Surgery

A 25-year-old man is brought to the emergency department via ambulance after sustaining a stab wound to the right side of his chest. He appears pale and lethargic. Vital signs show a temperature of 36.8°C (98.2°F), blood pressure of 80/50 mmHg, heart rate of 130/min, and respiratory rate of 24/min. Physical examination reveals a single 2-cm laceration in the right fifth intercostal space at the midaxillary line. Breath sounds are markedly diminished on the right side, and dullness to percussion is present. After placing large-bore intravenous access and initiating fluid resuscitation, a right-sided tube thoracostomy is rapidly performed. The chest tube yields an immediate return of 1,600 mL of bright red blood. Which of the following is the most appropriate next step in management?

A $28$-year-old woman, G $1$ P $0$ at $24$ weeks gestation, is evaluated in the surgical recovery unit for sudden-onset agitation and severe palpitations. She underwent an uncomplicated subtotal thyroidectomy $18$ hours ago for medically refractory Graves disease. Her preoperative regimen included propylthiouracil and propranolol, but she admits to missing multiple doses in the two weeks preceding surgery due to severe nausea. Her temperature is $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$), pulse is $158/\text{min}$ and irregularly irregular, blood pressure is $165/70\text{ mm Hg}$, and respirations are $24/\text{min}$. Physical examination reveals marked diaphoresis, a fine resting tremor, and a clean, intact cervical incision without swelling or erythema. The lungs are clear to auscultation bilaterally, and the abdomen is soft and nontender. Fetal heart tracing is reassuring. ECG demonstrates atrial fibrillation with a rapid ventricular response. Which of the following is the most appropriate next step in the management of this patient?

A 71-year-old man presents to the emergency department with a 5-day history of progressive abdominal distension, cramping abdominal pain, and obstipation. His past medical history is significant for hypertension and type 2 diabetes mellitus. Vital signs show a blood pressure of 135/85 mm Hg, heart rate of 92/min, respiratory rate of 16/min, and temperature of 37.4°C (99.3°F). Physical examination reveals a markedly distended, tympanitic abdomen. There is diffuse mild tenderness but no guarding, rigidity, or rebound tenderness. Digital rectal examination is empty. Laboratory studies show a blood urea nitrogen of 42 mg/dL and a serum creatinine of 1.8 mg/dL (baseline 0.9 mg/dL). Plain abdominal radiography demonstrates massive dilation of the transverse and descending colon with a sudden cutoff in the sigmoid region, without pneumoperitoneum. Arrange the following interventions in the most appropriate sequential order for the optimal management of this patient, anticipating the most likely underlying etiology.

A 72-year-old man with a history of hypertension and a 40-pack-year smoking history is brought to the emergency department by ambulance after a witnessed syncopal episode. He is currently awake but complains of sudden-onset, severe, and tearing lower back and abdominal pain. His temperature is 36.8°C (98.2°F), blood pressure is 75/40 mm Hg, pulse is 122/min, and respiratory rate is 22/min. Physical examination reveals a diaphoretic and pale man in severe distress. Abdominal examination demonstrates a prominent, pulsatile, and tender mass in the epigastrium. Bedside ultrasonography reveals an 8.0 cm abdominal aortic aneurysm with an adjacent collection of free intraabdominal fluid. Arrange the following management steps in the most appropriate chronological sequence for this patient.

Match each clinical presentation of nephrolithiasis or ureterolithiasis with the most appropriate surgical or procedural intervention.

A 68-year-old man comes to the urology clinic to discuss the results of a recent procedure. He initially presented with a $2$-month history of painless, intermittent gross hematuria. His past medical history is notable for hypertension, hyperlipidemia, and a $40$-pack-year smoking history. Physical examination is unremarkable. Last week, he underwent cystoscopy which revealed a $4$-cm solid, sessile tumor on the posterior wall of the bladder. A transurethral resection of the bladder tumor (TURBT) was performed. The pathology report from the resected tissue demonstrates high-grade urothelial carcinoma with extensive invasion into the muscularis propria (detrusor muscle). A subsequent staging computed tomography (CT) scan of the chest, abdomen, and pelvis shows no evidence of pelvic lymphadenopathy or distant metastasis. Which of the following is the most appropriate next step in the management of this patient?

A 48-year-old man is referred to the endocrine surgery clinic for evaluation of treatment-resistant hypertension and unprovoked hypokalemia. He currently takes maximal doses of amlodipine, lisinopril, and doxazosin. Suspecting primary hyperaldosteronism, his physician initiates a diagnostic workup to determine if he is a candidate for surgical intervention. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient.

A 27-year-old graphic designer schedules a clinic appointment after discovering a firm, painless lump in his left testicle while showering. He denies any recent scrotal trauma, dysuria, urethral discharge, or fever. He is otherwise healthy and takes no medications. On physical examination, vital signs are within normal limits. Scrotal examination reveals a 3-cm, hard, non-tender mass within the left testicle that does not transilluminate. The right testicle is normal to palpation, and there is no inguinal lymphadenopathy. A scrotal ultrasound confirms the presence of a solid, hypervascular intratesticular lesion. Serum laboratory testing shows significantly elevated levels of $\beta$-human chorionic gonadotropin ($\beta$-hCG) and $\alpha$-fetoprotein (AFP). What is the most appropriate next step in the management of this patient?

Emergency medical services bring a 45-year-old male construction worker to the trauma bay after he fell two stories from scaffolding. On arrival, he is restless, agitated, and diaphoretic. Vital signs show a heart rate of 135/min and a blood pressure of 82/45 mmHg. Oxygen saturation is 96% on room air. Primary survey reveals clear lungs and a non-distended abdomen. A bedside ultrasound for trauma is negative for free fluid. His pelvis is stable to gentle compression. The right thigh is tense, markedly swollen, and shortened compared to the left, but there is no break in the overlying skin. Bilateral pedal pulses are faint but palpable. Following securing of intravenous access and initiation of crystalloid fluids, which of the following is the most appropriate next step in management?

A 19-year-old female collegiate gymnast is brought to the emergency department after a severe fall during a dismount. She landed awkwardly, sustaining a hyperextension injury to her left knee. On arrival, she is in severe pain. Examination reveals a gross deformity with a prominent anterior tibia. The overlying skin is intact but tense. She has decreased sensation over the dorsum of her left foot and is unable to actively dorsiflex her left ankle. Palpation reveals absent dorsalis pedis and posterior tibial pulses on the left. The emergency physician immediately performs a closed reduction, which restores anatomical alignment. Following the reduction, the patient's pain significantly improves. Her left foot becomes warm and pink, and both the left dorsalis pedis and posterior tibial pulses are now palpable and graded as 2+ (normal). Her blood pressure is 125/75 mm Hg and heart rate is 88/min. Doppler ultrasound is used to measure systolic pressures: the left brachial pressure is 130 mm Hg, the left ankle pressure is 104 mm Hg, and the right ankle pressure is 130 mm Hg. Which of the following is the most appropriate next step in the management of this patient?

A 27-year-old man is brought to the emergency department via ambulance after a high-speed motorcycle collision. He was found approximately $6 \text{ meters}$ ($20 \text{ feet}$) from his motorcycle without a helmet. Upon arrival, the patient is unresponsive. His temperature is $36.2^\circ \text{C}$ ($97.2^\circ \text{F}$), blood pressure is $72/40 \text{ mmHg}$, heart rate is $145\text{/min}$, and respiratory rate is $28\text{/min}$ with shallow breaths. Oxygen saturation is $92\%$ on high-flow oxygen. The patient is immediately intubated for airway protection. Physical examination reveals a large, actively bleeding scalp laceration over the right parietal area. Neurological evaluation demonstrates a Glasgow Coma Scale score of 3T. The right pupil is $8\text{ mm}$ and nonreactive to light; the left pupil is $3\text{ mm}$ and reactive. The abdomen is grossly distended and rigid. A focused assessment with sonography for trauma (FAST) exam reveals a large amount of anechoic fluid in the hepatorenal and splenorenal recesses. Arterial blood gas analysis on $100\%$ FiO2 reveals:

pH: $7.15$
PaCO2: $38\text{ mmHg}$
PaO2: $210\text{ mmHg}$
HCO3: $12\text{ mEq/L}$

What is the most appropriate next step in management?

A $56$-year-old woman is referred to the surgical clinic due to asymptomatic hypercalcemia discovered during a routine wellness examination. Laboratory studies reveal a serum calcium level of $11.2$ mg/dL (normal: $8.4$-$10.2$ mg/dL) and an intact parathyroid hormone (PTH) level of $118$ pg/mL (normal: $10$-$65$ pg/mL). Her serum creatinine and $25$-hydroxyvitamin D levels are within normal limits. Bone densitometry demonstrates a T-score of $-2.6$ at the lumbar spine. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for this patient.

A 66-year-old man with a 45-pack-year smoking history is found to have a 1.8-cm solitary pulmonary nodule with irregular borders in the right upper lobe on a preoperative chest radiograph for an elective inguinal hernia repair. He is entirely asymptomatic and has no significant past medical history other than tobacco use. Arrange the following steps in the most appropriate chronological sequence for the standard evaluation and management of this patient's pulmonary finding.

Emergency medical personnel transport a 71-year-old man to the trauma bay due to the abrupt onset of excruciating abdominal pain that radiates to the lumbar region. The episode started one hour ago while he was resting at home. His past medical history is significant for hypertension, chronic obstructive pulmonary disease, and tobacco use disorder. On arrival, he appears pale, diaphoretic, and confused. His temperature is 36.6°C (97.9°F), blood pressure is 74/42 mm Hg, heart rate is 118/min, and respiratory rate is 24/min. Pulse oximetry is 94% on room air. Cardiopulmonary examination reveals tachycardia and scattered bilateral expiratory wheezes. Abdominal examination reveals a tender, expansile, pulsatile mass in the periumbilical region. Two large-bore intravenous lines are placed, and fluid resuscitation is initiated. A bedside point-of-care ultrasound confirms a 7.2-cm abdominal aortic aneurysm and free fluid in the hepatorenal recess.

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

A 72-year-old man is brought to the emergency department by his daughter due to increasing confusion and lethargy over the past 24 hours. The daughter reports that the patient has not urinated since yesterday morning. For the past several years, he has had progressive difficulty initiating urination, a weak stream, and nocturia. His temperature is 37.1°C (98.8°F), blood pressure is 168/92 mm Hg, pulse is 96/min, and respirations are 16/min. Physical examination reveals a dull, suprapubic mass extending to the umbilicus that is mildly tender to palpation. Digital rectal examination demonstrates a symmetrically enlarged, smooth prostate without nodules. Laboratory studies show a blood urea nitrogen of 78 mg/dL and serum creatinine of 5.2 mg/dL. A renal ultrasound demonstrates bilateral hydronephrosis and a markedly distended urinary bladder. Which of the following is the most appropriate initial step in the management of this patient?

A 28-year-old man is brought to the emergency department following a high-speed motor vehicle collision. He has a severe pelvic fracture. On physical examination, there is blood at the urethral meatus, a scrotal hematoma, and a high-riding prostate on digital rectal examination. He is unable to void despite a strong urge. Arrange the following management steps in the most appropriate chronological order for this patient.

An obese 61-year-old man with poorly controlled type 2 diabetes mellitus is evaluated in the emergency department for worsening anterior chest pain, shortness of breath, and chills. He underwent elective four-vessel coronary artery bypass grafting 12 days ago. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $86/54\text{ mmHg}$, and pulse is $122/\text{min}$. On physical examination, the patient appears toxic and diaphoretic. The sternal incision is erythematous, warm, and draining foul-smelling, purulent fluid. Palpation of the anterior chest wall reveals a palpable click during deep inspiration, and the sternal edges are independently mobile. Laboratory evaluation is notable for a leukocyte count of $24,500/\text{mm}^3$ with $20\%$ bands, and a serum lactate of $4.1\text{ mmol/L}$. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation and characteristic neuroimaging findings with the most likely primary intracranial tumor diagnosis.

A $55$-year-old man is evaluated in the surgical clinic for a palpable neck lump he noticed while shaving. He reports increasing fatigue, cold sensitivity, and occasional dizziness upon standing over the past four months. He also mentions a significant decrease in libido during this period.

Vital signs show a blood pressure of $102/64$ mm Hg and a heart rate of $54$/min. Physical examination reveals delayed relaxation of deep tendon reflexes and a solitary, firm, $2.2$-cm nodule in the right lobe of the thyroid gland. No cervical lymphadenopathy is present.

Laboratory results are as follows:
Thyroid-stimulating hormone (TSH): $1.8$ $\mu$ U/mL (normal: $0.4$–$4.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.3$ ng/dL (normal: $0.9$–$1.7$ ng/dL)

Ultrasound of the neck demonstrates a $2.2$-cm, solid, isoechoic right thyroid nodule with regular margins. Which of the following is the most appropriate next step in the management of this patient?

A $54$-year-old male construction worker is urgently evaluated in the emergency department after leaving work due to the abrupt onset of excruciating, unremitting mid-abdominal pain. He reports vomiting greenish fluid twice since the pain began $6$ hours ago. His surgical history is notable for a complex open appendectomy performed for a ruptured appendix $10$ years ago. Current vital signs include a temperature of $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure of $92/58\text{ mm Hg}$, pulse of $122\text{/min}$, and respirations of $22\text{/min}$. On physical examination, the patient is diaphoretic and avoids any movement. His abdomen is mildly distended and exhibits board-like rigidity, diffuse severe tenderness to light palpation, and absent bowel sounds.

Laboratory investigations reveal:
- Leukocyte count: $19,000\text{/mm}^3$
- Serum bicarbonate: $15\text{ mEq/L}$
- Blood urea nitrogen: $34\text{ mg/dL}$
- Serum creatinine: $1.6\text{ mg/dL}$
- Lactic acid: $5.4\text{ mmol/L}$

An initial upright chest and abdominal radiograph series demonstrates a nonspecific bowel gas pattern with no pneumoperitoneum and no distinct air-fluid levels. Aggressive intravenous crystalloid resuscitation is initiated. Which of the following is the most appropriate next step in the management of this patient?