45-year-old man is brought to the emergency department by his wife due to the sudden onset of an excruciating headache that began 2 hours ago. He describes it as the "worst headache of my life." He also complains of nausea, photophobia, and double vision. Vital signs are temperature 37.2°C (99.0°F), heart rate 95/min, blood pressure 175/105 mmHg, and respiratory rate 16/min. His Glasgow Coma Scale score is 14. Neurologic examination reveals marked nuchal rigidity. His right eyelid is drooping, and the right pupil is dilated and minimally reactive to light. The right eye is deviated downward and outward. Which of the following is the most appropriate initial diagnostic step?

In the management of severe traumatic brain injury and refractory intracranial hypertension, various interventions are utilized to lower intracranial pressure (ICP) while maintaining adequate cerebral perfusion. Match each advanced neurocritical care intervention with its precise physiological mechanism of action and primary clinical limitation.

A 68-year-old man is brought to the emergency department due to a rapid decline in his ability to walk over the past 24 hours. He has a 3-week history of progressively worsening mid-back pain that awakens him from sleep. His medical history is significant for castration-resistant prostate cancer. Upon arrival, his temperature is 37.0°C (98.6°F), blood pressure is 142/88 mmHg, pulse is 88/min, and respiratory rate is 16/min. His Glasgow Coma Scale score is 15. Neurologic examination of the upper extremities is unremarkable. In the lower extremities, motor strength is 2/5 bilaterally. There is hyperreflexia at the patellar and Achilles tendons, and plantar reflexes are upgoing bilaterally. Sensation to pinprick is decreased below the level of the umbilicus. Bladder ultrasound demonstrates 550 mL of retained urine.

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

A 31-year-old female patient schedules an appointment to discuss persistent bilateral breast secretions that began four months ago. She also reports feeling unusually sluggish, experiencing new-onset constipation, and gaining $5\text{ kg}$ ($11\text{ lbs}$) during this timeframe. Her menstrual periods, previously predictable, are now occurring every 45 to 50 days. A home pregnancy test taken last week was negative. She is not taking any over-the-counter or prescription medications. Vital signs show a heart rate of $58\text{/min}$ and a blood pressure of $110/70\text{ mmHg}$. On physical examination, there are no palpable masses, skin dimpling, or axillary lymphadenopathy. Gentle expression yields a milky white fluid from both nipples.

Laboratory testing reveals the following:

Based on these findings, which of the following is the most appropriate next step in management?

A neuro-intensive care nurse urgently pages the on-call physician regarding a 64-year-old male patient who has become acutely unresponsive. The patient is on postoperative day 5 following a right-sided craniotomy for resection of a large glioblastoma. He has been receiving high-dose dexamethasone since admission to manage peritumoral edema. He is intubated, mechanically ventilated, and was previously localizing to pain.

Over the last 15 minutes, his neurologic status has sharply declined. He now exhibits extensor posturing to painful stimuli. The right pupil has dilated to 7 mm and is nonreactive to light, while the left pupil remains 3 mm and reactive.

Vital signs are:
Temperature: 37.8°C (100.0°F)
Blood pressure: 72/40 mmHg
Heart rate: 138/min
Respiratory rate: 18/min (ventilator-controlled)

Morning laboratory studies drawn 6 hours ago showed a hemoglobin level of 13.2 g/dL.

Upon physical examination, the physician notes that the orogastric tube is suddenly draining a massive volume of bright red blood into the suction canister. His extremities are cool and diaphoretic.

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

A 60-year-old man presents to the emergency department with sudden-onset, severe "tearing" chest pain that radiates to his back. His blood pressure is 190/110 mmHg in both arms, and his heart rate is 105/min. An electrocardiogram shows left ventricular hypertrophy but no acute ischemic changes, and a portable chest x-ray reveals a widened mediastinum. Acute aortic dissection is highly suspected. Arrange the following steps in the most appropriate sequential order for the management of this patient.

A 62-year-old man is brought to the emergency department with sudden-onset, severe, tearing chest pain that radiates to his back. He has a history of poorly controlled hypertension. Upon arrival, he appears lethargic and diaphoretic. Blood pressure is $80/40\text{ mmHg}$ in the right arm and $75/35\text{ mmHg}$ in the left arm. Pulse is $125\text{/min}$, and respirations are $22\text{/min}$. Physical examination shows significant jugular venous distention. The lungs are clear to auscultation bilaterally. Heart sounds are distant and muffled. A bedside echocardiogram demonstrates a dilated aortic root with an intimal flap, as well as a large pericardial effusion with right ventricular diastolic collapse. Which of the following is the most appropriate next step in management?

Paramedics arrive at the trauma bay with a 19-year-old male who was injured in a high-speed skateboarding accident without a helmet. He is profoundly comatose with a Glasgow Coma Scale score of 5. Initial physical examination reveals a fixed, dilated left pupil and right-sided extensor posturing in response to pain. Determine the correct chronological order for the subsequent management steps in this scenario.

Match each clinical presentation of a urologic injury or surgical complication to its most appropriate definitive management or immediate next step.

A 34-year-old man is brought to the emergency department after a high-speed motorcycle collision. He is hemodynamically stable, and a primary trauma survey reveals no acute intracranial, thoracic, or abdominal life-threatening injuries. Pelvic radiography demonstrates a displaced fracture of the pubic rami. On physical examination, there is prominent blood at the urethral meatus, a severely swollen and ecchymotic scrotum, and the patient reports a strong urge to void but is unable to do so. Digital rectal examination reveals a high-riding, boggy prostate. Arrange the following steps in the most appropriate chronological sequence for the standard diagnostic and surgical management of this patient's urologic injury.

A 26-year-old man is brought to the emergency department after a severe motor vehicle collision. Primary survey reveals an unstable pelvic fracture. Genitourinary examination shows blood at the urethral meatus, a scrotal hematoma, and a high-riding prostate on digital rectal examination. A transurethral Foley catheter has not been placed. Arrange the following steps in the most appropriate sequential order for the diagnosis and definitive management of this patient's urologic injury.

A 42-year-old woman presents to the clinic with episodic palpitations, severe headaches, and diaphoresis. Her blood pressure is 180/110 mmHg, and her heart rate is 105/min. She is highly suspected of having a pheochromocytoma. Arrange the following steps in the most appropriate chronological order for her diagnostic workup and perioperative surgical management.