Surgery

Match each specific burn or environmental injury presentation with the most appropriate immediate or targeted management step.

A 72-year-old man is brought to the emergency department by ambulance after losing consciousness at home. His wife reports that he had a brief episode of vomiting bright red blood earlier in the morning, which stopped spontaneously. However, just before the ambulance arrived, he experienced a massive episode of hematemesis and collapsed. His medical history is significant for hypertension, hyperlipidemia, tobacco use, and an open infrarenal abdominal aortic aneurysm repair four years ago. On arrival, he is diaphoretic and pale. His temperature is 37.1°C (98.8°F), blood pressure is 75/40 mmHg, pulse is 132/min, and respirations are 22/min. The abdomen is soft, non-tender, and mildly distended. Peripheral pulses are weak but symmetric. Two large-bore intravenous lines are placed and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

Match each clinical vignette describing a distinct peripheral vascular presentation to its most appropriate anatomic diagnosis or pathophysiologic syndrome.

A 45-year-old man comes to the emergency department due to intermittent, crampy abdominal pain and nausea for the past 24 hours. He has vomited twice and has not passed flatus since yesterday. His surgical history is significant for an open appendectomy for a perforated appendix 10 years ago.

Vital signs include a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse of $88/\text{min}$, respirations of $14/\text{min}$, and blood pressure of $130/82\text{ mm Hg}$. The abdomen is moderately distended and tympanitic to percussion. High-pitched, hyperactive bowel sounds are auscultated. There is mild, diffuse abdominal tenderness to deep palpation, but no guarding, rigidity, or rebound tenderness is present.

Laboratory studies show a leukocyte count of $8,200/\text{mm}^3$ and a normal basic metabolic panel. A CT scan of the abdomen and pelvis with intravenous contrast reveals dilated loops of small bowel up to $4\text{ cm}$ in diameter, a transition point in the distal ileum, and a collapsed colon. The bowel wall enhances normally, and there is no evidence of pneumatosis intestinalis, free intraperitoneal air, or free fluid.

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

A series of patients present to the trauma bay with various acute orthopedic injuries. Match each specific fracture pattern or dislocation with its most likely associated neurovascular deficit observed on physical examination.

A $19$-year-old male college student is brought to the emergency department $30$ minutes after a bicycle accident. He was riding down a steep trail when he lost control, flipped over the handlebars, and struck his left upper abdomen against a large rock. He complains of severe abdominal pain and pain radiating to his left shoulder. His temperature is $36.8^{\circ}\text{C}$ ($98.2^{\circ}\text{F}$), blood pressure is $82/50$ mm Hg, pulse is $130$/min, and respirations are $24$/min. Pulse oximetry shows $98\%$ on room air. He appears pale and diaphoretic. Physical examination reveals ecchymosis over the left upper quadrant. The abdomen is distended, rigid, and diffusely tender with involuntary guarding. A focused assessment with sonography for trauma (FAST) exam demonstrates a large anechoic stripe in the splenorenal recess and hepatorenal recess. Two large-bore intravenous lines are established, and fluid resuscitation with $1$ L of warmed crystalloid is initiated. Repeat blood pressure is $84/52$ mm Hg. Which of the following is the most appropriate next step in management?

A $68$-year-old male is evaluated in the intensive care unit on postoperative day $2$ following an emergent open repair of a ruptured abdominal aortic aneurysm. During the procedure, he received $8\text{ L}$ of crystalloid and $6$ units of packed red blood cells. The patient remains intubated and mechanically ventilated. Over the past $4$ hours, his urine output has dropped to $5\text{ mL/hr}$. Current vital signs include a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure of $82/50\text{ mmHg}$, and heart rate of $124/\text{min}$. The ventilator is alarming for high peak airway pressures, which have increased from $24\text{ cm H}_2\text{O}$ to $48\text{ cm H}_2\text{O}$ since the morning. Central venous pressure is $19\text{ mmHg}$. Physical examination reveals a tightly distended, firm abdomen and bilateral basilar crackles. Laboratory studies demonstrate a serum creatinine of $2.7\text{ mg/dL}$ (baseline $1.0\text{ mg/dL}$) and a leukocyte count of $15,500/\mu\text{L}$. Which of the following is the most appropriate next step in management?

Match each upper extremity fracture or dislocation pattern with its most classically associated neurovascular complication.

A $62$-year-old man is evaluated on postoperative day $5$ following an elective anterior resection of the rectum for a malignant mass. Over the past $6$ hours, he has developed progressively worsening, severe abdominal pain and altered mental status. His medical history is significant for type 2 diabetes mellitus and hypertension. His current temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $86/52\text{ mm Hg}$, pulse is $128/\text{min}$, and respiratory rate is $26/\text{min}$. Physical examination reveals an ill-appearing, diaphoretic patient. The abdomen is distended, tense, and diffusely tender to palpation with involuntary guarding and pronounced rebound tenderness. Bowel sounds are absent. The surgical incision shows no signs of erythema or purulent discharge. Laboratory studies demonstrate a leukocyte count of $19,400/\text{mm}^3$ with $14\%$ band forms, and a serum lactate level of $4.2\text{ mmol/L}$. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated immediately. Which of the following is the most appropriate next step in management?

A surgical rapid response is called for a patient experiencing acute deterioration on the surgical ward. The patient, a $68$-year-old male, underwent an uncomplicated laparoscopic repair of a large type III paraesophageal hernia $48$ hours ago. His medical history is significant for hypertension, type $2$ diabetes mellitus, and polymyalgia rheumatica. He has been taking amlodipine, metformin, and prednisone ($15$ mg daily) for the past year. Due to severe postoperative nausea and emesis, he has been strictly nil per os (NPO) since the surgery and has only received intravenous lactated Ringer solution and prochlorperazine. Currently, he appears lethargic. Vital signs reveal a temperature of $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), heart rate of $128$/min, respiratory rate of $22$/min, and blood pressure of $78/48$ mmHg. Physical examination shows dry mucous membranes and a non-distended, soft, and non-tender abdomen. His surgical port sites are clean without erythema. An electrocardiogram demonstrates sinus tachycardia. Laboratory studies are returned as follows:

* Sodium: $126$ mEq/L
* Potassium: $5.6$ mEq/L
* Chloride: $94$ mEq/L
* Bicarbonate: $18$ mEq/L
* Blood urea nitrogen: $32$ mg/dL
* Creatinine: $1.4$ mg/dL
* Glucose: $52$ mg/dL

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

During a collegiate rugby match, an 18-year-old athlete sustains a high-impact direct blow to the anterior right proximal tibia while the foot is firmly planted on the turf. The athlete falls to the ground in severe distress and is unable to bear weight. On examination in the emergency department 45 minutes later, there is a prominent step-off at the right knee joint, with the tibia displaced posteriorly relative to the femur. The overlying skin is intact. The patient reports severe pain but denies any numbness or tingling in the foot. Dorsalis pedis and posterior tibial pulses are palpable and symmetric to the uninjured leg. Capillary refill is less than 2 seconds. A bedside closed reduction is performed promptly under conscious sedation, successfully restoring normal anatomic alignment of the knee. Post-reduction, the distal pulses remain palpable and symmetric. Which of the following is the most appropriate next step in the management of this patient?

Match each patient's clinical presentation with the most appropriate procedural or operative intervention.

A 28-year-old woman is brought to the trauma bay by emergency medical services after being ejected from a motorcycle at highway speeds. She is confused, tachypneic, and covered in significant abrasions. According to Advanced Trauma Life Support (ATLS) principles, arrange the following initial assessment and management steps in the correct chronological order.

A 24-year-old man is brought to the emergency department via ambulance after sustaining a gunshot wound to his left thigh. On arrival, he is diaphoretic and confused. His temperature is $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, heart rate is $134/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals a single penetrating wound on the anteromedial aspect of the left distal thigh. There is a rapidly expanding, pulsatile hematoma surrounding the wound, and bright red blood is actively spurting from the site. The left foot is pale and cold to the touch. The dorsalis pedis and posterior tibial pulses are not palpable on the left but are $2+$ on the right. Intravenous access is established, and isotonic fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

A $31$-year-old man comes to the physician for evaluation of a painless neck mass he noticed while shaving two weeks ago. For the past four months, he has experienced episodic, severe headaches accompanied by profound sweating and palpitations, which he attributed to work-related stress. His blood pressure is $172/98$ mm Hg, and his pulse is $108$/min. Physical examination reveals a $2.5$-cm, firm, mobile, non-tender mass in the right anterior neck. Laboratory studies show a serum thyroid-stimulating hormone (TSH) level of $6.2$ $\mu$ U/mL (normal: $0.4$–$4.0$ $\mu$ U/mL) and a free thyroxine (T4) level of $1.1$ ng/dL (normal: $0.9$–$2.4$ ng/dL). An ultrasound of the neck demonstrates a $2.3$-cm solid, hypoechoic nodule with microcalcifications in the right thyroid lobe. Fine-needle aspiration biopsy of the nodule reveals clusters of spindle-shaped cells with pleomorphic nuclei and extracellular deposits that demonstrate apple-green birefringence under polarized light after Congo red staining. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old man is brought to the emergency department by his neighbor after collapsing in his driveway. The patient is awake but lethargic, complaining of agonizing, tearing pain in his left flank that radiates to his groin. His medical history includes hypertension, severe chronic obstructive pulmonary disease (COPD), and atrial fibrillation. He states he ran out of all his medications two weeks ago.

Vital signs are temperature 36.8°C (98.2°F), blood pressure 76/48 mmHg, heart rate 134/min and irregularly irregular, respiratory rate 28/min, and oxygen saturation 92% on room air.

Physical examination reveals a pale, diaphoretic patient who is oriented only to person. Pulmonary auscultation reveals diffuse expiratory wheezes. The abdomen is distended, firm, and diffusely tender with absent bowel sounds. Deep palpation reveals a prominent pulsatile mass in the periumbilical region. A bedside ultrasound demonstrates a 7.2-cm infrarenal aortic aneurysm with a surrounding hypoechoic collection in the retroperitoneum.

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

A surgical clerkship student is reviewing the classic presentations of cardiovascular and thoracic disorders. For each clinical scenario described below, select the most accurate diagnosis.

Match each patient's clinical presentation with the most appropriate next step in diagnosis or surgical management. Assume initial standard resuscitation (e.g., intravenous access, basic labs) has been initiated for all patients.

A $65$-year-old man presents to the clinic complaining of left-sided scrotal swelling and discomfort that he first noticed $1$ month ago. The patient describes a dull, heavy ache in the scrotum that worsens after standing for prolonged periods. Over the past $2$ weeks, he has also experienced intermittent left flank pain and noticed that his urine occasionally appears pink. His medical history is significant for hypertension and a $40$-pack-year smoking history. Vital signs are within normal limits. Physical examination in the standing position reveals a soft, irregular, cord-like mass superior to the left testicle. When the patient is placed in the supine position, the scrotal mass does not decrease in size. The testicles are bilaterally smooth, non-tender, and without discrete nodules. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman presents to the emergency department with a severe, diffuse headache, nausea, and three episodes of projectile vomiting that began 12 hours ago. She has a history of congenital hydrocephalus treated with a ventriculoperitoneal shunt placed during infancy; her last shunt revision was five years ago. Vitals show a blood pressure of 155/95 mmHg, heart rate of 52/min, respiratory rate of 12/min, and temperature of 37.0°C. Her Glasgow Coma Scale score is 14 (confused conversation). Neurologic examination reveals bilateral papilledema and impaired upward gaze, with no focal motor weakness in the extremities. Which of the following is the most appropriate next step in management?