Surgery

A 62-year-old man is evaluated on postoperative day 2 following a four-vessel coronary artery bypass grafting (CABG) procedure. His temperature is 38.3°C (101.0°F), blood pressure is 128/82 mmHg, pulse is 88/min, and respirations are 16/min. He reports mild chest wall pain at the incision site but denies shortness of breath, cough, dysuria, or leg swelling. Physical examination reveals decreased breath sounds at the lung bases bilaterally without crackles or wheezing. The sternal surgical wound is clean, dry, and intact with no erythema, induration, or discharge. His indwelling urinary catheter was removed on postoperative day 1. Which of the following is the most likely cause of this patient's fever?

A 62-year-old female with a history of hormone receptor-positive breast cancer treated with a mastectomy four years ago visits an outpatient clinic due to progressively worsening mid-back pain over the past three weeks. The pain is localized to the thoracic region and worsens when she coughs or lies flat. Over the last 48 hours, she has noticed increasing heaviness in both legs and had an episode of urinary incontinence earlier today. Her temperature is 37.0°C (98.6°F), blood pressure is 138/86 mmHg, and heart rate is 82/min. Neurologic examination reveals 3/5 muscle strength in the bilateral lower extremities. Deep tendon reflexes are 3+ at the patellae and ankles, and bilateral plantar reflexes are extensor. Pinprick sensation is diminished below the level of the umbilicus. Which of the following is the most appropriate initial step in management?

Match each clinical presentation with the most appropriate next step in surgical management.

A 28-year-old man is evaluated in the intensive care unit. He was involved in a high-speed motor vehicle collision 24 hours ago. His injuries include a severe traumatic brain injury and a closed, comminuted midshaft fracture of the right tibia. He is currently intubated, sedated, and unresponsive to commands. His vital signs include a blood pressure of $105/65\text{ mm Hg}$ and a heart rate of $98/\text{min}$. The nursing staff reports that the patient's right lower leg has become increasingly firm over the past two hours. On physical examination, the right calf is tense, swollen, and non-compressible. The right dorsalis pedis and posterior tibial pulses are easily palpable, and capillary refill in the toes is less than 2 seconds. Which of the following is the most appropriate next step in the management of this patient's extremity?

Pair each patient presentation with the most appropriate initial diagnostic test or immediate management step.

A 22-year-old man is brought to the emergency department by emergency medical services after being ejected from a motorcycle at high speed. He was not wearing a helmet. Upon arrival, he does not open his eyes to pain, makes incomprehensible sounds, and exhibits abnormal extension of his upper extremities to painful stimuli. His right pupil is 7 mm and nonreactive to light, while the left is 3 mm and reactive. Blood pressure is 165/95 mmHg, heart rate is 55/min, and respiratory rate is 10/min and irregular.

Arrange the following interventions in the correct chronological order from FIRST to LAST in the acute management of this patient.

Awakened abruptly by excruciating unilateral pelvic and scrotal pain, a $16$-year-old adolescent is brought directly to the emergency department triage desk at $3:00$ AM. He is visibly distressed, pacing the room, and reports vomiting twice since the onset of symptoms $2$ hours ago. The patient has no past medical history and states he is not sexually active. Vital signs reveal a heart rate of $110$/min and blood pressure of $135/85$ mm Hg, and he is afebrile. Genitourinary examination demonstrates an indurated, highly tender left testicle that is positioned abnormally high in the hemiscrotum with a horizontal axis. Stroking the inner aspect of the left thigh elicits no elevation of the ipsilateral testicle, whereas the reflex remains intact on the right side. Which of the following interventions is most urgently indicated?

Match the following specific orthopedic injuries with their most commonly associated neurovascular complication.

A 68-year-old male with a 20-year history of poorly controlled type 2 diabetes mellitus and chronic kidney disease presents to the vascular surgery clinic due to progressive, severe pain in his right foot. The pain has been present for four weeks, worsens at night when he is lying in bed, and improves significantly when he sits on the edge of the bed and dangles his legs. Physical examination reveals a cool, pale right foot with a 1-cm, shallow, dry, well-demarcated ulcer on the tip of the great toe. No surrounding erythema, warmth, or purulent exudate is noted. The right femoral pulse is palpable, but the popliteal, dorsalis pedis, and posterior tibial pulses are nonpalpable. A bedside ankle-brachial index (ABI) test is performed. The right ABI is 1.45, and the left ABI is 1.10. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A 32-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He reports severe pain in his hips and lower back. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 82/50 mmHg, pulse of 134/min, and respiratory rate of 22/min. Physical examination reveals an ecchymotic and unstable pelvis upon gentle anterior-posterior compression. A focused assessment with sonography for trauma (FAST) is negative for free intra-abdominal fluid, and a chest x-ray is clear. There are no obvious external sources of bleeding. Large-bore intravenous access is established, and aggressive fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

During morning rounds on the surgical ward, the care team evaluates a patient recovering from a radical cystoprostatectomy and ileal conduit formation performed $48$ hours ago for high-grade urothelial carcinoma. The patient reports generalized fatigue and mild nausea but no acute distress. Vital signs include a temperature of $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), heart rate of $95/\text{min}$, blood pressure of $128/78\text{ mmHg}$, and respiratory rate of $18/\text{min}$. Auscultation of the chest reveals faint crackles at both lung bases. Abdominal examination demonstrates mild distension without rigidity or guarding; bowel sounds are absent. The stoma appears pink and healthy. The ostomy appliance contains $180\text{ mL}$ of cloudy, mucus-laden urine collected over the past four hours.

Laboratory studies obtained this morning reveal the following:
Leukocyte count: $11,500/\text{mm}^3$
Sodium: $139\text{ mEq/L}$
Potassium: $4.6\text{ mEq/L}$
Chloride: $110\text{ mEq/L}$
Bicarbonate: $18\text{ mEq/L}$
Blood urea nitrogen: $22\text{ mg/dL}$
Creatinine: $1.1\text{ mg/dL}$

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

Match each patient's clinical presentation with the most appropriate surgical management or preoperative intervention.

A high school student is evaluated in the surgical assessment unit for sudden-onset, severe right-sided scrotal pain that began two hours ago during a soccer match. The pain is continuous, radiates to the right lower abdomen, and is accompanied by nausea and one episode of emesis. He is not sexually active and reports no preceding genitourinary trauma or urinary symptoms. His vital signs are within normal limits. On physical examination, the right hemiscrotum is swollen, exquisitely tender, and visibly elevated compared to the left. The right testicle lies in a transverse orientation. Stroking the medial aspect of the right thigh elicits no ipsilateral testicular retraction, whereas the left testicle retracts normally. Which of the following is the most appropriate next step in management?

A 58-year-old woman is brought to the emergency department by her husband due to a 24-hour history of severe right upper quadrant abdominal pain, confusion, and shaking chills. Her past medical history is significant for hypertension and type 2 diabetes mellitus. Her temperature is 39.4°C (102.9°F), blood pressure is 82/50 mmHg, heart rate is 126/min, and respiratory rate is 22/min. Physical examination reveals scleral icterus and marked right upper quadrant tenderness without rebound or guarding. The patient is oriented only to person. Laboratory studies show a leukocyte count of 18,000/mm³, total bilirubin of 6.2 mg/dL, direct bilirubin of 4.8 mg/dL, and alkaline phosphatase of 450 U/L. Right upper quadrant ultrasound demonstrates a 12-mm common bile duct and multiple stones in the gallbladder. Place the following management steps in the most appropriate chronological sequence for this patient.

Match the following complex orthopedic injuries with their defining pathophysiologic mechanism, critical diagnostic finding, or absolute surgical management principle.

Match each clinical presentation of genitourinary trauma with the most appropriate immediate diagnostic test or intervention.

A 42-year-old man is brought to the emergency department by emergency medical services after his roommates found him unable to walk. The patient states he has had severe, constant mid-back pain for the past two weeks, which became excruciating over the last 48 hours. Today, he developed profound weakness in both legs and has not been able to urinate since yesterday morning. His past medical history is significant for intravenous heroin use and a recent hospitalization for a cutaneous abscess that he left against medical advice. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, and heart rate is $112/\text{min}$. Neurologic examination reveals $1/5$ strength in the bilateral lower extremities, absent patellar and Achilles reflexes, and decreased sensation to all modalities below the umbilicus. Digital rectal examination shows decreased anal sphincter tone. A bladder scan reveals $800\text{ mL}$ of retained urine. Which of the following is the most appropriate immediate next step in the diagnostic or therapeutic management of this patient?

Match each clinical presentation to its most likely underlying pathophysiological mechanism or diagnosis.

Following a high-velocity head-on vehicular collision, emergency medical services transport a 41-year-old woman to the local trauma center. She reports intense chest discomfort that radiates toward her scapulae. Initial vital signs indicate a blood pressure of 158/92 mmHg and a heart rate of 108 beats/min. Bedside ultrasound evaluation of the abdomen and pericardium is negative for free fluid. A portable anteroposterior chest radiograph demonstrates an enlarged mediastinal silhouette and indistinctness of the aortic arch contour. Arrange the subsequent clinical management steps in the correct chronological order.

A $38$-year-old woman presents to the breast clinic complaining of bilateral, milky nipple discharge for the past $4$ months. She also reports cessation of her menses $6$ months ago, generalized fatigue, and occasional morning headaches. She has no prior medical history and takes no medications. Physical examination reveals normal-appearing breasts with no palpable masses, skin dimpling, or axillary lymphadenopathy. Gentle pressure elicits a non-bloody, milky discharge from both nipples. A urine pregnancy test is negative. Laboratory evaluation reveals the following:

Prolactin: $185 \text{ ng/mL}$ (Reference: $4 - 23 \text{ ng/mL}$)
Thyroid-stimulating hormone (TSH): $0.2 \text{ \mu U/mL}$ (Reference: $0.4 - 4.0 \text{ \mu U/mL}$)
Free thyroxine (T4): $0.5 \text{ ng/dL}$ (Reference: $0.9 - 2.4 \text{ ng/dL}$)

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